Change In Bishop Score Research Articles

Randomised placebo‐controlled trial of outpatient (at home) cervical ripening with isosorbide mononitrate (IMN) prior to induction of labour – clinical trial with analyses of efficacy and acceptability. The IMOP Study

To determine whether isosorbide mononitrate (IMN), self-administered vaginally by women at home, improves the process of induction of labour. Randomised double blind placebo-controlled trial. Large UK maternity hospital. Nulliparous women with a singleton pregnancy, cephalic presentation > or = 37 weeks gestation, requiring cervical ripening prior to induction of labour. IMN (n = 177) or placebo (n = 173) self-administered vaginally at home at 48, 32 and 16 hours prior to the scheduled time of admission for induction. Admission to delivery interval and women's experience of induction of labour. IMN did not shorten the admission to delivery interval as compared with placebo [mean difference of -1.6 hours (95% CI -5.1,1.9, P = 0.37)], despite being more effective than placebo in inducing a change in Bishop score [mean difference of 0.65 (95% CI 0.14,1.17, P = 0.013)]. While both groups found the overall experience of home treatment to be positive, (mean score of 3.8/10 +/- 2.3/10 for the IMN group, where 1 = extremely good and 10 = not at all good) women in the placebo group found it marginally more positive than those in the IMN group (just over half a unit on a 10-point scale, P = 0.043). There were no differences between the groups in the pain or anxiety experienced or willingness to take the treatment in a subsequent pregnancy. IMN self-administered vaginally at home does not shorten admission to delivery interval despite a significant effect on cervical ripeness assessed using the Bishop score. However, women report positive views on cervical ripening at home, and the setting deserves further investigation.

The routine use of oxytocin after oral misoprostol for labour induction in women with an unfavourable cervix is not of benefit

Induction of labour with misoprostol is often augmented with oxytocin with the possible consequence of uterine hypercontractility. It is important to determine whether the use of oxytocin in this circumstance has benefit as well as risk. To compare two regimens for labour induction in women with an unfavourable cervix: oral misoprostol vs. oral misoprostol routinely followed by oxytocin. A prospective randomised trial in which 200 women with an unfavourable cervix received either oral misoprostol 25 microg every 3 h (group 1, n = 100) or two such doses routinely followed by oxytocin (group 2, n = 100). Outcomes included change in Bishop score, induction delivery interval, oxytocin requirement, contraction abnormalities, mode of delivery and neonatal outcome. The improvement in Bishop score with two misoprostol doses in all 200 women was highly significant (2.9 +/- 1.5 to 6.6 +/- 1.9, P < 0.0001). The induction delivery interval, Caesarean delivery rate, vaginal delivery rate within 24 h, contraction abnormalities and neonatal outcome were similar in both groups. Contraction abnormalities were remarkably low with either regimen (1%). Routine addition of oxytocin 3 h after the second misoprostol dose (group 2) resulted in the maximum oxytocin dose (64 mU/min) being given to more women (66% in group 2; 36% in group 1). There was no benefit of routine addition of oxytocin after two doses of misoprostol. Reduced oxytocin requirement was observed when it was added only if needed. Both regimens achieved 85-87% vaginal deliveries with low incidence of hypercontractility.

Intravaginal glyceryl trinitrate and dinoprostone for cervical ripening and induction of labor

This study was undertaken to evaluate the efficacy and safety of intravaginal administration of glyceryl trinitrate plus dinoprostone versus dinoprostone, for cervical ripening and induction of labor. A prospective, double-blind, placebo-controlled, randomized clinical trial was conducted among 196 singleton low-risk nullipara women with term pregnancies and unfavorable cervices who were randomly assigned to receive intravaginal glyceryl trinitrate plus dinoprostone or placebo plus dinoprostone. The main outcome variables were time from application to active phase of labor and to delivery. Secondary outcomes were change in Bishop score, fetal and maternal morbidity, and incidence of cesarean deliveries. The interval from application of the initial dose to the beginning of active phase of labor was 868 +/- 582 and 1136 +/- 692 minutes (P = .004) and from initial dose to delivery was 1339 +/- 826 and 1620 +/- 975 minutes (P = .03) for the glyceryl trinitrate and placebo groups, respectively. There were no significant differences in Bishop score change, cesarean section rate, and in the incidence of hypersystole and hyperstimulation. The incidence of tachysystole was significantly lower in the glyceryl trinitrate group (4% vs 15%, P < or = .02). No maternal and neonatal adverse effects were noted. The association of glyceryl trinitrate with dinoprostone is more effective than dinoprostone alone for labor induction in low-risk patients at term with unfavorable cervices.

Intravaginal misoprostol versus Foley catheter for cervical ripening and induction of labor

Objective To compare the efficacy and safety of 100 μg of intravaginal misoprostol with intracervical Foley catheter for cervical ripening and induction of labor. Method One hundred women being induced in the Lagos University Teaching Hospital, Nigeria, were randomized to receive a single 100 μg dose of misoprostol intravaginally or intracervical insertion of Foley catheter. Data analyses were by the Student's t-test and chi-square test. Result Misoprostol was more effective in terms of induction to delivery interval (11.84 ± 5.43 versus 20.03 ± 4.68 h, P < 0.05), change in Bishop score, and number delivered within 24 h, in patients with a one-time successful induction. Uterine hyperactivity and rupture were more frequent in the misoprostol group. Conclusion A single 100 μg dose of intravaginal misoprostol is more efficacious than intracervical insertion of Foley catheter for cervical ripening and induction of labor. Further studies using lower doses are needed to determine the safest dose.

Induction of labor in women with oligohydramnios

Objective. To prospectively evaluate the outcome of labor induction in women with oligohydramnios at term.Methods. This was a prospective case-control study which included 120 consecutive patients with Amniotic Fluid Index (AFI) ??5 undergoing labor induction. One hundred and sixteen patients with normal amniotic fluid matched for gestational age (?± 3 days) and Bishop-score served as controls. Inclusion criteria were: requirement of labor induction, singleton pregnancy, nulliparity, Bishop score <?5, gestational age ??266. Preinduction treatment included the use of up to 3 successive doses of dinoprostone intracervical gel (0.5?mg). Vaginal dinoprostone (2?mg) and/or oxytocin were then applied to induction labor, if necessary.Results. The rate of cesarean section in AFI???5 group (38.3%) was not significantly different to that in control group (34.2%). The interval from induction to vaginal delivery was not significantly different for AFI ??5 group (1499?±?895?min.) and control group (1398?±?852?min.). The changes in Bishop score evaluated at 6th and 12th hour after dinoprostone were not significantly different in control and AFI???5 group. More women in the latter group (11.7% vs 3.3%, Chi Square:4.86, p?=?0.027) required the use of drugs in order to manage tachysystole/hyperstimulation allowing a OR?=?3.83 (95%C.I.?=?1.13–14.27). The length of stay at hospital was 4.2?±?1.8 days for AFI ??5 group and 4.3?±?1.3 for control group.Conclusions. Oligohydranmios at term did not influence the outcome of induction of labour in nulliparous women with unfavorable cervix.

Induction of labor in women with oligohydramnios

To prospectively evaluate the outcome of labor induction in women with oligohydramnios at term. This was a prospective case-control study which included 120 consecutive patients with Amniotic Fluid Index (AFI) < or =5 undergoing labor induction. One hundred and sixteen patients with normal amniotic fluid matched for gestational age (+/- 3 days) and Bishop-score served as controls. Inclusion criteria were: requirement of labor induction, singleton pregnancy, nulliparity, Bishop score <5, gestational age > or =266. Preinduction treatment included the use of up to 3 successive doses of dinoprostone intracervical gel (0.5 mg). Vaginal dinoprostone (2 mg) and/or oxytocin were then applied to induction labor, if necessary. The rate of cesarean section in AFI < or = 5 group (38.3%) was not significantly different to that in control group (34.2%). The interval from induction to vaginal delivery was not significantly different for AFI < or =5 group (1499 +/- 895 min.) and control group (1398 +/- 852 min.). The changes in Bishop score evaluated at 6th and 12th hour after dinoprostone were not significantly different in control and AFI< or =5 group. More women in the latter group (11.7% vs 3.3%, Chi Square:4.86, p = 0.027) required the use of drugs in order to manage tachysystole/hyperstimulation allowing a OR = 3.83 (95%C.I. = 1.13-14.27). The length of stay at hospital was 4.2 +/- 1.8 days for AFI < or =5 group and 4.3 +/- 1.3 for control group. Oligohydranmios at term did not influence the outcome of induction of labour in nulliparous women with unfavorable cervix.

Comparison of two preparations of dinoprostone for pre-induction of labour in nulliparous women with very unfavourable cervical condition: a randomised clinical trial

The aim of this study was to compare the clinical effects of preinduction cervical ripening by using two ways of dinoprostone administration. In a prospective, open-label trial, 144 consecutive nulliparous women with a Bishop score <4 who required induction of labour at term were randomised to receive dinoprostone via either a vaginal insert (10 mg over 12 h) or a cervical gel (0.5 mg, twice in 12 h). If labour did not start by 24 h after this preinduction, patients received 2 mg vaginal dinoprostone gel followed 6 h later by oxytocin infusion. The main outcome measure was the rate of caesarean sections (CS). Secondary measures were: changes in Bishop score at 6 h and 12 h, delivery within 12 h and 24 h, need for oxytocin for induction, failure of induction (delivery after >48 h), need for pharmacological interventions to manage tachysystole/hyperstimulation, length of stay in hospital. The CS rate was lower in the vaginal insert group (22.9%) than in the cervical gel group (34.3%), though the difference did not reach statistical significant difference ( P = 0.13). The indications for CS overlapped between the groups. The rate of vaginal delivery within 12 h and 24 h was similar, as was the rate of failure of induction. More women in the gel group (41.4% versus 24.3%) required the use of oxytocin (OR = 2.21; 95% CI = 1.07–4.55). Tachysystole or hyperstimulation in the vaginal insert group (7) was twice that with cervical gel (4). Four women in the vaginal insert group and three in the cervical gel group reported infectious complications. A long stay in hospital (>4 days) was less frequent with vaginal inserts (21.4 versus 38.6%; OR = 0.43, 95% CI = 0.19–0.97). The more challenging preinductions of labour at term are associated with increased obstetric interventions such as a high CS rate and a more frequent requirement for oxytocin inductions. In terms of success and failure, vaginal inserts releasing dinoprostone do not differ from dinoprostone given by the traditional cervical route. However, the use of vaginal inserts reduces the need for obstetric interventions and allows shorter periods in hospital.

Comparison of prostaglandin E2 tablets or Foley catheter for labour induction in grand multiparas

The efficacy, safety and outcome of prostaglandin (PG)E2 was compared with Foley catheter for labour induction in grand multiparous women. At a hospital in Jordan, 147 women with Bishop score < or = 5 were randomized to receive 3 mg PGE2 vaginal tablets (n = 75) or 50 mL intracervical Foley catheter (n = 72). The change in Bishop score was significantly higher in the PGE2 group than the catheter group, and time from induction to delivery was significantly shorter in the PGE2 group. Significantly more women needed oxytocin for labour augmentation in the catheter than the PGE2 group and fetal distress was significantly more frequent. For grand multiparas, PGE2 vaginal tablets may be preferable for ripening the cervix as well as for labour induction.

Comparative efficacy and cost of the prostaglandin analogs dinoprostone and misoprostol as labor preinduction agents

Objective: The purpose of this study was to compare the relative efficacy and cost of three commercially available prostaglandin analogs, misoprostol (Cytotec), dinoprostone gel (Prepidil), and dinoprostone insert (Cervidil), as labor preinduction agents. Study design: One-hundred eleven women with an unfavorable cervix who underwent labor induction were assigned randomly to receive either misoprostol 50 μg every 6 hours for two doses, dinoprostone gel 0.5 mg every 6 hours for two doses, or dinoprostone insert 10 mg for one dose intravaginally. Twelve hours later, oxytocin induction was initiated per standardized protocol. Efficacy and cost of the labor preinduction/induction with the study treatments were compared. Results: Mean Bishop score change (±SD) over the initial 12-hour interval was significantly greater in the misoprostol group (5.2 ± 3.1) compared with the dinoprostone insert (3.2 ± 2.3) or the dinoprostone gel groups (2.2 ± 1.3, P < .0001). The proportion of women who reached complete dilation (68.4%, 50.0%, 51.4%, respectively; P = .14) and who were delivered (60.5%, 47.4%, 40.0%, respectively; P = .10) within 24 hours of the initiation of induction were not significantly different between the misoprostol, dinoprostone insert, and dinoprostone gel groups. Induction-to-delivery intervals, however, were significantly shorter among women who treated with misoprostol (24.0 ± 10.8 hours) compared with either the dinoprostone gel (31.6 ± 13.4 hours) or the dinoprostone insert (32.2 ± 14.7 hours, P < .05). Overall mean cost per patient that was incurred by labor induction was significantly less for the misoprostol group ($1036.13) compared with the dinoprostone insert group ($1565.72) or the dinoprostone gel group ($1572.92, P < .0001). No significant differences were noted with respect to the mode of delivery or to the adverse maternal/neonatal outcome. Conclusion: Misoprostol is more cost-effective than the comparable commercial dinoprostone prostaglandin preparations as an adjuvant to labor induction in women with an unfavorable cervix. (Am J Obstet Gynecol 2003;188:560-5.)

Effect of vaginal pH on efficacy of the controlled-release dinoprostone vaginal insert for cervical ripening/labor induction

Objective: To evaluate whether vaginal pH alters the efficacy of the controlled-release dinoprostone vaginal insert (Cervidil®) for cervical ripening/labor induction.Methods:Thirty-four women with an unfavorable cervix undergoing labor induction were enrolled in this prospective, double-blind investigation. Vaginal pH and Bishop score assessments were made by an independentexaminer. All women received preinduction with the dinoprostone vaginal insert 10 mg intravaginally for 12 h. Twelve hours later, oxytocin induction initiated according to the standardized protocol andoutcome data were collected.Results: Mean (± SD) initial vaginal pH was 4.9 ± 0.5 for the study cohort. No significant differences were noted between women with a high vaginalpH (> 4.5, n = 18) and those with a low vaginal pH (≤ 4.5, n = 16) with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change overthe preinduction interval (3.2 vs. 3.3), time to active labor (28.6 vs. 24.6 h) and time to delivery (33.7 vs. 31.4 h) were not significantly different between the low and the high pH groups, respectively.Linear regression analysis revealed no significant association between vaginal pH and Bishop score change during the preinduction interval, time to active labor, time to complete dilatation, or time todelivery.Conclusion: Vaginal pH does not appear to influence the efficacy of the controlled-released dinoprostone vaginal insert for cervical ripening/labor induction.

Effect of vaginal pH on efficacy of the dinoprostone gel for cervical ripening/labor induction

Objective: The purpose of this study was to evaluate whether vaginal pH has an effect on the efficacy of the dinoprostone gel for cervical ripening/labor induction. Study Design: Thirty-two women with an unfavorable cervix who were undergoing labor induction were enrolled in this prospective, double-blinded investigation. Initial vaginal pH and Bishop score assessment were made by an independent examiner. All women received cervical ripening with the dinoprostone gel 5 mg intracervically, with repeated dosing one time 6 hours later. Twelve hours later, oxytocin induction was initiated per standardized protocol, and outcome data were collected. Results: Mean (±SD) initial vaginal pH was 4.7 ± 0.6 (range, 4.0-6.0) for the study cohort. No significant differences were noted between women with a high vaginal pH (>4.5, n = 16 women) and women with a low vaginal pH (≤4.5, n = 16 women) with respect to maternal age, parity, gestational age, or initial Bishop score. Although Bishop score change over the initial 12 hours of cervical ripening did not significantly differ between the high vaginal pH (2.3 ± 2.3) and the low vaginal pH group (2.3 ± 2.5, P = not significant), time to active labor (19 ± 10 hours vs 33 ± 17 hours, P =.001), complete dilation (24 ± 10 hours vs 37 ± 19 hours, P =.03), and delivery (26 ± 10 hours vs 38 ± 18 hours, P =.02) were significantly shorter in women with a high vaginal pH compared with women with a low vaginal pH, respectively. A significant association was noted between vaginal pH and time to active labor (r = −0.52, P =.003), complete dilation (r = −0.50, P =.006), and delivery (r = −0.44, P =.01); however, pH was not significantly associated with Bishop score change during the initial 12 hours of cervical ripening. Conclusion: Vaginal pH is an important factor that affects the efficacy of the dinoprostone gel as an adjuvant for labor induction. (Am J Obstet Gynecol 2002;187:843-6.)

Transcervical foley catheter for preinduction cervical ripening in an outpatient versus inpatient setting

OBJECTIVE: To compare use of the Foley catheter for preinduction cervical ripening in an inpatient versus outpatient setting. METHODS: A randomized trial was conducted from May 1998 to December 1999. Women with a term gestation in the vertex presentation, a reactive nonstress test, an amniotic fluid index above the fifth percentile, and a Bishop score of no more than 5 were included. The primary outcome variable was a change in Bishop score. A Foley catheter with a 30-mL balloon was placed through the cervix on gentle traction in each group. The outpatient group was then discharged home with written instructions and returned in the morning for induction. The inpatient group was admitted to labor and delivery, with induction started upon extrusion of the Foley. RESULTS: Sixty-one women were randomized into the outpatient group, and 50 women into the inpatient group. Maternal age, gravidity, previous cesarean delivery, and gestational age did not differ between the groups. The median Bishop score at entry was 3.0 for each group ( P = .97). The mean change in Bishop scores after catheter placement was not different between the inpatient and outpatient groups (3.0 versus 3.0; P = .74). The maximum dose of oxytocin, time of oxytocin, epidural rate, induction time, 1-minute and 5-minute Apgar scores, and cord pH were not significantly different. The outpatient group on average avoided 9.6 hours of hospitalization. There were no adverse events or maternal morbidity in either group. CONCLUSIONS: The Foley bulb is as effective in the outpatient as the inpatient setting for preinduction cervical ripening.

A randomized comparison of transcervical Foley catheter to intravaginal misoprostol for preinduction cervical ripening

Objective: To compare the efficacy of intravaginal misoprostol tablets with transcervical Foley catheter for preinduction cervical ripening. Methods: Pregnant women who presented for induction of labor with unfavorable cervices (Bishop score less than 6) were assigned randomly to intravaginal misoprostol (50 μg tablet every 4 hours for a maximum of six doses) or 30-mL Foley catheter placed transcervically with maintenance of traction. Results: Among 111 women, 53 were allocated to misoprostol and 58 to Foley bulb. Contractile abnormalities were more frequent in the misoprostol group (20.4%) than the Foley group (0%) ( P < .001). No statistically significant differences were noted between groups in change in Bishop score, preinduction cervical ripening times, and total induction times. There were no statistically significant differences in mode of delivery or adverse neonatal outcomes. Uterine rupture occurred in one woman with two previous cesarean deliveries in the misoprostol group. Conclusion: Intravaginal misoprostol and transcervical Foley catheter are equivalent for cervical ripening. Uterine contractile abnormalities and meconium passage are more common with misoprostol.

Plasma Prostaglandin E2 Metabolite Levels During Labor Induction With a Sustained-Release Prostaglandin E2 Vaginal Insert

To measure prostaglandin E(2) levels during labor induction with a sustained-release vaginal polymer insert (prostaglandin E(2) insert) and to determine whether Bishop score change correlated with tachysystole. Twelve primiparas and 12 multiparas were treated with a 0.3 mg per hour sustained-release polymer vaginal prostaglandin E(2) insert for up to 24 hours. Bishop score was assessed at start and end of therapy, and serum samples were collected at 4-hour intervals. Prostaglandin E(2) metabolite (PGEM) levels were measured by specific enzyme immunoassay. Exposure averaged 13.5 +/- 7.2 hours. Four patients (16.7%, three nulliparas) had tachysystole. Mean PGEM levels increased from 187 +/- 42 pg/mL at baseline to 548 +/- 110 pg/mL at 12 hours (P <.05) and remained relatively stable thereafter. Nulliparas with Bishop score changes of four points or more had the highest increase, with average peak levels of 985 +/- 109 pg/mL, compared with 452 +/- 58 pg/mL for all others (P <.001). Patients with tachysystole had higher 4-hour (P <.01) and overall (P <.04) increases in PGEM level. Removal of the insert led to an average decrease of 335 pg/mL in PGEM levels (P <.01). The decrease correlated with the PGEM level measured before removal (r =.94, P <.0001) and the maximum PGEM increase from baseline (r =.94, P <.0001). The mean mixed venous cord PGEM level was 409 +/- 375 pg/mL. Administration of the prostaglandin E(2) insert led to a sustained increase in circulating PGEM levels in women who had labor induction. Peak PGEM levels correlated with Bishop score improvement. Rapid increases in prostaglandin E(2) levels might cause tachysystole.

Effect of vaginal pH on efficacy of misoprostol for cervical ripening and labor induction

Objective: We sought to evaluate whether vaginal pH has an effect on the relative efficacy of misoprostol for cervical ripening and labor induction. Study Design: Thirty-seven gravid women with an unfavorable cervix and indication for labor induction were enrolled in this prospective, double-blind, observational study. Baseline assessments of cervicovaginal pH and Bishop score were made at the time of enrollment by an independent examiner. All patients received 50 μg misoprostol intravaginally every 6 hours for 12 hours. After the initial 12 hours of preinduction, a repeat Bishop score assessment was made by the same initial examiner. Patients not in active labor at 12 hours were placed on a standardized oxytocin induction regimen. Labor was managed by the on-call obstetric team, who remained blinded to pH assessment. Clinical outcomes were evaluated. Statistical analyses were made by the Student t test, the Fisher exact test, and linear regression analysis. Results: Average initial vaginal pH was 4.8 ± 0.5 (range, 3.5-7.0) for the study cohort. No significant differences were noted between those patients with low vaginal pH (≤4.5) compared with those with high pH vaginal (>4.5) with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change over preinduction interval (5.6 vs 4.9), time to active labor (16.3 vs 17.1 hours), time to complete dilatation (20.0 vs 19.9 hours), and time to delivery (21.0 vs 21.6 hours) were not significantly different between the low and high pH groups, respectively. Linear regression analysis revealed no significant association between vaginal pH and Bishop score change during preinduction interval, time to active labor, time to complete dilatation, or time to delivery. Conclusion: Vaginal pH does not appear to influence the efficacy of intravaginally administered misoprostol for cervical ripening and labor induction. (Am J Obstet Gynecol 2000;182:1616-9.)

Effect of vaginal ph on efficacy of the dinoprostone vaginal insert for cervical ripening/labor induction

Objective: To evaluate whether vaginal pH has an effect on the relative efficacy of the dinoprostone vaginal insert (Cervidil) for cervical ripening/labor induction.Methods: Thirty-four gravidas, with an unfavorable cervix and indication for labor induction, were enrolled in this prospective, double-blinded clinical evaluation. Baseline assessment of cervicovaginal pH and Bishop score were made at the time of enrollment by an independent examiner. All patients received Cervidil, 10 mg, intravaginally for 12 hours. Following the initial 12 hours of preinduction, a repeat Bishop score assessment was made by the same initial examiner. Patients not in active labor at 12 hours were placed on a standardized oxytocin induction regimen. Labor was managed by the on-call obstetric team who remained blinded to pH assessment. Clinical outcomes were evaluated. Statistical analyses were made using Students’ t test and linear regression analysis.Results: Average initial vaginal pH was 4.9 ± 0.5 (range 4.0–6.5) for the study cohort. No significant differences were noted between those patients with low vaginal pH (≤4.5), compared with the high pH group (>4.5), with respect to maternal age, parity, gestational age, or initial Bishop score. Similarly, Bishop score change over preinduction interval (3.2 versus 3.3), time to active labor (28.6 versus 24.6), time to complete dilation (31.2 versus 30.2 hr), and time to delivery (33.7 versus 31.4 hr) were not significantly different between the low and high pH groups, respectively. Linear regression analysis revealed no association between vaginal pH and Bishop score change during preinduction interval, time to complete dilation, or time to delivery (P = NS).Conclusion: Vaginal pH does not seem to affect the efficacy of the dinoprostone vaginal insert (Cervidil) for cervical ripening/labor induction.

Randomized comparison between intravaginal misoprostol and dinoprostone for cervical ripening and induction of labor

Objective: We sought to evaluate the efficacy and safety of intravaginal misoprostol and dinoprostone for labor induction. Study Design: One hundred eighty-nine women with singleton term pregnancies and unfavorable cervices were randomly assigned to receive intravaginal misoprostol or dinoprostone. The outcome variables were change in Bishop score, time from application to active phase of labor and delivery, fetal and maternal morbidity, and the incidence of cesarean deliveries. Results: The interval from application of the initial dose to the beginning of the active phase of labor was 9.8 ± 5.8 and 14.2 ± 10.2 hours ( P < .01), and the interval from initial dose to delivery was 15.3 ± 9.8 and 19.1 ± 13.2 hours ( P = .027) for the misoprostol and dinoprostone groups, respectively. There were no significant differences in Bishop score change, cesarean delivery rate, and the incidence of tachysystole, hypersystole, and hyperstimulation. No maternal and neonatal adverse effects were noted. Conclusion: Intravaginal misoprostol is more effective than intravaginal dinoprostone for labor induction in low-risk patients at term with unfavorable cervices. (Am J Obstet Gynecol 1999;181:626-9.)

A prospective, randomized comparison of Foley catheter insertion versus intracervical prostaglandin E 2 gel for preinduction cervical ripening

Objective: The objective of this study was to compare intracervical prostaglandin E 2 gel with insertion of a Foley bulb for efficacy in preinduction cervical ripening. Study Design: Women who came to the hospital for induction of labor with a Bishop score ≤5 were randomly assigned to treatment with either prostaglandin E 2 gel or a Foley bulb. Prostaglandin E 2 gel was used according to the manufacturer's recommendation. The Foley group had a number 14 Foley catheter inserted, inflated, and placed on traction. Immediately after Foley bulb extrusion or 6 hours after prostaglandin E 2 gel course completion, a dilute oxytocin solution was started if the patient was not in labor. Results: Seventy-seven women were entered into the Foley group and 72 were entered into the prostaglandin E 2 gel group. Both the Bishop score after preinduction ripening (6.5 vs 5.1, P < .001) and the change in Bishop score (3.5 vs 2.7, P = .015) were significantly higher in the Foley group. There were no differences between the groups in mode of delivery, infant weight, rate of hyperstimulation, shoulder dystocia, patient discomfort, epidural use, oxytocin use, or nonreassuring fetal heart rate patterns. The preinduction time (9.9 vs 17.2 hours, P < .001) and the total induction time (22.4 vs 30.4 hours, P < .001) were significantly shorter in the Foley group. Patient charges were 31% lower in the Foley group ( P < .001). Conclusion: Use of the Foley catheter resulted in a higher postinduction Bishop score, a greater change in Bishop score, a shorter induction time, and lower patient charges than did intracervical prostaglandin E 2 gel. (Am J Obstet Gynecol 1999;180:55-9.)

Efficacy and Patient Satisfaction with Outpatient Prostaglandin E2 versus Foley Catheter for Cervical Ripening—A Randomized Trial

Introduction: an important factor in the success of labour induction is the presence of a ripe cervix. The safety and efficacy of outpatient prostaglandin E2 (PGE2) administered intracervically compared to extra-amniotic cervical Foley catheter placement to ripen the cervix were studied. Patient satisfaction and overall cost with both methods were reported for the first time.Methods: pregnant women with uncomplicated term pregnancies having an indication for induction of labour were enrolled. Singleton pregnancies with intact membranes and cervical Bishop scores < 5 were randomized blindly to receive .5 mg intracervical PGE2 (n=67) every six to eight hours or intracervical Foley catheter (extra-amniotic) (n=62) insertion overnight. Cervical assessments were carried out prior to treatment and again before induction of labour. Patients filled out a post-treatment Likert questionnaire.Results: overall change in Bishop score did not differ between the two groups. The Foley treatment group were more likely to have Mated to three to four cm (χ2=5.48 DF=1 p=.02). Intrapartum variables, mode of delivery and post-partum complications were similar. For patients completing the questionnaire, pain experienced during insertion was similar, however, fewer patients would recommend the Foley catheter treatment to a pregnant friend (F[1,64]=5.53 p=.02). The price of the Foley catheter is much less than the PGE2.Conclusion: both methods lead to similar changes in overall Bishop score although the intracervical Foley catheter was more likely to lead to cervical dilatation of three centimetres or more—a dilatation which facilitates amniotomy. There were no differences in the mode of delivery, maternal or neonatal outcomes. Patients reported the same amount of pain with both treatments but patients seem to prefer the more expensive PGE2.

A randomized clinical trial of prostaglandin E 2 intracervical gel and a slow release vaginal pessary for preinduction cervical ripening

OBJECTIVE: Our purpose was to compare the efficacy of 2 different prostaglandin E 2 delivery methods for preinduction cervical ripening. STUDY DESIGN: Ninety patients admitted for labor induction with a Bishop score <8 were randomized to either 0.5 mg prostaglandin E 2 intracervical gel (Prepidil) every 6 hours for 2 doses or 10 mg prostaglandin E 2 slow release vaginal pessary (Cervidil). Oxytocin induction was begun after 12 hours. It was estimated that enrollment of 90 women would be required to identify a 30% difference in the percent delivered in < 24 hours (1 – β = .80, α = .05). Data were analyzed with use of χ 2 analysis or the Student t test. RESULTS: There were 45 subjects in each treatment arm. The percent delivered by 24 hours was 53% with intracervical gel and 63% with vaginal pessary ( P = .28). Mean change in Bishop score was 1.8 ± 1.9 for the intracervical gel versus 3.2 ± 3.1 for the vaginal pessary ( P = .01). No difference was demonstrated in mean time to delivery, 28.3 versus 24.0 hours ( P = .19) or percent requiring cesarean section. CONCLUSION: Preinduction cervical ripening with a slow release prostaglandin E 2 vaginal pessary resulted in greater change in Bishop score than with intracervical prostaglandin E 2. There was a trend toward shorter time to delivery with the pessary. There was no statistically significant difference in percent delivered in <24 hours. (Am J Obstet Gynecol 1998;179:349-53.)