Outpatient Induction Of Labour Research Articles

Embodiment and the technologies of induction of labour

ObjectiveTo critically engage with the body project of induction of labour. DesignA nested, qualitative study that formed part of a feasibility Random Controlled Trial investigating different methods of outpatient induction of labour. The data reported in this article were gathered via interview with women and midwives involved in the trial. All the participants who took part in the trial presented as cisgender women. FindingsAnalysis of 27 interview transcripts suggested that the expansion in choice of when, how and where to start labour can change the way decisions about labour onset is understood. The space needed for a new body project is emerging where distinctions between medicalised labour and spontaneous labour are less clear. ConclusionThe embodiment of the new technologies of induction for those involved in this study was both a facet of increased freedom and autonomy and a gendered discourse where the normative function of routine intervention appeared more complete.

A randomised open-label trial to assess outpatient induction of labour (HOMEIND) and compare efficacy of Propess vs Dilapan-S® for induction of labour at 39 weeks’ gestation in normal risk nulliparous women: study protocol for a randomised controlled trial

BackgroundInduction of labour (IOL) at 39 weeks has been shown to decrease maternal and neonatal adverse outcomes. Given the growing demand for 39-week IOL, it is imperative that effective methods be assessed for induction in the outpatient setting.The aim of this study is to answer the clinical question as to whether Dilapan-S® vs Propess® as a method of cervical ripening is non-inferior in the outpatient setting at 39 weeks and to ascertain whether Dilapan-S® 12 h is non-inferior to Dilapan-S® 24 h.MethodsThis study is an open-label parallel group single-centre randomised trial.Participants are normal risk nulliparous women who have no pregnancy-related or medical contraindication to IOL. Women will be randomised to one of three induction groups—Dilapan-S® (12-h insertion or 24-h insertion) or Propess. Induction will be initiated between 39+0 and 39+4 weeks’ gestation and participants will return home for either 12 or 24 h. They will be readmitted 12/24 h later in order to continue with induction of labour.Patient recruitment will take place over 30 months within a single centre. The study will recruit a maximum 109 women for each study arm. Total duration of participants’ involvement in the trial will be 8 weeks to allow for postpartum follow-up.DiscussionThis study will definitively answer whether Dilapan-S is non-inferior to Propess® as a method of induction of labour in the outpatient setting and whether cervical ripening with Dilapan-S over a 12-h timeframe is non-inferior to cervical ripening with Dilapan-S over a 24-h timeframe.Trial registrationEudraCT Number 2019-004697-25 Registered 14 September 2020

Using the WHO-INTEGRATE evidence-to-decision framework to develop recommendations for induction of labour

BackgroundIn 2019, WHO prioritized updating recommendations relating to three labour induction topics: labour induction at or beyond term, mechanical methods for labour induction, and outpatient labour induction. As part of this process, we aimed to review the evidence addressing factors beyond clinical effectiveness (values, human rights and sociocultural acceptability, health equity, and economic and feasibility considerations) to inform WHO Guideline Development Group decision-making using the WHO-INTEGRATE evidence-to-decision framework, and to reflect on how methods for identifying, synthesizing and integrating this evidence could be improved.MethodsWe adapted the framework to consider the key criteria and sub-criteria relevant to our intervention. We searched for qualitative and other evidence across a variety of sources and mapped the eligible evidence to country income setting and perspective. Eligibility assessment and quality appraisal of qualitative evidence syntheses was undertaken using a two-step process informed by the ENTREQ statement. We adopted an iterative approach to interpret the evidence and provided both summary and detailed findings to the decision-makers. We also undertook a review to reflect on opportunities to improve the process of applying the framework and identifying the evidence.ResultsUsing the WHO-INTEGRATE framework allowed us to explore health rights and equity in a systematic and transparent way. We identified a lack of qualitative and other evidence from low- and middle-income settings and in populations that are most impacted by structural inequities or traditionally excluded from research. Our process review highlighted opportunities for future improvement, including adopting more systematic evidence mapping methods and working with social science researchers to strengthen theoretical understanding, methods and interpretation of the evidence.ConclusionsUsing the WHO-INTEGRATE evidence-to-decision framework to inform decision-making in a global guideline for induction of labour, we identified both challenges and opportunities relating to the lack of evidence in populations and settings of need and interest; the theoretical approach informing the development and application of WHO-INTEGRATE; and interpretation of the evidence. We hope these insights will be useful for primary researchers as well as the evidence synthesis and health decision-making communities, and ultimately contribute to a reduction in health inequities.

Outpatient labour induction.

The inexorable rise in induction rates over the past two decades, in parallel with increasing medical costs and pressure to reduce length of stay, has led to marked logistic difficulties for health care workers, managers and planners. Maternity services are being overwhelmed by the need to allocate staff and delivery suite space for the scheduling and undertaking of induction processes, rather than focussing care for women in spontaneous labour. Induction of labour according to the majority of current protocols and guidelines necessitates increased length of stay and relatively aggressive use of oxytocin (to reduce the time expended in the labour ward from artificial rupture of membranes (AROM) to establishment of labour). This increased oxytocin usage requires increased use of continuous electronic foetal monitoring, and may also increase epidural usage, further increasing the complexity of labour for the woman and her health care workers. Outpatient care after cervical priming and even outpatient care after AROM may help to ease these pressures and may reduce the medicalisation of the birth experience when induction is indicated, with a potential to reduce oxytocin use and associated interventions. If the period between cervical priming to AROM is managed as outpatient care, then the woman may be able to find better psychological and social support at home, as well as maintain autonomy and get better rest prior to the onset of labour. Inpatient AROM could also be followed by outpatient care until the pregnant person returns to the hospital, either in spontaneous labour, or for initiation of syntocinon after 12-18h. High-quality research has already demonstrated that outpatient care for cervical ripening is acceptable to mothers and caregivers, has economic benefits and has an acceptable safety profile in appropriately selected low-risk inductions.

Prostaglandin insert dinoprostone versus trans-cervical balloon catheter for outpatient labour induction: a randomised controlled trial of feasibility (PROBIT-F)

BackgroundThe aim was to assess the feasibility of conducting a randomised controlled trial (RCT) of induction of labour comparing use of two methods in the outpatient setting.MethodsAn open-label feasibility RCT was conducted in two UK maternity units from October 2017 to March 2019. Women aged ≥ 16 years, undergoing induction of labour (IOL) at term, with intact membranes and deemed suitable for outpatient IOL according to local guidelines were considered eligible. They were randomised to cervical ripening balloon catheter (CRB) or vaginal dinoprostone (Propess). The participants completed a questionnaire and a sub-group underwent detailed interview. Service use and cost data were collected via the Adult Service Use Schedule (AD-SUS). Women who declined to participate were requested to complete a decliners’ questionnaire.ResultsDuring the study period, 274 eligible women were identified. Two hundred thirty (83.9%) were approached for participation of whom 84/230 (36.5%) agreed and 146 did not. Of these, 38 were randomised to Propess (n = 20) and CRB (n = 18). Decliner data were collected for 93 women. The reasons for declining were declining IOL (n = 22), preference for inpatient IOL (n = 22) and preference for a specific method, Propess (n = 19). The intended sample size of 120 was not reached due to restrictive criteria for suitability for outpatient IOL, participant preference for Propess and shortage of research staff.The intervention as randomised was received by 29/38 (76%) women. Spontaneous vaginal delivery was observed in 9/20 (45%) women in the dinoprostone group and 11/18 (61%) women in the CRB group. Severe maternal adverse events were recorded in one woman in each group. All babies were born with good condition and all except one (37/38, 97.4%) remained with the mother after delivery. No deaths were recorded. − 21% of women in the dinoprostone group were re-admitted prior to diagnosis of active labour compared to 12% in the CRB group.ConclusionsA third of the approached eligible women agreed for randomisation. An RCT is not feasible in the current service context. Modifications to the eligibility criteria for outpatient IOL, better information provision and round the clock availability of research staff would be needed to reach sufficient numbers.Trial registrationNCT03199820. Registered on June 27, 2017

Women’s experiences of outpatient induction of labour with double balloon catheter or prostaglandin pessary: A qualitative study

BackgroundOne quarter to one third of women experience induction of labour. Outpatient induction of labour may be safe and effective but women’s views of this setting and of different methods of induction are sparse. AimTo explore women’s experiences of outpatient induction of labour with either prostaglandin pessary or double balloon catheter. MethodsQualitative study using semi-structured, audio-recorded interviews with twenty-one women recruited to a feasibility trial of outpatient induction of labour. Transcripts were coded and analysed using a thematic framework approach. FindingsTwo key themes were identified. ‘Ownership of induction of labour’ concerned how women understood and experienced the induction of labour process and tried to maintain control of a procedure managed by medical professionals. Women felt unprepared for the steps in the process and for the time it would take. The balloon method was preferred as it was considered a gentler start to the process, although some women reported it was painful on insertion. ‘Importance of place’ reflected women’s associations of the home with comfort, ease of support and distraction, and the hospital with safety yet also with discomfort and delays. DiscussionThis sample of women were keen to start induction without hormones. The randomised controlled trial design may have biased the sample towards women who wanted to experience the balloon method and outpatient setting where these were not usually offered, thus further cohort studies would be beneficial. ConclusionsWomen were positive about experiencing the early stages of induction of labour at home with the balloon catheter.

Inpatient versus outpatient induction of labour: a systematic review and meta-analysis

BackgroundAs the number of indications for labour induction continue to increase, the focus has shifted to performing these procedures in an outpatient setting. This study aims to systematically review published data from randomized controlled trials that compare outpatient with inpatient labour induction, to ascertain the role of outpatient labour induction for low-risk pregnancies.MethodsWe conducted a systematic review wherein we searched MEDLINE, EMBASE, Biosis Previews®, and International Pharmaceutical s from inception to January 2020 to identify randomized controlled trials that reported on maternal, fetal and resource-related outcomes following outpatient versus inpatient labour induction. Pooled incidences and mean differences were calculated using random-effects meta-analysis. Risk-of-bias was assessed using the Cochrane Risk of Bias tool. Subgroup analysis was conducted based on the method of induction.ResultsOf the 588 records identified, 12 publications, representing nine independent randomized controlled trials conducted in Australia, Europe and North America, were included. These reported on 2615 cases of labour induction (1320 outpatients versus 1295 inpatients). Overall, apart from a higher number of suspicious fetal heart rate tracings [RR = 1.43 (1.10, 1.86)] and a shorter mean length of hospital stay [MD = 282.48 min (160.23, 404.73) shorter] in the outpatient group, there were no differences in delivery method, adverse outcomes or resource-use between the two arms. On subgroup analysis, when comparing the use of balloon catheters in both arms, those induced as outpatients had fewer caesarean deliveries [RR = 0.52 (0.30, 0.90)], a shorter admission-to-delivery interval [MD = 370.86 min (19.19, 722.54) shorter], and a shorter induction to delivery interval [MD = 330.42 min (120.13, 540.71) shorter].ConclusionOutpatient labour induction in resource-rich settings is at least as effective and safe, in carefully selected patient populations, when compared with inpatient labour induction. Whether outpatient labour induction results in lower rates of caesarean deliveries needs to be explored further.Trial registrationThis systematic review was prospectively registered in Prospero (CRD42019118049).

Women's experiences of outpatient induction of labour

Background Outpatient induction of labour is offered to relieve the pressure on inpatient stay and to improve women's experiences. Aim To contribute to the knowledge of outpatient induction of labour with the focus on women's experiences to inform practice. The question was: ‘What are women's experiences of outpatient induction of labour?’ Method A comprehensive literature review using a pluralistic approach and thematic analysis. Findings The review found three themes: the home as a positive setting for outpatient induction of labour, the value of outpatient induction of labour in promoting normality and the importance of receiving reassurance during outpatient induction of labour. Conclusion Although the results were mostly positive and in favour of outpatient induction of labour, there were variations in service provision. There was a lack of understanding as to how best to offer reassurance to women once discharged home, which was found to have a direct effect on their experiences.

A prospective pilot study of Dilapan-S compared with Propess for induction of labour at 41+ weeks in nulliparous pregnancy.

The incidence of labour induction has risen worldwide over the past decade, and this may contribute to the rising caesarean delivery rate. The mechanisms for induction of labour are generally divided into two categories: mechanical and pharmacological. The objective of this study was to determine if mechanical induction with Dilapan-S is an acceptable, safe method of induction of labour in post-dates uncomplicated nulliparous pregnancy. This was a single-centre prospective observational pilot study trial. Fifty-two low-risk nulliparous women with an unfavourable cervix, scheduled for induction of labour for post-dates ≥ 41weeks gestation, were offered induction of labour with Dilapan-S or Propess from May 2016 until November 2016. The primary outcomes measured were compliance to study protocol and maternal (infection, hyperstimulation) and neonatal outcomes (Apgar score at birth). The secondary outcome measures included change in Bishop's score and caesarean delivery rate. Compliance to study protocol was 25/26 (96%); it was possible to insert Dilapan-S in all but one woman. There were no differences in maternal and neonatal primary outcomes between the groups. There were no cases in either arm of hyperstimulation with either induction method. No difference between the groups was noted in the caesarean delivery rate nor in the mean change in Bishop's score. Dilapan-S is an acceptable, safe form of induction of labour in post-dates uncomplicated nulliparous pregnancy. No cases of hyperstimulation were found, and therefore, Dilapan-S may be a suitable option for outpatient induction of labour in low-risk post-dates nulliparas.

Outpatient induction of labour with prostaglandins: Safety, effectiveness and women's views

Background Nearly 28% of women underwent induction of labour in England in 2015-16. Women frequently report delays and poor experiences, and the process can put additional pressure on busy labour wards. Outpatient induction of labour (OPIOL) enables women to return home to await the onset of contractions. Aim To explore the research about OPIOL using prostaglandins and to identify gaps in the evidence base. Outcomes will be compared with those induced as inpatients. Method An electronic search was conducted to identify relevant studies using keywords. Once the studies had been identified, a narrative synthesis of the findings was conducted. Findings Adverse outcomes were rare but studies were not sufficiently powered to detect significant differences between outpatients and inpatients. There were some differences in cost and effectiveness that may be explained by disparities in study design, participant characteristics and operational issues. Time avoided in hospital by outpatients ranged from 7.5–11.76 hours. Satisfaction was generally higher with OPIOL, although some women expressed apprehension about being at home. Conclusion While OPIOL with prostaglandins is acceptable to women, it is not clear whether there are significant differences in safety and effectiveness outcomes, due to the low frequency of adverse perinatal events as well as methodological and quality issues of the included studies. Further research is needed to compare outcomes, maternal experiences and cost effectiveness of OPIOL.

Outpatient cervical ripening in a district general hospital: a five-year retrospective cohort study

The number of women undergoing induction of labour has risen steadily in recent years. Outpatient induction is becoming more common in the UK in response to the required increase in resources, although evidence supporting its safety is lacking. We reviewed the notes of low-risk women presenting for outpatient cervical ripening using prostaglandins over a five-year period, and compared our neonatal and maternal outcomes to local and national data. Of the 502 eligible women, 400 underwent outpatient treatment. Most women returned early, in labour. There were no foetal, neonatal or maternal deaths, and our neonatal morbidity compared favourably with local rates. Mode of delivery and major maternal complication rates were comparable to national maternity indicators. We conclude that outpatient cervical ripening following careful case selection does not appear to increase neonatal or maternal mortality or morbidity. It offers patients an alternative to traditional inpatient induction and may improve allocation of hospital resources.Impact statementWe present a retrospective cohort study of neonatal and maternal outcomes in 502 women selected for outpatient cervical ripening for postmaturity at Bedford Hospital over the five-year period from 2010 to 2015.This study was conceived following a previous publication in this journal from Bedford Hospital in 2002 by Neale et al., which described the outcomes of 100 women who underwent outpatient cervical ripening. Our conclusions compare the results from the two studies.Out of our combined sample of 602 women, 491 were discharged home following administration of prostaglandins. This represents the largest sample size in the published literature on outpatient induction of labour, which was first undertaken in our unit in 1998 and is now widely practiced within the UK.Several publications, including the 2013 Cochrane review by Kelly et al. and a recent large survey of practice (Sharp et al. 2016) have highlighted the paucity of available data regarding the safety of this procedure as an outpatient. We therefore hope that the results of our study will be of interest to many maternity units who currently undertake or are considering to provide the facility for outpatient cervical ripening as a prelude to induction of labour.

Observational Study of Neonatal Safety for Outpatient Labour Induction Priming with Dinoprostone Vaginal Insert.

To evaluate the safety of outpatient induction with dinoprostone insert in low-risk labour inductions for premature rupture of membranes or postdates gestation. This retrospective cohort study compared outpatient labour induction priming with inpatient induction in terms of neonatal safety, mode of delivery, and obstetrical parameters. The sample included all inductions for premature rupture of membranes or postdate gestation. The analysis used logistic regression. The statistical power of the sample was 80% to detect a difference of 5.6% for the composite neonatal safety outcome (5-minute Apgar score <7 and NICU admission for >12 hours or transfer to a level III nursery). Compared with the inpatient cohort (n= 568), the outpatient cohort (n= 611) included more postdate gestations (93% vs. 67%) with less cervical dilatation (0.5 cm vs. 1.0 cm) and larger infants (3705 g vs. 3551 g). There were no differences in measures of neonatal safety or mode of delivery. The outpatient cohort required more dinoprostone inserts (1.59 vs. 1.23) and were less likely to deliver within 24 hours (OR 0.24, 95% CI 0.17 to 0.34) but were also less likely to deliver by CS (OR 0.71, 95% CI 0.54 to 0.95), after adjusting for obstetrical parameters. An outpatient model of labour induction using dinoprostone inserts is feasible and safe.

Development of a home induction of labour framework

Background Nationally, it is recommended that women should be offered post-dates induction of labour (IOL) at 40 weeks + 10–12 days. There is evidence that an outpatient IOL service may be associated with improved maternal satisfaction. Aims A home IOL service was developed to offer women choice about where labour onset can be awaited. Methods In an attempt to fully understand key factors and improve the local IOL service, a baseline audit of care and outcomes for low-risk post-dates women was undertaken (hospital group). A home IOL service was then set up (home group) for women to await labour onset in the comfort of their own home. Once this option was available, a second audit aimed to highlight any advantages or disadvantages with the new service so as to inform future improvement. Findings Audit findings highlighted that the majority of women remained at home for between 6–14 hours and all returned to the hospital safely. Conclusions Findings from the audits undertaken before, during and after the home IOL service was implemented, highlight useful benefits for women. It is recommended that other Trusts considering implementing the same improvement carefully monitor their findings.

Outpatient induction of labour in the UK: a survey of practice

ObjectiveTo identify the current UK use of outpatient procedures for cervical ripening prior to induction of labour. Study designPostal survey of consultant led obstetric units within the United Kingdom.A questionnaire was sent by post to 210 NHS consultant led obstetric units within the UK. Units that provided outpatient induction of labour (OP IOL) were asked complete a series of questions defining their protocol for risk stratification and management. ResultsThe survey had a 78% response rate. 17.6% of units stated that they currently or soon will provide OP IOL. All units were willing to provide OP IOL for post-dates singleton pregnancies and none provided this service for women with a previous caesarean or multiple pregnancy. 96% of inductions were initiated in a hospital setting prior to discharge home. 84% of units used Propess® to initiate OP IOL and 96% had a fetal assessment with CTG. Only 40% of units had a clear mechanism for assessment once the woman had gone home. 72% of units performed regular audit of their practice. ConclusionsWe suggest that robust comparative research within a UK context is urgently required to establish the safety and cost effectiveness of outpatient induction of labour before this technique becomes fully embedded in clinical care without an adequate evidence base.

Outpatient Approaches to Elective Induction of Labor

Assessing the feasibility, acceptability and safety of outpatient labour induction. MEDLINE database was searched for "outpatient labor induction" from January 1, 1986 to February 28, 2013. Main outcomes of interest included hyperstimulation, cesarean births, Apgar scores <7 at 5 minutes, arterial-cord pH of <7.10, and neonatal morbidity/mortality. Overall cesarean rates vary significantly (2.6% to 42%). Hyperstimulation with CTG changes is rare. Neonatal admissions for diverse reasons are often not associated with outpatient induction agent. Overall, maternal satisfaction is high. Outpatient labor induction is feasible and important adverse events are rare. However, paucity of available data and heterogeneity of different studies make it difficult to quantify adverse events or identify a preferred induction method.

PLD.21 Impact of Induction of labour on labour ward and finding alternative ways to improve women satisfaction

IntroductionNational UK average of Induction of labour (IOL) is 22.1%. It has huge impacts on labour ward and staffing. Most common pharmacological method used is vaginal PGE2 tablet (Prostin), which...

Outpatient Foley catheter versus inpatient prostaglandin E2 gel for induction of labour: a randomised trial

BackgroundInduction of labour (IOL) is one of the commonest obstetric interventions, with significant impact on both the individual woman and health service delivery. Outpatient IOL is an attractive option to reduce these impacts. To date there is little data comparing outpatient and inpatient IOL methods, and potential safety concerns (hyperstimulation) if prostaglandins, the standard inpatient IOL medications, are used in the outpatient setting. The purpose of this study was to assess feasibility, clinical effectiveness and patient acceptability of outpatient Foley catheter (OPC) vs. inpatient vaginal PGE2 (IP) for induction of labour (IOL) at term.MethodsWomen with an unfavourable cervix requiring IOL at term (N = 101) were randomised to outpatient care using Foley catheter (OPC, n = 50) or inpatient care using vaginal PGE2 (IP, n = 51). OPC group had Foley catheter inserted and were discharged overnight following a reassuring cardiotocograph. IP group received 2 mg/1 mg vaginal PGE2 if nulliparous or 1 mg/1 mg if multiparous. Main outcome measures were inpatient stay (prior to birth, in Birthing Unit, total), mode of birth, induction to delivery interval, adverse reactions and patient satisfaction.ResultsOPC group had shorter hospital stay prior to birth (21.3 vs. 32.4 hrs, p < .001), IP were more likely to achieve vaginal birth within 12 hours of presenting to Birthing Unit (53% vs. 28%, p = .01). Vaginal birth rates (66% OPC Vs. 71% IP), total induction to delivery time (33.5 hrs vs. 31.3 hrs) and total inpatient times (96 hrs OPC Vs. 105 hrs IP) were similar. OPC group felt less pain (significant discomfort 26% Vs 58%, p = .003), and had more sleep (5.8 Vs 3.4 hours, p < .001), during cervical preparation, but were more likely to require oxytocin IOL (88 Vs 59%, p = .001).ConclusionsOPC was feasible and acceptable for IOL of women with an unfavourable cervix at term compared to IP, however did not show a statistically significant reduction in total inpatient stay and was associated with increased oxytocin IOL.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN:12609000420246.

Women's experiences of outpatient induction of labour with remote continuous monitoring

Objectiveto gain insight into women's experiences and preferences for induction in the home as part of a trial investigating the feasibility and acceptability of outpatient induction of labour with remote monitoring. Designa qualitative study using semi-structured individual interviews. Interview transcripts were subjected to thematic analysis to identify the dominant themes regarding women's experiences of outpatient induction. Settinga large maternity hospital in the North West of England. Participantsfifteen women who participated in the main trial of outpatient induction of labour with remote continuous monitoring. Findingsthree main themes were identified; the need for women to ‘labour within their comfort zone’; their desire to achieve ‘the next best thing to a normal labour’ and the importance of a ‘virtual presence’ to offer remote reassurance. Conclusionswomen's preference for the outpatient setting of induction of labour is dominated by their need to labour within their comfort zone. Outpatient induction offered women the familiarity and freedom of the home environment, and the resulting physical and emotional comforts helped women cope better with their labour and improved their birth experiences. While remote monitoring offered some reassurance, women still depended on effective communication from hospital staff to provide the virtual presence of a health professional in the home. Implicationsthe combination of slow-release prostaglandin and a remote monitoring device may provide low risk women with an improved induction and labour experience. While ongoing studies continue to explore further the safety of interventions at home, this study has importantly considered women's views and confirmed that induction at home is not only acceptable to women but also that the outpatient experience is preferable to long inpatient inductions.

Induction of labour (IOL): women's satisfaction in the inpatient and outpatient settings

Ensuring a positive childbirth experience is a central feature of running a modern maternity service. Support, information and expectation all contribute to perception of care. Our aim was to compare...

Comparison of inpatient and outpatient induction of labour for postmaturity using vaginal controlled release prostaglandin-E2

IntroductionInduction of labour (IOL) for postmaturity is recommended between 41+0 and 42+0 weeks. Controlled release prostaglandin-E2 has been used for IOL in an outpatient setting and has been shown to...