Outpatient labour induction

Logistics for achieving delivery: A secondary analysis of the home induction randomised controlled trial

OBJECTIVE

This secondary analysis evaluates the logistics of achieving vaginal delivery following outpatient induction. This includes changes in Bishop score before and after cervical ripening, the need for additional ripening agents, time interval from induction to delivery, all of which provide invaluable information when developing an outpatient induction of labour service.

STUDY DESIGN

We randomised healthy nulliparous women with no significant medical history, who agreed to elective induction of labour at 39 weeks' gestation, to one of three forms of initial cervical ripening at home: 12 h of Dilapan-S, 24 h of Dilapan-S, or 24 h of slow-release dinoprostone (Propess). Patients returned to the hospital after 12 or 24 h for either amniotomy or, if the cervix remained unripe, additional doses of Prostin. We present our experience with the development of a regulated protocol for outpatient induction of labour, as well as safety considerations, in order to assist those wishing to adopt such practice. Effectiveness of each induction agent, time to delivery, and length of hospital stay were assessed as part of this secondary analysis.

RESULTS

A total of 180/271 (66%) of all nulliparous women were delivered within 48 h of induction commencing, and 254/271 (94%) delivered within 72 h, inclusive of the time period spent at home. Participants in the Propess group were more likely to require early readmission than in the Dilapan-S groups (45% vs 9%). Patients randomised to Dilapan-S 12 h and Dilapan-S 24 h were more likely to require additional Prostin prior to amniotomy being possible (65% vs 34%). Those who did not require additional ripening had very high vaginal delivery rates ranging from 80% to 88%. Induction agent removal time to delivery was similar across all groups. The length of hospital stay ranged from a median of 76 to 88 h from readmission to discharge.

CONCLUSION

Outpatient cervical ripening is an efficient and useful option for dealing with the logistical challenges facing busy Labour Wards, with the majority of nulliparous patients delivering within 48 h, including time spent at home. This resource-friendly option requires less time within the hospital setting for a carefully selected cohort.

Outpatient cervical ripening and labor induction with low-dose vaginal misoprostol reduces the interval to delivery: a systematic review and network meta-analysis

OBJECTIVE

Several systematic reviews and meta-analyses have summarized the evidence on the efficacy and safety of various outpatient cervical ripening methods. However, the method with the highest efficacy and safety profile has not been determined conclusively. We performed a systematic review and network meta-analysis of published randomized controlled trials to assess the efficacy and safety of cervical ripening methods currently employed in the outpatient setting.

DATA SOURCES

With the assistance of an experienced medical librarian, we performed a systematic search of the literature using MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. We systematically searched electronic databases from inception to January 14, 2020.

STUDY ELIGIBILITY CRITERIA

We considered randomized controlled trials comparing a variety of methods for outpatient cervical ripening.

METHODS

We conducted a frequentist random effects network meta-analysis employing data from randomized controlled trials. We performed a direct, pairwise meta-analysis to compare the efficacy of various outpatient cervical ripening methods, including placebo. We employed ranking strategies to determine the most efficacious method using the surface under the cumulative ranking curve; a higher surface under the cumulative ranking curve value implied a more efficacious method. We assessed the following outcomes: time from intervention to delivery, cesarean delivery rates, changes in the Bishop score, need for additional ripening methods, incidence of Apgar scores <7 at 5 minutes, and uterine hyperstimulation.

RESULTS

We included data from 42 randomized controlled trials including 6093 participants. When assessing the efficacy of all methods, 25 μg vaginal misoprostol was the most efficacious in reducing the time from intervention to delivery (surface under the cumulative ranking curve of 1.0) without increasing the odds of cesarean delivery, the need for additional ripening methods, the incidence of a low Apgar score, or uterine hyperstimulation. Acupressure (surface under the cumulative ranking curve of 0.3) and primrose oil (surface under the cumulative ranking curve of 0.2) were the least effective methods in reducing the time to delivery interval. Among effective methods, 50 mg oral mifepristone was associated with the lowest odds of cesarean delivery (surface under the cumulative ranking curve of 0.9).

CONCLUSION

When balancing efficacy and safety, vaginal misoprostol 25 μg represents the best method for outpatient cervical ripening.