Induction of labour with an unfavourable cervix

Efficacy and safety of misoprostol compared with dinoprostone for labor induction at term: an updated systematic review and meta-analysis of randomized controlled trials

Background

Labor induction is a common obstetric intervention, increasingly performed worldwide, often using prostaglandins like misoprostol and dinoprostone.

Objective

This study aims to compare the effectiveness and safety of intravaginal misoprostol versus dinoprostone for inducing labor, examining their impact on various maternal and neonatal outcomes.

Methods

A systematic review and meta-analysis were conducted using four databases-PubMed, Google Scholar, EBSCO, and the Cochrane Library-from January 2000 to April 2023. We included randomized controlled trials (RCTs) involving singleton pregnancies at term (37-42 weeks) with unfavorable cervices, where intravaginal misoprostol was compared to dinoprostone. Key outcomes evaluated for effectiveness included vaginal delivery within 24 h, overall vaginal delivery rate, and need for oxytocin augmentation. Safety outcomes assessed were tachysystole, uterine hyperstimulation, abnormal cardiotocography, NICU admissions, cesarean delivery, and APGAR scores. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model in Review Manager (RevMan) version 5.4.1.

Results

Eight RCTs with a total of 1,801 participants (937 in the misoprostol group and 864 in the dinoprostone group) met the inclusion criteria. Misoprostol required a significantly less oxytocin augmentation than dinoprostone [RR = 0.83; 95% CI (0.71, 0.97), p = 0.02]. Other outcomes, including rates of cesarean delivery, uterine tachysystole, hyperstimulation, and NICU admissions, showed no significant differences between the two groups, indicating comparable safety and efficacy profiles.

Conclusion

This meta-analysis demonstrates that intravaginal misoprostol is an effective and safe alternative to dinoprostone for labor induction at term. Misoprostol achieved comparable efficacy and safety outcomes while requiring less oxytocin augmentation, supporting its potential as a practical induction agent in clinical settings.

Clinical experience with misoprostol vaginal insert for induction of labor: a prospective clinical observational study

Purpose

To provide real-world evidence using misoprostol vaginal insert (MVI) for induction of labor in nulliparous and parous women at two German Level I Centers in a prospective observational study.

Methods

Between 1 August 2014 and 1 October 2015, eligible pregnant women (≥ 36 + 0 weeks of gestation) requiring labor induction were treated with MVI. Endpoints included time to and mode of delivery rates of tocolysis use, tachysystole, uterine hypertonus or uterine hyperstimulation syndrome and newborn outcomes.

Results

Of the 354 women enrolled, 68.9% (244/354) achieved vaginal delivery (nulliparous, 139/232 [59.9%]; parous 105/122 [86.1%]; p < 0.001). Median time from MVI administration to vaginal delivery was 14.0 h (nulliparous, 14.5 h; parous, 11.9 h; p < 0.001). A total of 205/244 (84.0%) and 228/244 (93.4%) women achieved a vaginal delivery within 24 h and 30 h, respectively. The most common indications for cesarean delivery were pathologic cardiotocography (nulliparous, 41/232 [17.4%]; parous, 13/122 [10.7%]; p = 0.081) and arrested labor (dilation or descent; nulliparous, 45/232 [19.4%], parous, 3/122 [2.5%]; p ≤ 0.001). A total of 24.3% of women experienced uterine tachysystole and 9.6% experienced uterine tachysystole with fetal heart rate involvement, neither of which were significantly different for nulliparous and parous women. In total, 42/345 (12.2%) of the neonates had an arterial pH < 7.15 and 12/345 3.5% had a 5-min Apgar score ≤ 7.

Conclusion

When clinically indicated, MVI was efficient and safe for induction of labor in women with an unfavorable cervix. Women, however, should be counseled regarding the risk of uterine tachysystole prior to labor induction with MVI.

Comparison of single- and double-balloon catheters for labor induction: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

There is a paucity of head-to-head randomized trials that compare single- and double-balloon catheters, and the results of the available data in terms of time from catheter insertion to delivery and delivery mode are mixed. This meta-analysis of randomized controlled trials compares the efficacy of single- and double-balloon catheters in women undergoing labor induction.

STUDY DESIGN

Searches were made in MEDLINE, EMBASE, PubMed, ClinicalTrials.gov, and the Cochrane Library from inception through June 2016. Peer-reviewed randomized and quasi-randomized trials that compared single- and double-balloon catheters head-to-head for cervical ripening or labor induction were identified. Eligible study populations consisted of women with singleton pregnancies that had any indication for labor induction and were randomly assigned to undergo induction with a single- or a double-balloon catheter. The primary outcome was time from catheter insertion to delivery and delivery mode. The secondary outcomes were intrapartum fever or chorioamnionitis, woman's satisfaction, and neonatal Apgar score.

RESULTS

Of the 520 records identified, five randomized trials (996 women; 491 with single-balloon and 505 with double-balloon catheters) were considered eligible and included in the meta-analysis. Time from catheter insertion to delivery did not differ between the two types of catheter (p = 0.527; WMD -0.87; 95% CI: -3.55, 1.82). The incidence of cesarean delivery also did not differ (p = 0.844; RR 0.97; 95% CI: 0.69, 1.35). Delivery within 24 h, delivery mode, incidences of intrapartum fever or chorioamnionitis, and neonatal Apgar score <7 at 5 min did not differ between the two types of catheter as well. Women who were induced with the single-balloon catheter were more satisfied (p = 0.029; WMD 0.56; 95% CI: 0.06, 1.06).

CONCLUSION

Time from catheter insertion to delivery and delivery mode were comparable between the two types of catheter.

Worth the Wait? The Effect of Early Term Birth on Maternal and Infant Health

Early term birth is defined as birth at 37 or 38 weeks gestation. While infants born early term are not considered premature, the medical literature suggests that they have an increased risk of serious adverse health outcomes compared to infants born at term (39 or 40 weeks). Despite these known harms, we document a rise in early term births in the United States from 1989 to the mid-2000s, followed by a decline in recent years. We posit that the recent decline in early term births has been driven by changes in medical practice advocated by the American College of Obstetricians and Gynecologists, programs such as the March of Dimes’ "Worth the Wait" campaign, and by Medicaid policy. We first show that this pattern cannot be attributed to changes in the demographic composition of mothers, and provide some evidence that efforts to reduce early term elective deliveries (EEDs) through Medicaid policy were effective. We next exploit county-level variation in the timing of these changes in medical practice to examine the effect of early term inductions (our proxy for EEDs) on infant and maternal health. We find that early term inductions lower birth weights and increase the risks of precipitous labor, birth injury, and required ventilation. Our results suggest that reductions in early term inductions can explain about one-third of the overall increase in birth weights between 2010 and 2013 for births at 37 weeks gestation and above.

Bishop scoring: Perceived benefits of using in labour induction by Turkish midwives

It is not always possible to achieve a successful induction. Bishop scoring system is an efficient method used in determining whether the induction will be effective or not. The aim of this study was to train midwives on the benefits and use of the Bishop scoring system and to minimize the unnecessary use of induction. This study was conducted as pretest-posttest quasi-experimental design. This study was conducted in a maternity hospital in Erzurum between 01 February and 31 July 2012. In the study, the midwives received training on the use of the Bishop scoring system, and changes in their knowledge levels and application during practice of induction were then evaluated. While only 20% of midwives were using the Bishop score before the training, 56.7% started to use this tool after the training. Comparing the examinations performed on pregnant women by the midwives in the pre-induction period before and after the training, the mean of the Bishop score changed from 7.26 to 9.68 after the training. It was determined that the training could increase the knowledge levels of midwives regarding the Bishop scoring system and their attention paid to the Bishop scoring system in the practice of induction.

In vitro myometrial contractility profiles of different pharmacological agents used for induction of labor

OBJECTIVE

To investigate the effects of different pharmacological induction agents on myometrial contractility.

STUDY DESIGN

Myometrial biopsies were obtained from 13 term nonlaboring women undergoing scheduled cesarean delivery. Tissue strips were suspended in organ chambers for isometric tension recording. The effects of cumulative doses (10-10 mol/L to 10-5 mol/L) of prostaglandin E1 (PGE1), E2 (PGE2), and oxytocin on spontaneous uterine contractility were determined. Areas under the contraction curve were compared using one-way analysis of variance on ranks with Dunn post hoc test.

RESULTS

Oxytocin-induced myometrial contractility was superior to PGE1, PGE2, and time controls (CTR) at all the concentrations tested. When only prostaglandins were compared with CTR, PGE1 10-5 mol/L increased myometrial contractility, and PGE2 had no effects.

CONCLUSION

Oxytocin and prostaglandins have different effects on myometrial contractility accounting for different mechanisms of action and side effects. The increased uterine contractility observed with PGE1 as compared with PGE2 can contribute to explain the higher success of vaginal delivery.

Cervical ripening and induction of labour-awareness, knowledge and perception of antenatal attendees in Ibadan, Nigeria

The levels of awareness, knowledge and the perceptions of women about cervical ripening and induction of labour were assessed in a cross-sectional questionnaire-based interview of 265 antenatal attendees of the University College Hospital, Ibadan, Nigeria from 1 March to 30 April 2009. Questions included evaluated sociodemographic data, obstetric history, awareness of both procedures and knowledge of specific methods. Data analysis was done using SPSS v.14.0 for Windows; frequency tables were utilised to determine proportions and significant variables from χ(2) analysis were entered into a logistic regression model. The majority of respondents were between 26 and 34 years; 56.4% were nulliparous. Awareness of cervical ripening and induction of labour was found in 71% of respondents. Knowledge of misoprostol and Foley's catheter however, was present in 25% and 13% of all women, respectively. Both procedures were perceived to prevent caesarean section or reduce burden of health workers in 16% of respondents. No significant predictor of knowledge was found but history of previous induction was a predictor of awareness (p < 0.05). Improved counselling is required to further increase knowledge of methods for induction and correct wrong perceptions, particularly in women at risk of labour induction.

Failed induction of labor: strategies to improve the success rates

The rates of induction of labor (IOL) are rising all over the world. In developed countries, one of every 4 babies is born after IOL at term. The recent World Health Organization guidelines on IOL recommend that failure of induction does not necessitate cesarean delivery [WHO recommendations for induction of labor. World Health Organization, 2011]. These guidelines come when there are concerns that failed primary inductions in nulliparous women, which have led to escalation of the cesarean delivery rates. Obstetricians must recognize the risks associated with IOL (including failure and need for cesarean delivery) and avoid inductions for borderline indications, which are not evidence based. The issue of "failed induction of labor" is topical, and there is a need to define this entity and offer alternatives to cesarean delivery in the management of this group of women. Research is required to develop a test to accurately identify those fetuses most at risk of morbidity or stillbirth who would truly benefit from an early IOL and assess the cost-effectiveness of policies of routine IOL. In this review, we summarized the current recommendations for best practice in the area of IOL, defined "failed induction," and described options to improve the success rate after "failed primary induction of labor."

TARGET AUDIENCE

Obstetricians & Gynecologists and Family Physicians.

LEARNING OBJECTIVES

After the completing the CME activity, physicians should be better able to classify the factors determining success or failure of induction of labor, counsel women about risks and benefits of various methods of induction of labor, and compare the options of management available after failed primary induction of labor.

Is transcervical Foley catheter actually slower than prostaglandins in ripening the cervix? A randomized study

OBJECTIVE

The purpose of this study was to determine whether the maximum time for cervical ripening (from 24-12 hours) would influence the efficacy of a transcervical Foley catheter and to compare efficacy to that of a prostaglandin E(2) vaginal insert.

STUDY DESIGN

Three hundred ninety-seven women were assigned randomly to (1) Foley catheter left in place for a maximum of 24 hours, (2) Foley catheter left in place for a maximum of 12 hours, or (3) prostaglandin E(2) controlled-release vaginal insert. Primary outcome was vaginal delivery within 24 hours.

RESULTS

There were no differences in vaginal delivery rates. The proportion of women who achieved vaginal delivery in 24 hours was lower in the 24-hour Foley catheter group than in the other 2 groups (24-hour Foley catheter, 21.0%; 12-hour Foley catheter, 59.8%; vaginal prostaglandin E(2), 48.5%; P < .0001).

CONCLUSION

Cutting the ripening time with a Foley catheter by one-half increases the proportion of women who deliver vaginally within 24 hours and yields efficacy similar to that of prostaglandin E(2) vaginal insert.

Foley catheter balloon vs locally applied prostaglandins for cervical ripening and labor induction: a systematic review and metaanalysis

We performed a metaanalysis of publications comparing the efficacy and safety of cervical ripening and labor induction by Foley catheter balloon (FCB) vs locally applied prostaglandins (LAPG) in the third trimester of pregnancy. Twenty-seven randomized controlled trials (1966-2008; 3532 participants) were selected from MEDLINE, EMBASE, and CENTRAL searches. There was no significant difference between FCB and LAPG in cesarean delivery rates. LAPG had a significantly increased risk of excessive uterine activity (P = .001). FCB had a significantly higher risk of oxytocin induction/augmentation during labor (P = .0002). Cervical prostaglandin-E2 was less effective (P = .04), and vaginal prostaglandin-E1 bore a significantly higher risk of excessive uterine activity (P < .0001) and meconium staining (P = .04). We concluded that FCB and LAPG result in similar cesarean delivery rates, that FCB bears a higher risk of oxytocin use for labor induction and/or augmentation, and that LAPG carries a higher risk of contraction abnormalities.

Women's expectations of management in their next pregnancy after an unexplained stillbirth: an Internet-based empirical study

BACKGROUND

Unexplained stillbirth is the largest contributor to perinatal death, accounting for one-third of stillbirths. There appears to be no increase in perinatal death rates in the pregnancies that follow an unexplained stillbirth. However, these pregnancies have increased rates of induced labour and elective caesarean section, as well as preterm birth, low birthweight, instrumental delivery, 'fetal distress' and postpartum haemorrhage.

AIM

To study the wishes for future pregnancy management in women who have suffered an unexplained stillbirth.

METHODS

An Internet-based survey of women after an unexplained stillbirth, seeking demographic information and reproductive history, details of management of the index stillbirth and information about their wishes for subsequent pregnancy management (antenatal surveillance, early delivery and caesarean delivery).

RESULTS

Of the total respondents included in the study, 93% wanted 'testing' over and above normal pregnancy care in their next pregnancy. Of the respondents, 81% wanted early delivery and 26% wanted a Caesarean delivery, irrespective of obstetric indications. These wishes were not influenced by socio-demographic factors, management of the index stillbirth (with the exception of having had a Caesarean delivery) or advice received on management of the next pregnancy (with the exception of being advised to have an early or Caesarean delivery).

CONCLUSIONS

The women surveyed wanted increased fetal surveillance and early delivery, but not necessarily elective caesarean section.

Low-dose oral misoprostol for induction of labor: a systematic review

OBJECTIVE

To estimate the efficacy and safety of low-dose oral misoprostol compared with dinoprostone (PGE2), vaginal misoprostol, and oxytocin for labor induction in women with a viable fetus.

DATA SOURCES

We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published before January 2008 using the keywords misoprostol, labor, induction, randomized controlled trials, dinoprostone, oxytocin, pregnancy, and maternal and fetal side effects.

METHODS OF STUDY SELECTION

We included randomized controlled trials comparing 20-25 micrograms oral misoprostol with vaginal misoprostol, dinoprostone or oxytocin given to women at 32-42 weeks of gestation for labor induction. From 401 citations identified, results from nine studies were finally analyzed using the Review Manager software. Relative risk (RR) and 95% confidence intervals (CIs) were calculated using fixed and random-effects models.

TABULATION, INTEGRATION, AND RESULTS

Nine articles with 2,937 women met the inclusion criteria. The five trials comparing oral misoprostol and dinoprostone showed significantly fewer women requiring cesarean delivery in the misoprostol group (20% compared with 26%; RR 0.82, 95% CI 0.71-0.96). There were no statistically significant differences in risks of uterine hyperstimulation or need for oxytocin augmentation. Two trials compared oral with vaginal low-dose misoprostol. Women using oral misoprostol were significantly less likely to experience uterine hyperstimulation with fetal heart rate changes (2% compared with 13%; RR 0.19, 95% CI 0.08-0.46), but there were no significant differences in other outcomes.

CONCLUSION

Low-dose oral misoprostol solution (20 micrograms) administered every 2 hours seems at least as effective as both vaginal dinoprostone and vaginal misoprostol, with lower rates of cesarean delivery and uterine hyperstimulation, respectively.

Efficacy and safety of six hourly vaginal misoprostol versus intracervical dinoprostone: a randomized controlled trial

OBJECTIVE

To compare the efficacy and safety of intravaginal misoprostol versus dinoprostone cervical gel for cervical ripening and labour induction.

METHODS

We carried out an experimental clinical trial in which we enrolled 130 cervical consecutive patients with cervical ripening, randomly assigned to one of the following two treatment groups: (1) intravaginal misoprostol and (2) intracervical dinoprostone gel. A total of 50 microm of misoprostol was placed in the posterior vaginal fornix every 6 h for a maximum period of 24 h and 0.5 mg of dinoprostone was administrated in the uterine cervix every 6 h, for a maximum period of 24 h. The primary outcome measure was the number (rate) of women who went to vaginally deliver within 24 h of the protocol initiation.

RESULTS

Among 130 patients evaluated, 65 were allocated to the misoprostol group and 65 to the dinoprostone group. The proportion of vaginal delivery within 24 h was significantly higher in the misoprostol group (75%) than in the dinoprostone group (53.8%) (RR = 1.40, 95% CI [1.07-1.45], P = 0.02). There was no significant difference between the mean time interval of delivery in the misoprostol group and the dinoprostone group (14.9 vs.15.8 h) (P = 0.51). The Bishop score was significantly higher in the misoprostol group, 6 h after the onset of the study (1.38; relative risk, 95% CI [1.02-1.85], P = 0.03). The Caesarean delivery rate for fetal distress was higher in the dinoprostone group (21 vs. 10.8%, P = 0.15). The tachysystole (Misoprostol 6.1% vs. dinoprostone 4.6%, relative risk 1.15, 95% CI [0.6-2.24]) and hyperstimulation syndrome rates (Misoprostol 7.6% vs. dinoprostone 4.6%, relative risk 1.26, 95% CI [0.72-2.24]) were slightly increased in the misoprostol group than in the dinoprostone group without reaching the level of statistical signification.

CONCLUSION

Misoprostol as used in this protocol is more effective than cervical dinoprostone gel application in the cervical ripening and labour induction. There is a tendency for an increase in the rate of tachysystole and hyperstimulation syndrome.

A randomised comparison of patient satisfaction with vaginal and sublingual misoprostol for induction of labour at term*

OBJECTIVE

To compare patient satisfaction with two routes of misoprostol for term labour induction.

DESIGN

Prospective randomised trial.

SETTING

Tertiary care hospital.

POPULATION

A total of 170 women admitted at > or = 37 weeks of gestation for induction of labour.

METHODS

Women were randomised to receive 50 micrograms of either sublingual or vaginal misoprostol.

MAIN OUTCOME MEASURES

Patient satisfaction with the route of administration.

RESULTS

Despite a similar proportion reporting the labour induction as more painful than expected in both groups, a significantly lower proportion mentioned that the pelvic examinations were very painful in the sublingual group (19.7 versus 36.1%, relative risk [RR] 0.5, 95% CI 0.3-0.9). Request for analgesia was similar in both groups. More women in the sublingual group thought that the labour experience was better than expected (RR 2.0, 95% CI 1.2-3.3), had a positive attitude towards induction in subsequent pregnancies (RR 1.6, 95% CI 1.1-2.3) and preferred the same route in subsequent pregnancies (RR 3.1, 95% CI 2.2-4.5). Mean number of misoprostol doses, oxytocin augmentation, tachysystole and hyperstimulation, induction to vaginal delivery interval, vaginal delivery after a single dose, vaginal birth within 12 and 24 hours, and caesarean delivery rates were similar in both groups.

CONCLUSION

Sublingual misoprostol (50 micrograms) is associated with a significantly higher patient satisfaction rate compared with a similar dose of vaginal misoprostol. Sublingual administration offers additional choice to women, in particular those wishing to avoid vaginal administration.

Sublingual compared with vaginal misoprostol for labour induction at term: a randomised controlled trial

OBJECTIVE

To compare the efficacy and safety of 50 microg of sublingual misoprostol with 25 microg of vaginal misoprostol administered for labour induction at term. Design Double-blinded, randomised controlled trial. Setting University Hospital, Kaunas, Lithuania. Sample A total of 140 women at term with indications for labour induction. Methods Women were randomised to receive either 50 microg of sublingual misoprostol with vaginal placebo (n = 70) or sublingual placebo with 25 microg of vaginal misoprostol (n = 70) every 4 hours (maximum six doses). Main outcome measures The number of women delivering vaginally within 24 hours of labour induction. Results Fifty-eight women (83%) in the sublingual misoprostol group and 53 (76%) in the vaginal misoprostol group delivered vaginally within 24 hours [relative risk (RR) 1.1, 95% confidential interval (CI) 0.9-1.3]. However, the induction to vaginal delivery time was significantly shorter in the sublingual group (15.0 +/- 3.7 hours) compared with the vaginal group (16.7 +/- 4.1 hours, P = 0.03). The incidence of tachysystole was more than three-fold higher in the sublingual than in the vaginal group (14 versus 4.3%; RR 3.3, 95% CI 0.9-11.6), but this was not statistically significant. There were no significant differences in the incidence of hypertonus or hyperstimulation syndrome, mode of delivery, interventions for fetal distress or neonatal outcomes between the two groups. Conclusion A 50 microg of sublingual misoprostol 4 hourly for labour induction at term seems to have similar efficacy as 25 microg of vaginal misoprostol. Further studies on safety with larger numbers of women need to be conducted before routine sublingual misoprostol use in this setting.

Misoprostol compared with prostaglandin E2 for labour induction in women at term with intact membranes and unfavourable cervix: a systematic review*

BACKGROUND

Misoprostol is a commonly used prostaglandin to induce labour. A potential risk of induction, however, is caesarean delivery, especially in women with an unfavourable cervix.

OBJECTIVES

To evaluate the use of misoprostol, compared with prostaglandin E2 (PgE2), for labour induction in women at term with an unfavourable cervix and intact membranes.

SEARCH STRATEGY

PubMed, Medline, EMBASE and the Cochrane Library were searched for articles published in any language from January 1987 to December 2005, using the keywords 'misoprostol', 'labour/labor' and 'induction'.

SELECTION CRITERIA

We identified randomised trials of women at term (> or =37 weeks of gestation) with intact membranes and unfavourable cervix, undergoing labour induction with misoprostol, orally, vaginally, sublingually or buccally, compared with PgE2 vaginally or intracervically.

DATA COLLECTION AND ANALYSIS

Caesarean delivery was the primary outcome, with tachysystole and hyperstimulation as secondary outcomes. The primary analysis compared any misoprostol with any PgE2 for all women, with a subgroup analysis for nulliparous women. Secondary analyses compared different routes and doses of misoprostol (oral or vaginal and 25 microgram or >25 microgram) and PgE2 (intracervical or vaginal). Relative risks (RR) and 95% confidence intervals (CI) were calculated using random effects models. Main results Fourteen of 611 articles identified met the criteria for systematic review, with three providing information for nulliparous women. There was no difference in the risk of caesarean delivery between misoprostol and PgE2 groups (RR = 0.99, 95% CI = 0.83-1.17). Any misoprostol was associated with higher risks of tachysystole and hyperstimulation compared with any PgE2 (RR = 1.86, 95% CI = 1.01-3.43 and RR = 3.71, 95% CI = 2.00-6.88, respectively). There was a higher rate of vaginal delivery within 24 hours among all vaginal deliveries with any misoprostol compared with any PgE2 (RR = 1.14, 95% CI = 1.00-1.31), and among all deliveries, a lower rate of oxytocin use (RR = 0.71, 95% CI = 0.60-0.85) but a trend towards increased meconium staining was observed (RR = 1.22, 95% CI = 0.96-1.55). The use of misoprostol at starting dosages >25 microgram had similar findings to the primary analysis. Studies of lower misoprostol dosing (starting dose of 25 microgram) did not show any differences in the outcomes of interest, but the sample size of this secondary analysis was small (304 women, 155 receiving misoprostol).

AUTHOR'S CONCLUSIONS

Although misoprostol in women at term with an unfavourable cervix and intact membranes was more effective than PgE2 in achieving vaginal delivery within 24 hours, misoprostol does not reduce the rate of caesarean delivery either in all women or in the subgroup of nulliparous women, and it increases the rates of tachysystole and hyperstimulation. Further studies of misoprostol using a starting dose of 25 microgram may be warranted.

High iNOS mRNA and protein levels during early third trimester suggest a role for NO in prelabor cervical ripening in the bovine

Nitric oxide (NO) plays a key role in the processes leading to cervical softening prior to labor. Inducible nitric oxide synthase (iNOS) contributes most to the increased production of NO during labor, as demonstrated in the rat cervix, or at term pregnancy in women. Changes in expression of iNOS during late gestation have not yet been studied longitudinally in any species, because repeatedly taking biopsies could not be performed. iNOS mRNA (n = 6) and protein expression (n = 3) in serial cervical biopsies of pregnant pluriparous cows taken around days 225, 250, and 275 of pregnancy and within 1.5 hr after calving (d225, d250, d275 and parturition biopsies, respectively) were measured using quantitative RT-PCR and Western blotting. iNOS mRNA expression decreased from the d225 biopsy onwards, differences being significant between the d250 and d275 (P < 0.05) and between the d275 and parturition biopsies (P < 0.05). iNOS protein expression decreased from d225 to d250 onwards. Immunohistochemical analysis of biopsies showed, besides positive staining in endothelium and epithelium, which remained unchanged at different time points, that iNOS expressing cells in the connective tissue cells of early biopsies were predominantly spindle shaped (mostly smooth muscle cells and some fibroblasts). In the parturition biopsies, iNOS reactivity was mainly found in mononuclear leucocytes. These results lead us to suggest that iNOS from spindle shaped cells is involved in prepartum cervical ripening, while iNOS in mononuclear inflammatory cells may be important for local tissue repair mechanisms during postpartum cervical involution.

Use of the Atad catheter for the induction of labour in women who have had a previous Caesarean section - a case series

Abstract The induction of labour of women with an unfavourable cervix who have had a previous Caesarean section, is challenging. Eight women who had a Caesarean section in a previous pregnancy had labour induced with an Atad catheter. Six out of eight women achieved labour, and two out of these six women had a vaginal delivery. An Atad catheter is an option for women needing induction of labour with an unfavourable cervix who have had a Caesarean section previously and are motivated to have a vaginal delivery.