Vaginal Dinoprostone Insert versus Cervical Ripening Balloon for Term Induction of Labor in Obese Nulliparas-A Randomized Controlled Trial

[Prostaglandins or cervical balloon for the induction of labor for cervical ripening: A literature review]

OBJECTIVE

Induction of labor in France concerns one birth out of four with 70% of induction starting by cervical ripening, either with a pharmacological (prostaglandins) or a mechanical (balloon) method. This review aims to compare these two methods within current knowledge, using the PRISMA methodology.

METHODS

Trials comparing these two methods, published or unpublished up to July 2023, in French or English were searched for in the PubMed, Cochrane Library and ClinicalTrial.govs datasets. Fifty articles including 10,689 women were selected. The outcomes of interest were those from the Core Outcome Set for trails on Induction of Labour (COSIOL) list: mode of delivery, time from induction-to-birth, maternal and neonatal morbidity, and maternal satisfaction.

RESULT

No differences were observed between the two methods for the mode of delivery or neonatal and maternal morbidity. The time from induction-to-birth was longer for mechanical methods. Those were also associated with a greater need for oxytocin, less uterine hyperstimulation and less instrumental deliveries. Maternal satisfaction was assessed in only nine trials using various scales which made the interpretation of maternal satisfaction.

CONCLUSION

The efficacy of these two induction methods is similar for vaginal delivery, but it remains to be seen which one best meets women's satisfaction criteria.

Cervical ripening balloon compared with vaginal dinoprostone for cervical ripening in obese women at term: A prospective cohort study

OBJECTIVE

To evaluate vaginal delivery in obese women who underwent cervical ripening at term using a dinoprostone vaginal insert or a cervical ripening balloon (CRB), and to assess maternal and neonatal morbidity according to the method.

METHODS

A prospective cohort study including obese women with a live singleton fetus in cephalic presentation who required cervical ripening at term (≥37 weeks) for maternal and/or fetal disease using a dinoprostone vaginal insert or a CRB. The primary outcome was vaginal delivery. Secondary outcomes were a favorable cervix (Bishop score >6) after 24 h, the time from device insertion to delivery, and composite maternal and neonatal morbidity.

RESULTS

In total, 135 consecutive women were analyzed (107 CRB, 79.3%; 28 dinoprostone vaginal insert, 20.7%). Vaginal delivery (86 [80.4%] after CRB vs 19 [67.9%] after dinoprostone vaginal insert; P = 0.248), favorable cervix within 24 h after device placement (52 [48.6%] vs 17 [60.7%]; P = 0.264), and maternal morbidity (12 [11.2%] vs 4 [14.3%]; P = 0.646) were similar between the groups. The time from device insertion to delivery also did not differ between the groups. Neonatal morbidity was significantly higher after the dinoprostone vaginal insert (11 [39.3%] vs 20 [18.7%]; P = 0.030). Cervical ripening using the dinoprostone vaginal insert, compared with the CRB, was significantly associated with neonatal morbidity (adjusted odds ratio 4.00, 95% confidence interval 1.34-12.5), but not with maternal morbidity (adjusted odds ratio 1.23, 95% confidence interval 0.30-4.38).

CONCLUSIONS

Vaginal delivery, a favorable cervix after 24 h, the time from device insertion to delivery, and maternal morbidity did not significantly differ between the CRB and the dinoprostone vaginal insert for cervical ripening in obese women at term. Nevertheless, neonatal morbidity was significantly associated with the dinoprostone vaginal insert, compared with the CRB, among obese women who required cervical ripening at term.

Outpatient cervical ripening with balloon catheters: A Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

One in four labors are induced. The process of cervical ripening can be lengthy and pre-labor hospitalization is required. Outpatient cervical ripening can be an attractive alternative.

OBJECTIVES

To evaluate the efficacy and safety of outpatient cervical ripening with a balloon catheter compared with inpatient balloon catheter or prostaglandin E2 (PGE2 ).

SEARCH STRATEGY

The PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases were searched from their inception to October 15, 2022.

SELECTION CRITERIA

Randomized controlled trials comparing the outpatient balloon catheter with inpatient balloon catheter or inpatient PGE2 for term cervical ripening.

DATA COLLECTION AND ANALYSIS

Bayesian network meta-analysis was performed. The primary outcome was the cesarean delivery rate. The secondary outcomes included instrumental delivery, the time from intervention-to-birth, oxytocin augmentation, total hospital duration, and maternal/neonatal adverse events.

MAIN RESULTS

Twenty-nine randomized controlled trials with a total of 6004 participants were identified. No difference in the cesarean delivery rate was revealed among the three interventions. Compared with inpatient balloon catheter, outpatient balloon catheter had shorter total hospital duration (mean difference -8.58, 95% confidence interval -17.02 to -1.10). No differences were revealed in the time from intervention-to-birth, instrumental delivery, postpartum hemorrhage, 5-min Apgar score less than 7, umbilical cord arterial pH less than 7.1, and neonatal intensive care unit admission among the three interventions.

CONCLUSIONS

Outpatient balloon catheter in low-risk term pregnancies is an available option that could be considered for cervical ripening. The safety and effectiveness are comparable to inpatient cervical ripening methods.

Comparison of cesarean delivery rates after 3 methods of cervical ripening among obese women at or after 41 weeks - Secondary analysis of two French randomized controlled trials: MAGPOP and CYTOPRO

OBJECTIVE

To compare cesarean rates and maternal and neonatal morbidity according to the cervical ripening method used among obese pregnant women requiring induction of labor at or after 41 weeks of gestation.

DESIGN

A secondary analysis of two multicenter randomized controlled trials conducted in French maternity units between 2015 and 2018.

PARTICIPANTS

336 women with a body mass index ≥30 kg/m2, a pregnancy ≥41 weeks, and an induction of labor requiring cervical ripening.

INTERVENTIONS

Cervical ripening with a PGE2 dinoprostone pessary (Propess®), or low-dose vaginal PGE1 (misoprostol) or a double-balloon catheter.

MEASUREMENTS AND FINDINGS

The rates of cesarean delivery did not differ significantly according to the cervical ripening method (PGE2 pessary vs PGE1, RR: 1.18, 95% CI: 0.80-1.75; PGE2 pessary vs double balloon catheter: RR, 0.88, 95% CI: 0.60-1.29), p = 0.52; double balloon catheter vs PGE1, RR: 1.34, 95% CI: 0.77-2.32, p = 0.29). More oxytocin was required for women from the double-balloon group compared to those from both the PGE1 and PGE2 pessary groups (respectively, RR: 1.31, 95% CI: 1.08-1.58, p = 0.005; RR: 1.17, 95% CI: 1.03-1.32, p = 0.01). The risk of perineal tears or episiotomy was significantly lower for women induced with the PGE2 pessary than with PGE1 (0.85; 95% CI: 0.74-0.99), p = 0.03).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

No cervical ripening method was associated with a lower cesarean rate in obese women who required cervical ripening from 41 weeks. Further trials are required among obese women to determine the cervical ripening method most efficacious for reducing the cesarean rate.

Using dinoprostone slow release vaginal insert for cervical ripening in term-pregnancy with oligohydramnios

AIMS

The study purposed to evaluate the success rate of cervical ripening using dinoprostone controlled-release vaginal insert and reveal some factors relating to successful cervical ripening.

METHODS

This cross-sectional study was conducted at Tu Du Hospital in Vietnam from December 2021 to August 2022. The study enrolled 200 pregnant women with gestational age ≥37 weeks diagnosed with oligohydramnios. These candidates underwent dinoprostone cervical ripening (DCR) according to the local protocol. The Bishop score ≥7 after 24 h was determined for the successful cervical ripening (SCR).

RESULTS

In total, the success rate of DCR achieved at 57.5% and the cesarean delivery rate was 46.5%. None of the severe side-effects and complications was present. Using multivariable logistic regression, the study found that the body mass index ≥25 kg/m² and oxytocin infusion drip related to SCR with adjusted odds ratio (aOR): 3.67 (95% confidence intervals [CI]: 1.78-7.57) and aOR: 4.68 (95% CI: 1.84-11.93), p < 0.001. Using the Kaplan-Meier curve, the present study revealed a significant difference between Bishop <3 and ≥3 following the duration time of cervical ripening, with hazard ratio: 1.38 (95% CI: 1.19-1.59), p < 0.001. The time duration of cervical ripening was not significantly different following amniotic fluid index from 3 to 5 cm.

CONCLUSIONS

Cervical ripening using a dinoprostone vaginal insert is a potentially acceptable method in term pregnancy accompanying with oligohydramnios. The probability of SCR can be predicted on a careful assessment of relative factors by obstetricians. Further studies are required to strengthen these findings.

A novel method for assessing the condition of the cervix before labor induction: Cervical length/thickness ratio

Background/Aim: Due to the increasing cesarean rates globally, new methods for supporting vaginal delivery and induction of successful vaginal delivery are still being developed. We aimed to obtain an easy-to-use method that can predict the effectiveness of cervical ripening agents before labor induction. So, we presented the effects on labor by measuring the thickness of the cervix and the cervical length/thickness ratio ultrasonographically. Methods: In this prospective cohort study, we evaluated 183 pregnant between 37 and 41 weeks of gestational age and will apply vaginal delivery induction. Before oxytocin induction, we applied 10 mg dinoprostone vaginally to women whose cervix was stiff. We started labor induction with oxytocin when regular uterine contractions or dilatation occurred. We used the Bishop Scoring System for favorable cervix defining. Then, we compared the groups with successful and unsuccessful cervical ripening regarding cervical length and thickness parameters. Results: The mean cervical thickness of the pregnant women with successful cervical ripening was 34.5 (7.5) mm before treatment, while the mean values of the unsuccessful group were 29.2 (9.1) mm (P < 0.001). The cervical length did not differ between the two groups (31.6 [8.2] vs. 32.5 [6.8], P = 0.44), while the cervical length/thickness ratio was lower in the group with successful ripening (0.9 [0.38–2], P < 0.001). Cervical length/thickness ratio was the highest predictor of the favorable cervix with dinoprostone. Each 1 unit decrease in the length/thickness ratio of the cervix increases the preparation of the cervix for induction by 0.25 times (P = 0.04). A successful response to dinoprostone can be obtained if the cervical length/thickness ratio is <1.06 mm (P < 0.001). Conclusion: In conclusion, assessing the cervix’s condition before labor induction by measuring the cervical length/thickness ratio may be a good predictor of cervical ripening activity.