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Background Objectives Search Strategy Selection Criteria Data Collection and Analysis Main Results Conclusion Misoprostol is largely used in labor induction in cases of intrauterine fetal death. However, recent randomized clinical trials (RCTs) showed that the combination of mifepristone and misoprostol might have better effects than the use of misoprostol alone.To compare mifepristone and misoprostol lines of treatment.Pubmed, Embase, Cochrane and Web of Science databases were systematically searched until April 9, 2024.The eligibility criteria were (1) RCT, (2) comparing misoprostol alone versus the combined treatment, (3) patients undergoing labor induction due to intrauterine fetal death and (4) reporting at least one relevant outcome.Data were examined using the Mantel–Haenszel method and 95% CIs. Heterogeneity was assessed using I2 statics. R, version 4.2.3 was used for statistical analysis. The analyzed outcomes were delivery time interval, adverse effects (fever, vomiting, diarrhea and nausea) and the preinduction Bishop score. Other important outcomes, such as uterus rupture, could not be included due to lack of data from the included studies.A total of seven RCTs comprising 599 patients with intrauterine fetal death were randomized to misoprostol or combined treatment to induce labor. Compared to the misoprostol only group, combined treatment presented lower delivery time interval (MD –6.86 h; 95% CI: −10.32 to −3.4; P = 0.0001; I2 = 87%). However, in terms of adverse effects, the combined treatment group presented lower occurrence of fever (2.25% vs 12.12%; RR 0.26; 95% CI: 0.09–0.74; P = 0.01; I2 = 0%) and vomiting (7.64% vs 14.45%; RR 0.54; 95% CI: 0.29–1.01; P = 0.05; I2 = 0%). No statistically significant differences were observed when comparing the preinduction Bishop score of the two groups (MD –0.09; 95% CI: −0.28–0.10; P = 0.35; I2 = 0%). Additionally, the mean of the preinduction Bishop score of the combined treatment was 2 versus 2.1 of the control group.In this updated meta‐analysis, consistent results suggest that the combined treatment is associated with more beneficial outcomes than the misoprostol alone treatment in patients undergoing labor induction in intrauterine fetal death. [ABSTRACT FROM AUTHOR]

Objective: To compare rates of adverse pregnancy outcomes in term pregnancies complicated by polyhydramnios between women who had induction of labor (IOB) versus women who had expectant management. Methods: This multicenter retrospective study included term pregnancies complicated by isolated polyhydramnios. Patients who underwent IOB were compared with those who had expectant management. The primary outcome was defined as a composite adverse maternal outcome, and secondary outcomes were various maternal and neonatal adverse outcomes. Univariate analyses were followed by multivariate logistic regression. Results: A total of 865 pregnancies with term isolated polyhydramnios were included: 169 patients underwent IOB (19.5%), while 696 had expectant management and developed spontaneous onset of labor (80.5%). Women who underwent IOB had significantly higher rates of composite adverse maternal outcome (23.1% vs 9.8%, P < 0.01), prolonged hospital stay, perineal tear grade 3/4, intrapartum cesarean, postpartum hemorrhage, blood products transfusion, and neonatal asphyxia compared with expectant management. While the perinatal fetal death rate was similar between the groups (0.6% vs 0.6%, P = 0.98), the timing of the loss was different. Four women in the expectant management group had a stillbirth, while in the induction group one case of intrapartum fetal death occurred due to uterine rupture. Multivariate analyses revealed that IOB was associated with a higher rate of composite adverse maternal outcome (adjusted odds ratio, 2.22 [95% CI, 1.28–3.83]; P < 0.01). Conclusion: IOB in women with term isolated polyhydramnios is associated with higher rates of adverse maternal outcomes in comparison to expectant management. Further research is needed to determine the optimal approach for the management of isolated polyhydramnios at term. Synopsis: Induction of labor in women with term isolated polyhydramnios is associated with higher rates of adverse maternal and neonatal outcomes in comparison to expectant management. [ABSTRACT FROM AUTHOR]

Objective: The study aims to assess how oral misoprostol for cervical ripening affects the time of cesarean delivery (CD) for fetal heart rate (FHR) abnormalities in pre‐eclampsia patients. Secondary goals include determining the role of uterine hyperstimulation, comparing misoprostol with Foley catheter, and identifying risk factors for FHR abnormalities associated with CD. Methods: A previously published randomized clinical trial was subjected to a secondary analysis (NCT01801410). We conducted a time‐dependent analysis, stratifying the population based on the final mode of induction used (low‐dose oral misoprostol vs Foley catheter). Results: There was no CD for FHR abnormalities within 2 h of starting misoprostol. At 5 h, the cumulative incidence of CD for FHR abnormalities in the misoprostol group was 2.10%, while it was 1.00% in the Foley group (P = 0.565). After 25 h, the CD risk for FHR abnormalities remained constant in both groups at 21.00% (95% confidence interval [CI] 15.00%–28.00%). Within 5 h of misoprostol induction, the risk of uterine hyperstimulation was similar in both groups (0.33% in misoprostol vs 0.34% in Foley group, P = 0.161). The risk of CD for FHR abnormalities was unaffected by newborn weight centiles. Conclusion: There was no significant difference in CD risk for FHR abnormalities between misoprostol and Foley catheter induction. Nonetheless, the cumulative incidence of CD for FHR abnormalities increased faster in the misoprostol group, indicating that FHR monitoring timing should be tailored to the induction method. Synopsis: The incidence of cesarean delivery for fetal heart anomalies increased faster in the misoprostol group than in Foley group, and for that reason tailoring fetal monitoring timing to induction method is critical. [ABSTRACT FROM AUTHOR]

Background: Misoprostol is widely used for cervical ripening and labour induction as it is heat‐stable and inexpensive. Oral misoprostol 25 μg given 2‐hourly is recommended over vaginal misoprostol 25 μg given 6‐hourly, but the need for 2‐hourly fetal monitoring makes oral misoprostol impractical for routine use in high‐volume obstetric units in resource‐constrained settings. Objectives: To compare the efficacy and safety of oral misoprostol initiated at 25 or 50 μg versus 25 μg vaginal misoprostol given at 4‐ to 6‐hourly intervals for labor induction in women at or beyond term (≥ 37 weeks) with a single viable fetus and an unscarred uterus. Search Strategy: We identified eligible randomized, parallel‐group, labor‐induction trials from recent systematic reviews. We additionally searched PubMed, Cochrane CENTRAL, Epistemonikos, and clinical trials registries from February 1, 2020 to December 31, 2022 without language restrictions. Database‐specific keywords for cervical priming, labor induction, and misoprostol were used. Selection Criteria: We excluded labor‐induction trials exclusively in women with ruptured membranes, in the third trimester, and those that initiated misoprostol at doses not specified in the review's objectives. The primary outcomes were vaginal birth within 24 h, cesarean section, perinatal mortality, neonatal morbidity, and maternal morbidity. The secondary outcomes were uterine hyperstimulation with fetal heart rate changes, and oxytocin augmentation. Data Collection and Analysis: Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived pooled weighted risk ratios with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the dose and frequency of misoprostol regimens. We used the I2 statistic to quantify heterogeneity and the random‐effects model for meta‐analysis when appropriate. We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach to assess certainty (confidence) in the effect estimates. Main Results: Thirteen trials, from Canada, India, Iran, and the US, randomizing 2941 women at ≥37 weeks of gestation with an unfavorable cervix (Bishop score <6), met the eligibility criteria. Five misoprostol regimens were compared: 25 μg oral versus 25 μg vaginal, 4‐hourly (three trials); 50 μg oral versus 25 μg vaginal, 4‐hourly (five trials); 50 μg followed by 100 μg oral versus 25 μg vaginal, 4‐hourly (two trials); 50 μg oral, 4‐hourly versus 25 μg vaginal, 6‐hourly (one trial); and 50 μg oral versus 25 μg vaginal, 6‐hourly (two trials). The overall certainty in the evidence ranged from moderate to very low, due to high risk of bias in 11/13 trials (affecting all outcomes), unexplained heterogeneity (1/7 outcomes), indirectness (1/7 outcomes), and imprecision (4/7 outcomes). Vaginal misoprostol probably increased vaginal deliveries within 24 h compared with oral misoprostol (risk ratio [RR] 0.82, 95% CI 0.70–0.96; 11 trials, 2721 mothers; moderate‐certainty evidence); this was more likely with 4‐hourly than with 6‐hourly vaginal regimens. The risk of cesarean sections did not appreciably differ (RR 1.00, 95% CI 0.80–1.26; 13 trials, 2941 mothers; very low‐certainty evidence), although oral misoprostol 25 μg 4‐hourly probably increased this risk compared with 25 μg vaginal misoprostol 4‐hourly (RR 1.69, 95% CI 1.21–2.36; three trials, 515 mothers). The risk of perinatal mortality (RR 0.67, 95% CI 0.11–3.90; one trial, 196 participants; very low‐certainty evidence), neonatal morbidity (RR 0.84, 95% CI 0.67–1.06; 13 trials, 2941 mothers; low‐certainty evidence), and maternal morbidity (RR 0.83, 95% CI 0.48–1.44; 6 trials; 1945 mothers; moderate‐certainty evidence) did not differ appreciably. The risk of uterine hyperstimulation with fetal heart rate changes may be lower with oral misoprostol (RR 0.70, 95% CI 0.52–0.95; 10 trials, 2565 mothers; low‐certainty evidence). Oxytocin augmentation was probably more frequent with oral compared with vaginal misoprostol (RR 1.29, 95% CI 1.10–1.51; 13 trials, 2941 mothers; moderate‐certainty evidence). Conclusions: Low‐dose, 4‐ to 6‐hourly vaginal misoprostol regimens probably result in more vaginal births within 24 h and less frequent oxytocin use compared with low‐dose, 4‐ to 6‐hourly, oral misoprostol regimens. Vaginal misoprostol may increase the risk of uterine hyperstimulation with fetal heart changes compared with oral misoprostol, without increasing the risk of perinatal mortality, neonatal morbidity, or maternal morbidity. Indirect evidence indicates that 25 μg vaginal misoprostol 4‐hourly may be more effective and as safe as the recommended 6‐hourly vaginal regimen. This evidence could inform clinical decisions in high‐volume obstetric units in resource‐constrained settings. Synopsis: Vaginal misoprostol 25 μg 4‐hourly may be an effective, safe, and pragmatic alternative to currently recommended labor‐induction regimens in high‐volume obstetric units in resource‐constrained settings. [ABSTRACT FROM AUTHOR]

Objective: To identify independent predictors of maternal satisfaction with labor induction. Method: In this prospective observational cohort study, 769 women prior to their labor induction had sleep and psychological well‐being assessed using Pittsburgh Sleep Quality Index and Depression, Anxiety and Stress Scales. Women were asked about the adequacy of labor induction information provided and their involvement and time pressure felt in the decision‐making for their labor induction. Maternal characteristics, induction and intrapartum care measures, and labor and neonatal outcomes were also assessed. Prior to discharge, women rated their satisfaction with their birth experience. Results: A total of 34 variables were considered for bivariate analysis, with 15 found to have P < 0.05. Following adjusted analysis, 10 independent predictors of maternal satisfaction were identified: maternal education, previous cesarean delivery, maternal involvement, information provided, and decision‐making time pressure regarding labor induction, amniotomy, induction to delivery interval, mode of delivery, postpartum hemorrhage, and neonatal admission. Maternal satisfaction was not associated with sleep, depression, anxiety, or stress. Conclusion: The identification of independent predictors of maternal satisfaction allows for patient selection, targeting of specific preinduction and intrapartum care, and focus on induction methods that can reduce induction to delivery interval, cesarean birth, and delivery blood loss to maximize women's satisfaction with labor induction. Synopsis: Maternal satisfaction with labor induction can be predicted by maternal characteristics, preinduction care, and delivery and neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether the risk of fetal malpresentation following mechanical labor induction could be accurately predicted. Methods: A retrospective study, including all individuals who underwent labor induction at a single tertiary medical center between March 2011 and May 2021. Cohorts of pharmacological (n = 16 480) and mechanical labor induction (n = 6864) were compared, determining malpresentation rate following induction. Individuals with and without fetal malpresentation following balloon placement were compared. Results: Malpresentation following balloon placement occurred in 62 patients (0.9%). Those patients with malpresentation following balloon placement were older, had higher body mass index during labor, higher parity, polyhydramnios, higher fetal station at the start of labor induction, and delivered at an earlier gestational age compared with control patients. The combined presence of at least three of these risk factors was associated with a malpresentation rate of 8% (7/88) and yielded a positive likelihood ratio of 9.48 (95% confidence interval [CI] 4.57–19.7). A prediction model using these variables was not sufficiently accurate to predict the risk of malpresentation following balloon labor induction; a calculated area under the generated receiver operating characteristic curve was 0.78 (95% CI 0.72–0.84). Conclusion: Several risk factors were identified for malpresentation following mechanical labor induction, although these were of low predictive value. Synopsis: Several risk factors were identified for malpresentation following labor induction via balloon placement, occurring in approximately 1% of instances, although of low predictive value. [ABSTRACT FROM AUTHOR]

Objective: To compare maternal and neonatal outcomes between oxytocin and vaginal misoprostol induction in women with term prelabor rupture of membranes (PROM) and unfavorable cervixes. Methods: In this retrospective study, 589 pregnant women with term singleton fetuses in cephalic presentation, reactive nonstress tests, PROM of 2–24 h duration, Bishop score <6, and no previous uterine surgery were reviewed and divided into oxytocin (n = 301) and misoprostol (n = 288) groups. The primary outcomes were the rate of vaginal delivery and delivery within 24 h. Results: After 24 h of induction, the misoprostol group showed a significantly higher proportion of vaginal delivery (64.6% vs. 49.5%, P < 0.001) and a lower cesarean section delivery rate (11.5% vs. 25.2%, P < 0.001) than the oxytocin group. More primiparas in the misoprostol group achieved vaginal delivery within 24 h than in the oxytocin group (60.5% vs. 45.4%, P = 0.001). Among primiparas, the misoprostol group had a significantly lower cesarean delivery rate (12.6% vs. 27.5%, P < 0.001). Conclusion: Vaginal misoprostol induction in term PROM gravidas with unfavorable cervixes was associated with lower cesarean section and higher vaginal delivery rates within 24 h than oxytocin infusion. Vaginal misoprostol and oxytocin infusion had similar maternal and neonatal outcomes. Synopsis: This retrospective study showed that vaginal misoprostol was more effective in induction and vaginal delivery for women with term PROM and unfavorable cervixes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate immediate oxytocin and early amniotomy compared with delayed amniotomy after Foley catheter cervical ripening in multiparous women on intervention‐to‐delivery interval. Methods: This randomized trial was conducted in Malaysia in 232 term multiparous women with balloon catheter–ripened cervixes (dilatation ≥3 cm), singleton fetus, cephalic presentation with intact membranes, and reassuring fetal heart rate tracing. They were randomized to immediate titrated intravenous oxytocin infusion and early amniotomy (116) or delayed amniotomy after 4 h of oxytocin (116). Primary outcome was intervention (oxytocin initiation)‐to‐delivery interval. Results: Oxytocin‐to‐delivery intervals were a median of 4.99 h (interquartile range [IQR], 3.21–7.82 h) versus 6.23 h (IQR, 4.50–8.45 h) (P < 0.001) for the early versus delayed amniotomy arms, respectively. Delivery rate at 4 h and 6 h after oxytocin infusion were 40 of 116 (35%) versus 22 of 116 (19%) (relative risk [RR], 1.82 [95% confidence interval (CI), 1.16–2.86], P = 0.011) and 77 of 116 (66%) versus 54 of 116 (47%) (RR, 1.43 [95% CI, 1.13–1.80], P = 0.003) for the early versus delayed amniotomy arms, respectively. Maternal satisfaction on birth process were 7 (IQR, 6–8) versus 7 (IQR, 7–8) (P = 0.006), uterine hyperstimulation rates were 10 of 116 (9%) versus 14 of 116 (12%) (RR, 0.71 [95% CI, 0.33–1.54]) (P = 0.519), and Cesarean delivery rates were 17 of 116 (15%) versus 19 of 116 (16%) (RR, 0.90 [95% CI, 0.49–1.63], P = 0.856) for the early versus delayed amniotomy arms, respectively. Conclusion: In multiparas at term following cervical ripening by Foley catheter, immediate oxytocin and early amniotomy compared with a scheduled 4‐h delay to amniotomy shortens the interval to birth and decreases uterine hyperactivity in labor but lowers maternal satisfaction. The cesarean delivery rate is not significantly reduced. Clinical Trial Registration: This study was registered with the International Standard Randomised Controlled Trial Number (ISRCTN) on September 29, 2020, with trial identification number: ISRCTN87066007 (https://doi.org/10.1186/ISRCTN87066007). The first participant was recruited on September 29, 2020, after ISRCTN registry confirmation was received. Synopsis: Immediate oxytocin and early amniotomy compared with delayed amniotomy after cervical ripening with Foley catheter in multiparous women hasten delivery. [ABSTRACT FROM AUTHOR]

Objective: To compare the ability of six scoring systems to predict successful labor induction with cervical ripening among women with a Bishop score <3. Methods: Secondary analysis of data from a prospective, multicenter observational Methods of Induction of Labor and Perinatal Outcomes (MEDIP) cohort study in 94 obstetrical French units. We included women with a Bishop score <3 before cervical ripening. We compared six scores: Bishop, simplified Bishop, modified Bishop, simplified Bishop including parity, Hughey, and Levine scores. Vaginal delivery defined successful labor induction. The ability of each score to predict successful labor induction was evaluated by comparing their area under the curve (AUC). Results: Among the 600 eligible women in this study, 408 (68%) delivered vaginally. Body mass index (calculated as weight in kilograms divided by the square of height in meters; mean ± standard deviation [SD]: 24.7 ± 5.5 vs 26.0 ± 5.7; P = 0.01) and nulliparity (48.8% vs 85.4%; P < 0.001) were lower in the successful induction group, whereas height was higher (mean ± SD: 165.3 ± 6.0 cm vs 163.7 ± 6.0 cm; P = 0.002). The simplified Bishop including parity, Hughey, and Levine scores had the highest AUC (0.70, 95% confidence interval [CI] 0.65–0.73; 0.68, 95% CI 0.64–0.74; and 0.69, 95% CI 0.65–0.74, respectively). Conclusion: In women with a very unfavorable cervix, scores that include parity predict successful labor induction more accurately, such as simplified Bishop including parity, Hughey, or Levine scores. Synopsis: In 600 women with a very unfavorable cervix, prediction of successful labor induction is more accurate with scores including parity. [ABSTRACT FROM AUTHOR]

Objective: To evaluate immediate oxytocin and early amniotomy compared with delayed amniotomy after Foley catheter cervical ripening in nulliparous women on intervention‐to‐delivery interval. Methods: A randomized trial was conducted from September 2020 to March 2021. A total of 140 term nulliparas (70 early amniotomy, 70 delayed amniotomy) with Foley catheter–ripened cervices (dilatation ≥3 cm achieved), singleton fetus, cephalic presentation with intact membranes, and reassuring fetal heart rate tracing were recruited. Women were randomized to immediate titrated intravenous oxytocin infusion and early amniotomy or delayed amniotomy (after 4 h of oxytocin). The primary outcome was intervention (oxytocin)‐to‐delivery interval (h). Results: Intervention‐to‐delivery intervals (h) were mean ± standard deviation 9.0 ± 3.6 versus 10.6 ± 3.5 h (mean difference of 1.4 h) (P = 0.004) for the early versus delayed amniotomy arms, respectively. Birth rates at 6 h after oxytocin infusion were 19 of 70 (27.1%) versus 8 of 70 (11.4%) (relative risk, 2.38 [95% confidence interval (CI), 1.11–5.06]; number needed to treat: 7 [95% CI, 3.5–34.4]) (P = 0.03), cesarean delivery rates were 29 of 70 (41.4%) versus 33 of 70 (47.1%) (relative risk, 0.88; 95% CI, 0.61–1.28) (P = 0.50), and maternal satisfaction on birth process were a median of 7 (interquartile range, 7–8) versus 7 (interquartile range, 7–8) (P = 0.40) for the early versus delayed amniotomy arms, respectively. Conclusion: In term nulliparas with cervices ripened by Foley catheter, immediate oxytocin and early amniotomy compared with a planned 4‐h delay to amniotomy shortened the intervention‐to‐delivery interval but did not significantly reduce the cesarean delivery rate. Synopsis: Immediate oxytocin and early amniotomy compared with delayed amniotomy after cervical ripening with Foley catheter in nulliparas shorten the intervention‐to‐delivery interval. [ABSTRACT FROM AUTHOR]

Objective: To assess the cost-effectiveness of vaginal misoprostol (PGE1; 25 µg) compared with a slow-release dinoprostone (PGE2) pessary (10 µg) for labor induction due to an unfavorable cervix at term. Methods: We used data from an open-label multicenter, randomized non-inferiority trial that recruited women for whom labor was induced for medical reasons. The incremental cost-effectiveness ratio was assessed from the payer's perspective, with the focus on inpatient care costs and using the cesarean deliveries avoided (CDA) rate as the primary analysis and the rate of vaginal delivery within 24 h (VD24) as the secondary analysis. Results: Analyses were based on 790 women in each group. Differences between treatment arms were the mean cost per patient of €4410 and €4399, a CDA rate of 80.1% and 77.9% and a VD24 rate of 46.1% and 59.4% for dinoprostone and misoprostol, respectively. Dinoprostone is not cost-effective according to the CDA rate and misoprostol was either a cost-effective or a dominant strategy according to the VD24. Conclusion: Misoprostol and dinoprostone have equal cost management with mixed efficacy according to the clinical outcome used. Finally, misoprostol may be an attractive option for hospitals as the price is lower and it is easier to use. [ABSTRACT FROM AUTHOR]

Objective: To examine the simultaneous effect of high-volume Foley catheter (HVFC) (60 ml) and vaginal misoprostol on labor induction in nulliparous women. Methods: A randomized, double- blind, controlled trial was conducted among nulliparous post-date (>40 weeks) pregnant women between June and December 2019. At enrollment 100 women were randomized into each group (either HVFC and vaginal misoprostol or low-volume Foley catheter [LVFC] [30 ml] and vaginal misoprostol), for labor induction. Demographic and clinical data were collected at enrollment and delivery. Results: Women in the HVFC group had statistically significantly shorter induction to delivery interval (median 860 min, interquartile range [IQR] 840-940 min vs. 1160 min, IQR 1080-1320 min, P < 0.001) and duration of labor (median 615 min, IQR 600-680 min vs. 750, IQR 692.5-800 min, P < 0.001). Mode of vaginal delivery (n = 94 vs. n = 78, P = 0.002), number of doses of misoprostol required (median 2, IQR 1-2 vs. 2, IQR 1-3), and need of oxytocin augmentation (n = 22 vs. n = 39, P = 0.014 and P < 0.001), was significantly better in the HVFC group. However, there was no significant difference with respect to other maternal or neonatal outcomes. Conclusion: Simultaneous use of HVFC and vaginal misoprostol for labor induction significantly shortens the induction to delivery interval and duration of labor in nulliparous women. Trial Registration: Clinical Trial Registry of India CTRI/2019/05/019394 (http://ctri. nic.in/Clini caltr ials/pmain det2.php?trial id=31554 &EncHi d=&userN ame=Foley %20cat heter). [ABSTRACT FROM AUTHOR]

Objective: To investigate whether the addition of oxytocin to cervical ripening with a Foley catheter (FC) among nulliparous women shortens the time to delivery. Methods: In this double-blinded randomized trial conducted at Moi Teaching and Referral Hospital, 220 women were randomly assigned to FC plus low-dose oxytocin as treatment or FC plus placebo as controls in a 1:1 ratio. A modified intention-to-treat analysis was performed using SPSS v24. The protocol was approved by the institutional ethics committee and registered at www.ctr.pharm acybo ardke nya.org; ECCT/19/08/02. Results: Baseline characteristics were similar. Time to delivery was shorter by 3 h in the treatment group compared with the controls (25.4 versus 28.4 h, P = 0.002). The treatment group had a 22% increased likelihood of delivery within 24 h compared with the controls (53.3% versus 43.1%, relative risk [RR] 1.22, 95% confidence interval [CI] 0.938-1.579, P = 0.135). The controls were however twice more likely to deliver by cesarean section than the treatment group (39% versus 21%, RR 2.32, 95% CI 1.16-2.73, P = 0.006). There were no significant differences in neonatal or other maternal outcomes. Conclusion: FC with adjunctive oxytocin for cervical ripening in nulliparous women results in a shorter time to delivery and reduced cesarean deliveries when compared with FC alone. [ABSTRACT FROM AUTHOR]

Objective: To investigate the role of abnormal cerebroplacental ratio (CPR) in predicting adverse fetal outcome in pregnancies with induction of labor. Methods: This prospective observational study conducted at Medeniyet University Göztepe Training and Research Hospital between December 1, 2018 and October 31, 2019 enrolled women with scheduled induction of labor at or beyond 37 weeks of pregnancy. Women with singleton non‐anomalous fetuses with cephalic presentation and who had Bishop scores of 5 or less in pelvic examination were included in the study. Exclusion criteria were the presence of uterine scar history, non‐cephalic presentation, multiple pregnancy, vacuum‐ or forceps‐assisted delivery, and shoulder dystocia. Using fetal Doppler ultrasound, CPR was calculated (the ratio of umbilical artery to middle cerebral artery pulsatility index) and categorized into abnormal CPR (<1) and normal CPR (≥1). Data on maternal and delivery characteristics, fetal birth weight, and fetal complications were compared between the groups. Results: A total of 145 women were included, 28 in the abnormal CPR group and 117 in the normal CPR group. Multivariate analysis revealed labor induction at a later week of pregnancy (odds ratio [OR] 10.33, P = 0.001), lack of intrauterine growth restriction (IUGR) (OR 13.21, P = 0.001), fetal distress (OR 8.14, P = 0.003) or meconium aspiration (OR 159.91, P = 0.001), and umbilical artery pH values greater than 7.31 (OR 17.51, P = 0.015) to be associated with an increased likelihood of having normal (≥1) CPR values. Receiver operating characteristic analysis revealed association of normal CPR values with later labor induction (cut‐off value of >38.3 weeks, P = 0.001), higher birth weight (cut‐off value of >2460 g, P = 0.022) and higher umbilical artery pH (cut‐off value of >7.31, P = 0.007). Conclusion: Our findings revealed the significant role of abnormal CPR in predicting adverse fetal outcome in singleton pregnancies with scheduled induction of labor. Synopsis: Low cerebroplacental ratio predicted higher risk of neonatal acidosis, fetal distress, cesarean delivery, 5‐min Apgar score less than 7, low birth weight, and meconium aspiration in neonates. [ABSTRACT FROM AUTHOR]

Objective: To examine the awareness, prevalence of use, and knowledge of risks of pepper injection (PI), an injection of highly concentrated oxytocin used to augment or induce labor, among clinicians. Methods: An anonymous pre‐ and post‐workshop evaluation conducted among 227 clinicians participating in emergency obstetric and newborn care training in Sierra Leone from June to October 2018. Results: Overall, 225 participants completed the surveys. Of these, 198 (88.0%) of clinicians reported awareness of PI, and 123 (54.7%) self‐reported prior use, which was highest among midwives (94/129; 72.9%). Before EmONC training, 82 (36.4%) clinicians reported that they were likely to use PI; this decreased to 39 (17.3%) after training (P<0.05). The mean number of participants correctly identifying risks of PI increased from 149 (66.2%) to 204 (90.7%) after training (P<0.05). Conclusion: There was widespread awareness of PI use among clinicians, and prevalent self‐reported prior use among midwives. Risk awareness improved after EmONC training, and the proportion of clinicians reporting likelihood of future use decreased. Improper use of oxytocin may be a major contributor to maternal and newborn morbidity and mortality in Sierra Leone. Initiatives to educate clinicians and to regulate and stop the practice are needed. Synopsis: Most midwives undergoing an obstetric training program in Sierra Leone reported prior use of pepper injection—namely, highly concentrated oxytocin—for labor augmentation or induction. [ABSTRACT FROM AUTHOR]

Objective: Adequate obstetric care requires the availability of essential diagnostic and management equipment; however, for centers with budget restrictions, the acquisition and maintenance of these devices can pose major challenges. The purpose of the present paper is to disseminate knowledge about the availability of affordable and low-maintenance obstetric devices, which might help to save lives in low- and medium-resource countries.Method: Over the course of 2015-2018, the International Federation of Gynecology and Obstetrics (FIGO) Safe Motherhood and Newborn Health Committee acquired information from different clinical and commercial sources regarding the availability of affordable and low-maintenance essential obstetric devices.Results: The Committee identified several devices that met the criteria of low cost and ease of maintenance: a winding handheld Doppler device for intermittent auscultation; a portable continuous fetal heart rate monitor; a validated semi-automated blood pressure monitor; the Foley catheter balloon for labor induction in women with an unfavorable cervix; reusable metal and plastic vacuum cups and manual pumps; an intrauterine tamponade balloon; and the non-pneumatic anti-shock garment.Conclusion: Several affordable and low-maintenance obstetric devices are currently available that offer the potential to save lives in resource-constrained settings. [ABSTRACT FROM AUTHOR]

Objective: To assess the cesarean delivery (CD) rate among low-risk pregnancies before and after implementation of a hospital-based program in Canada.Methods: A prospective before-and-after study was conducted to assess the effects of the CARE (CAesarean REduction) strategy, which was developed and implemented at Markham Stouffville Hospital, Toronto, ON, Canada, in 2010 to reduce CD among low-risk women. Hospital records were reviewed to identify changes in the proportions of CD performed during 12 months (April 2009-March 2010) before implementation of the CARE strategy versus 12 months after implementation (April 2012-March 2013) at Markham Stouffville Hospital and 36 hospitals of the same level in the same province.Results: At the intervention hospital, 30.3% (964/3181) of women underwent CD in 2009-2010, compared with 26.4% (803/3045) in 2012-2013 (difference -3.9%, P<0.001). By contrast, no significant difference was recorded in control hospitals (28.1% [23 694/84 361] vs 28.2% [23 683/83 895]; difference 0.1%, P=0.5157).Conclusion: Implementation of the CARE strategy reduced rates of CD among the target population. [ABSTRACT FROM AUTHOR]

Objective: To assess health service costs associated with labor induction according to different clinical situations in a tertiary-level hospital.Methods: In a prospective study, individual patient cost data were assessed for women admitted for induction of labor at a tertiary hospital in Spain between November 1, 2012, and August 31, 2013. The costs of labor induction were estimated according to maternal and neonatal outcomes, method of delivery, cervical condition at admission, and obstetric indication. Direct costs including professional fees, epidural, maternal stay, consumables, and drugs were calculated.Results: Overall, 412 women were included in the final cost analysis. The mean total cost of labor induction was €3589.87 (95% confidence interval [CI] 3475.13-3704.61). Cesarean delivery after labor induction (€4830.45, 95% CI 4623.13-5037.58) was significantly more expensive than spontaneous delivery (€3037.45, 95% CI 2966.91-3179.99) and instrumental vaginal delivery (€3344.31, 95%CI 3151.69-3536.93). The total cost for patients with a very unfavorable cervix (Bishop score <2; €4283.47, 95% CI 4063.06-4503.88) was almost double that for women with a favorable cervix (€2605.09, 95% CI 2327.38-2837.58). Labor induction for hypertensive disorders of pregnancy was the most expensive obstetric indication for induction of labor (€4347.32, 95% CI 3890.45-4804.18).Conclusion: Following the induction of labor, a number of patient- and treatment-related factors influence costs associated with delivery. [ABSTRACT FROM AUTHOR]

Background Both misoprostol and prostaglandin E2 (PGE2) gel are used for labor induction in women with premature rupture of membranes (PROM). Objectives To evaluate studies comparing the effects of misoprostol and PGE2 gel in labor induction. Search strategy Databases including Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant papers. Selection criteria Randomized controlled trials comparing the use of misoprostol and PGE2 gel for labor induction in women with PROM were included. Data collection and analysis For meta-analyses, the Mantel–Haenszel method was used for dichotomous data, and the inverse variance method was used for continuous data. Main results Four randomized controlled studies (n = 615) were included. There were no significant differences between the two groups in the induction-to-delivery interval (mean difference – 4.44 hours; 95% confidence interval [CI] –9.35 to 0.48), rate of cesarean delivery (odds ratio [OR] 0.90; 95% CI 0.44–1.85), and rate of neonatal intensive care unit admission (OR 0.89; 95% CI 0.57–1.38). Women receiving misoprostol had a significantly higher rate of tachysystole than did those receiving PGE2 gel (OR 4.84; 95% CI 2.46–9.54). Conclusions Misoprostol is as efficacious and safe as PGE2 gel for labor induction in women with PROM. [ABSTRACT FROM AUTHOR]

Background The effectiveness of Foley catheter plus misoprostol for cervical ripening has not been convincingly shown in trials. Objectives To summarize the evidence comparing Foley catheter plus misoprostol versus misoprostol alone for cervical ripening. Search strategy Embase, Medline, and Cochrane Collaboration databases were searched with the terms “Foley catheter,” “misoprostol,” “cervical ripening,” and “labor induction.” Selection criteria Randomized controlled trials comparing the methods of cervical ripening for delivery of a viable fetus were included. Data collection and analysis Study characteristics, quality, and outcomes were recorded. Random-effects models were used to combine data. Main results Eight trials were included, with 1153 patients overall. In a pooled analysis of seven high-quality studies, the combination group had a decreased time to delivery (mean difference –2.36 hours, 95% confidence interval [CI] –4.07 to –0.66; P = 0.007). Risk of chorioamnionitis was significantly increased in the combination group (risk ratio [RR] 2.07, 95% CI 1.04–4.13; P = 0.04), and that of tachysystole with fetal heart rate changes was decreased (RR 0.58, 95% CI 0.38–0.91; P = 0.02). Frequency of cesarean did not differ ( P = 0.77). Conclusions The combined use of Foley catheter and misoprostol results in a reduced time to delivery, a reduced frequency tachysystole with fetal heart rate changes, and an increased incidence of chorioamnionitis. [ABSTRACT FROM AUTHOR]

Abstract: Background: Misoprostol, a prostaglandin E1 analog, stimulates uterine contractility and cervical ripening. A number of randomized trials and systematic reviews have evaluated its use in obstetric and gynecologic conditions. Misoprostol is inexpensive, stable at room temperature, and available in more than 80 countries, making it particularly useful in resource-poor settings. WHO recognizes the crucial role of misoprostol in reproductive health and has incorporated recommendations for its use into 4 reproductive health guidelines focused on induction of labor, prevention and treatment of postpartum hemorrhage, and management of spontaneous and induced abortion. Methods and results: All guidelines were prepared in accordance with the WHO Handbook for Guideline Development. The process included: identification of priority questions and critical outcomes; retrieval of evidence; assessment and synthesis of evidence; formulation of recommendations; and planning for dissemination, implementation, impact evaluation, and updating. The present report summarizes recommendations for misoprostol use in line with each guideline. Conclusion: The present comprehensive reference document was designed to enable clinicians and policy makers to quickly access and compare recommendations for the use of misoprostol in various reproductive health settings. [Copyright &y& Elsevier]

Abstract: Objective: To compare the efficacy and safety of titrated oral misoprostol and a conventional oral regimen for cervical ripening and labor induction. Methods: A randomized double-blind trial of women with term singleton pregnancies with indications for labor induction. Participants were allocated to receive 20mL of misoprostol solution (1μg/mL) orally every 1 hour for 4 doses then titrated to 40μg every 1 hour (titrated group) or 50μg of misoprostol orally every 4hours up to 12hours (conventional group). Primary outcomes were success rate of cervical ripening within 12hours, interval from first dose until more favorable cervix or active labor occurred, and total dose of misoprostol. Results: Sixty-four participants were included. Mean total dose of misoprostol and incidence of tachysystole were significantly higher in the titrated compared with the conventional group (236.2±110.1μg vs 103.1±35.7μg; P =0.001 and 25.0% vs 6.3%; P =0.03), whereas success rate, interval from drug administration to more favorable cervix and delivery, proportion of patients delivered vaginally within 12hours and 24hours, need for oxytocin augmentation, cesarean delivery rate, maternal adverse effects and complications, and neonatal outcome were not significantly different (P >0.05). Conclusion: Conventional oral misoprostol is as effective as titrated misoprostol for cervical ripening and labor induction, but has a lower incidence of tachysystole and a lower total dose of misoprostol is required. ClinicalTrial.gov: NCT00886860. [Copyright &y& Elsevier]

Objectives: To evaluate pre-eclampsia/eclampsia-associated maternal mortality in high-income countries to understand better the potential improvements in pre-eclampsia/eclampsia-related mortality in low-income countries.Methods: We searched Medline, PubMed, and the Cochrane Database (1900-2010) using relevant search terms. Studies of the incidence of pre-eclampsia/eclampsia and case fatality rates in various geographic regions were included. The incidence of pre-eclampsia/eclampsia and the pre-eclampsia/eclampsia-associated case fatality rates are presented by location and year.Results: Most declines in maternal mortality associated with pre-eclampsia/eclampsia in high-income countries occurred between 1940 and 1970 and were associated with a 90% reduction in the incidence of eclampsia and a 90% reduction in the case fatality rate in women with eclampsia. The most important interventions were widespread use of prenatal care with blood pressure and urine protein measurement, and increased access to hospital care for timely induction of labor or cesarean delivery for women with severe pre-eclampsia or seizures.Conclusions: A substantial reduction in pre-eclampsia/eclampsia-related mortality could be made in low-income countries by widespread hypertension and proteinuria screening and early delivery of women with severe disease. Magnesium sulfate may reduce mortality, but should not be the cornerstone of maternal mortality reduction programs. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the 50-g glucose challenge test (GCT) on pregnancy outcome in a multiethnic Asian population at high risk for gestational diabetes (GDM). Methods: GCT was positive if the 1-hour plasma glucose level was ≥7.2 mmol/L. GDM was diagnosed by a 75-g glucose tolerance test using WHO (1999) criteria. Of the 1368 women enrolled in the study, 892 were GCT negative, 308 were GCT false-positive, and 168 had GDM. Pregnancy outcomes were extracted from hospital records. Multivariable logistic regression analysis was performed with GCT negative women as the reference group. Results: GCT false-positive status was associated with preterm birth (adjusted odds ratio [AOR] 2.1; 95% CI, 1.2–3.7) and postpartum hemorrhage (AOR 1.7; 95% CI, 1.0–2.7). GDM was associated with labor induction (AOR 5.0; 95% CI, 3.3–7.5), cesarean delivery (AOR 2.2; 95% CI, 1.6–3.2), postpartum hemorrhage (AOR 2.1; 95% CI, 1.2–3.7), and neonatal macrosomia (AOR 2.5; 95% CI, 1.0–6.0). Conclusion: GCT false-positive women had an increased likelihood of an adverse pregnancy outcome. The role and threshold of the GCT needs re-evaluation. [Copyright &y& Elsevier]

Abstract: Objective: To compare the values of preinduction transvaginal cervical length measurements and Bishop score to predict successful labor induction. Methods: A prospective, observational trial of nulliparous women undergoing labor induction. Inclusion criteria were gestational age between 36 and 42 weeks, singleton cephalic presentation of the fetus, and intact membranes. Preinduction cervical ripening was performed using 25 μg intravaginal misoprostol (PGE1), repeated every 4 h, up to a maximum of 3 doses. Induction was subsequently continued by oxytocin and amniotomy. Results: A total of 43 women met the inclusion criteria. Mean preinduction cervical length for women with successful or failed labor induction was 26 mm (95% Confidence interval [CI], 27–32) and 34 mm (95% CI, 33–38), respectively (P =0.002). Mean Bishop scores for successful and failed induction groups were 5.4 (95% CI, 5.2–6.2) and 3.1 (95% CI, 2.8–3.5), respectively (P =0.003). Conclusion: Digital examination and transvaginal ultrasound of the cervix predict successful labor induction with reasonable accuracy. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the effectiveness and safety of different administration routes of misoprostol for induction of labor.Method: PubMed, Cochrane Library and EMBASE searches were carried out using the keywords oral, vaginal, sublingual, buccal, misoprostol, labor induction, identifying randomized case–controlled trials comparing different routes for giving misoprostol to induce labor, published in English between 1994 and 2004. Results: Seventeen studies (3549 participants) were included. Compared to vaginal administration, oral misoprostol was associated with higher failure rates for achieving vaginal delivery within 24 h (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.23–2.10), higher rates of uterine hyperstimulation without fetal heart rate (FHR) changes (OR 2.21, 95% CI 1.12 – 4.34) and lower cesarean section rates (OR 0.74, 95% CI 0.56–0.97). A lower dose of oral misoprostol (50 μg) compared to the 25–50 μg administered vaginally was associated with a higher rate of vaginal delivery not being achieved within 24 h (OR 3.60, 95% CI 2.10 – 6.18), more need for oxytocin augmentation (OR 2.19, 95% CI 1.65–2.92), less uterine hyperstimulation both without FHR changes (OR 0.58, 95% CI 0.42–0.80) and with FHR changes (OR 0.34, 95% CI 0.17–0.67) and fewer cesarean sections (OR 0.69, 95% CI 0.51–0.91). Compared to vaginal administration, buccal misoprostol resulted in a higher rate of failure to achieve vaginal delivery after 24 h, more frequent uterine hyperstimulation and lower rates of cesarean section, but these differences were not significant. When 50 μg of misoprostol used sublingually was compared to oral administration, the sublingual misoprostol was associated with less failure to achieve vaginal delivery after 24 h, less oxytocin augmentation and reduced cesarean section, but none of the differences were statistically significant. Conclusions: Vaginal misoprostol appears more effective than the equivalent dosage administered orally. However, the vaginal route appears to be associated with a higher risk of uterine hyperstimulation. Sublingual misoprostol seems an effective route of administration, but a lack of data necessitates more clinical trials to establish the effectiveness and safety of the buccal/sublingual route. [Copyright &y& Elsevier]

Objective: To evaluate the effectiveness and safety of Foley catheter and hyaluronidase for cervical ripening.Method: Randomized controlled trial where 140 pregnant women, with gestational age > or = 37 weeks, indication for labor induction and an unripe cervix, were enrolled, allocated in two groups according to the method of cervical ripening before labor induction. Statistical analysis used Student's t-test, Mann-Whitney, Chi-square test, survival analysis, risk ratios and number needed to treat.Results: Time of induction, dose of oxytocin and mode of delivery had better results in the Foley catheter group. Comfort with the method was higher in the hyaluronidase group.Conclusions: Both methods were effective and safe for cervical ripening. The Foley catheter group experienced a shorter period of induction, required a lower dose of oxytocin and had higher vaginal delivery rates, while the women who used hyaluronidase declared greater comfort with the method. [ABSTRACT FROM AUTHOR]

Objectives: To study the relationship between maternal endogenous dehydroepiandrosterone sulfate (DHEAS) levels, success of labor induction, and Bishop scores in postterm pregnancies.Methods: There were 65 postterm pregnancies. Group 1 consisted of women spontaneously in the active phase of labor, and group 2 of women with hypotonic uterine contractions whose labor was inducted by oxytocin. Levels of DHEAS were studied from venous blood samples. Demographic data and Bishop scores were recorded.Results: The demographic characteristics of patients were similar, but DHEAS levels were higher in group 1 than in group 2 (P<0.001). Linear regression analysis showed a significant relationship between DHEAS and Bishop scores. DHEAS levels in women delivered vaginally were significantly higher than in women delivered by cesarean section. From the receiver operating characteristics (ROC) curve, DHEAS levels might determine the mode of delivery and success of labor induction; however, Bishop scores do not.Conclusions: DHEAS levels may be an important factor influencing the efficiency of labor and the success of labor induction in postterm pregnancies. [ABSTRACT FROM AUTHOR]

Objectives: To compare the effectiveness of 25 μg vs. 50 μg of intravaginal misoprostol for cervical ripening and labor induction beyond 41 weeks’ gestation. Methods: The study population consisted of 120 women not in active labor with a gestational age >41 weeks, singleton pregnancy with vertex presentation, reactive fetal heart rate tracing, amniotic fluid index ≥5, and Bishop score <5. Women were randomized to receive either 25 μg (n=60) or 50 μg (n=60) of intravaginal misoprostol. The dose was repeated every 4 h (maximum number of doses limited to six) until the patient exhibited three contractions in 10 min. The main outcome measure was the induction–vaginal delivery interval. Results: There was no significant difference between the two groups with regard to the induction–vaginal delivery interval (685±201 min in the 25 μg group vs. 627±177 min in the 50 μg group, P=0.09). The proportion of women delivering vaginally with one dose of vaginal misoprostol was significantly greater in the 50 μg group (0/49 vs. 41/47, P<0.001). There were no differences in the rates of cesarean and operative vaginal delivery rates, or in the incidences of tachysystole and hyperstimulation syndrome in the two treatment groups. Neonatal outcomes were also similar. Conclusions: Intravaginal administration of 25 μg of misoprostol appears to be as effective as 50 μg for cervical ripening and labor induction beyond 41 weeks’ gestation. [Copyright &y& Elsevier]

Objectives: To evaluate if labor induction with 50 μg of vaginal misoprostol twice per day is as effective as and safer than 100 μg used once per day. Methods: Misoprostol was used to induce labor in 204 consecutive pregnant women assessed as needing labor induction, 104 at the University Hospital of the West Indies in Kingston, Jamaica, and 100 at the Victoria Jubilee Hospital, also in Kingston. At the former institution the women were administered 100 μg of misoprostol once per 24 h and at the latter 50 μg every 12 h. The doses were repeated if there was no cervical change or if the woman was not in labor. Bishop scores were determined before initiation of induction and again 12 h later. Women''s records were reviewed after 24 h to determine delivery outcome. Results: The indications for labor induction were similar in each group. There was no significant difference in the group demographics. In the group given 50 μg of misoprostol twice per day the mean time±S.D. from insertion of misoprostol to delivery was significantly shorter than in the other group (560.14±269.20 min vs. 729.90±471.65 min; P<0.01), and the percentage of women who were delivered within 12 h was higher (75% vs. 56.8%; P<0.002). There was no significant difference between the two groups in the rate of cesarean births, the need for oxytocin, or blood loss. Only two patients experienced uterine hyperstimulation, both in the group that had received 100 μg of misoprostol per day. There was no significant difference between the two groups in the birthweight of the neonates and in the number of neonates with Apgar scores less than 7 at 1 min and 5 min. There were, however, significantly fewer neonates who needed resuscitation (6% vs. 14.7%; P=0.04) and admission to the special care nursery (7% vs. 17%; P=0.03) in the group that had received 50 μg of misoprostol twice per day. Conclusions: A dose of 50 μg of misoprostol twice per day appears to be more efficient and safer than a dose of 100 μg once per day, but this may partially be due to weaknesses in the study design. [Copyright &y& Elsevier]

Objective: To compare maternal and perinatal outcomes in twin pregnancy patients without any fetal or maternal disease, managed by labor induction or expectant management after 36 weeks gestation. Methods: We conducted a case–control study of 81 patients: labor induction (n=36) vs. expectant management (n=45). Labor was induced using oxytocin (n=18), vaginal prostaglandins (n=6) or intrauterine balloon catheter (n=12) according to the Bishop score. Maternal and perinatal outcome variables were compared among both groups. Results: The characteristics of the labor induction group and the expectant management group were not statistically different, except for the rate of nulliparae (55.6% vs. 33.3%) and the rate of epidural analgesia (100% vs. 80%). There was no significant difference in labor time (6.5±2.8 h vs. 6.0±3.6 h), cesarean section rate (8.3% vs. 13.3%) or duration of maternal hospitalization (7.3±2.0 days vs. 7.5±2.3 days) in the labor induction group and in the expectant management group, respectively. The birth weight was higher in the labor induction group than in the expectant management group (2639±352 g vs. 2463±298 g, P<0.001). The rate of Apgar score <7 at 5 min was 0% and 3.3%, respectively. Neonatal intensive care unit admission occurred in 30.5% and 26.6% of the groups, respectively. No perinatal death was reported. Conclusion: Induction of labor may be proposed to patients with uneventful twin pregnancy after 36 weeks gestation without increasing maternal–fetal morbidity. [Copyright &y& Elsevier]

Efficacy of misoprostol was studied for induction of labor at term. Seventy patients were randomized to Group A (n = 36, oral misoprostol 50 microg four hourly to maximum of 5 doses) and B (n = 34, continuous oxytocin infusion). Induction-delivery interval was shorter with misoprostol (7.7 +/- 2.8 h against 14.3 +/- 4.8 h with oxytocin) but the rates of vaginal delivery, cesarean, neonatal outcome variables were similar. Hence, misoprostol is an effective agent for induction of labor at term. [ABSTRACT FROM AUTHOR]