BackgroundMisoprostol 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.ObjectivesTo 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 StrategyWe 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 CriteriaWe 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 AnalysisTwo 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 ResultsThirteen 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).ConclusionsLow‐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.
