Labour induction with prostaglandins: a systematic review and network meta-analysis

Abstract

ObjeCtives To assess the effectiveness and safety of prostaglandins used for labour induction. Design Systematic review with Bayesian network metaanalysis Data sOurCesThe Cochrane Pregnancy and Childbirth Group's Database of Trials (which incorporates the results of a broad generic search for all pregnancy and postpartum trials). Sources included are CENTRAL, Medline, Embase, NHS Economic Evaluation Database, CINAHL, relevant journals, conference proceedings, and registries of ongoing trials.eligibility Criteria fOr seleCting stuDies Randomised clinical trials of prostaglandin or prostaglandin analogues used for third trimester cervical ripening or labour induction versus placebo or no treatment, alternative prostaglandin dose or administration, or a different type of prostaglandin. We included studies recruiting women with a viable fetus, but had no other restrictions relating to indication for labour induction or language of publication. Outcomes assessed were serious neonatal morbidity (trialist defined) or perinatal death; serious maternal morbidity (trialist defined) or death; vaginal delivery not achieved within 24 hours, caesarean section, and uterine hyperstimulation with fetal heart rate changes. results 280 randomised clinical trials were included (48 068 women) in the review. Maternal and neonatal mortality and serious morbidity were rarely reported and are summarized narratively. Unresolved inconsistency was observed for the hyperstimulation outcome. Relative to placebo, the odds of failing to achieve a vaginal delivery were lowest for vaginal misoprostol (≥ 50 μg) (odds ratio 0.06 (95% credible interval 0.02 to 0.12)), with a 39% absolute probability of event (95% credible interval 1% to 94%). Compared with placebo, odds of caesarean section were lowest for titrated oral misoprostol solution ( < 50 μg) (odds ratio 0.65 (0.49 to 0.83)), with an absolute probability of event of 15% (3% to 40%). COnClusiOnsLow dose( < 50 μg) titrated oral misoprostol solution had the lowest probability of caesarean section, whereas vaginal misprostol (≥50 μg) had the highest probability of achieving a vaginal delivery within 24 hours. These findings have important implications for a series of current national and international guidelines for induction of labour and future research in this area. systematiC review registratiOn PROSPERO 2013:CRD42013005116 IntroductionLabour inductions have increased steadily over the past two decades, with overall rates in many countries now exceeding 20% of all births. 1 2 Many different methods have been used, but prostaglandins remain a preferred method for cervical ripening and labour induction. 1 3 4 Although various prostaglandins have been tested in randomised trials, current recommendations have not been based on a quantitative overview of the accumulated evidence of their effectiveness and safety. Published meta-analyses have focused on pairwise "head to head" comparisons, 5-7 but clinicians, women, and policy makers tend to make informal indirect comparisons between dif...

Women's Experiences with and Preference for Induction of Labor with Oral Misoprostol or Foley Catheter at Term

“…4,5 Most research regarding induction of labor has focused on methods and different management strategies, with little attention for women's experiences and preferences. 6,7 In a prospective cohort study among 936 women, those who had their labor induced had a less positive birth experience compared with spontaneous labor (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.0-2.3). 5 Also, women who had their labor induced were less satisfied with the care received compared with women who had spontaneous onset of labor.…”

What is the optimal duration of oral misoprostol treatment for cervical ripening?

“…All studies have concluded that it is an effective medication for this indication [10][11][12]. WHO recommends that cervical ripening with misoprostol should have a maximum duration of 24 h [31].…”

“…The oral route may result in improved clinical outcomes over the vaginal route [10,11], and women's convenience and comfort also seem to be increased [15][16][17][18]. The regimens most frequently used were either 20-25 mg every 2 h for a maximum of 12 doses (24 h), or 50 mg every 4 h for a maximum of 6 doses (24 h).…”

“…It is cheap, stable at room temperature, easy to use, and without many digestive side effects [8]. Several studies comparing the effectiveness of prostaglandins for cervical ripening suggest that misoprostol is more effective than PGE 2 with a significant decrease in the cesarean section rate [9][10][11][12]. The World Health Organization, the International Federation of Gynecology and Obstetrics, and the ACOG allow the use of misoprostol for IOL under certain conditions [13].…”

Simplifying oral misoprostol protocols for the induction of labour

“…A recently completed UK National Institute of Health Research (NIHR) funded network and cost‐effectiveness analysis included 31 induction regimes evaluated in 611 trials with over 100 000 trial participants. Titrated low‐dose oral misoprostol was identified as likely to be the most cost‐effective method, and also had a favourable safety profile 5, 6. Sublingual or buccal misoprostol had significantly higher rates of hyperstimulation.…”