BACKGROUND AND PURPOSE:

• Labor induction rates in US and UK now over 20%
• For a woman with low risk for delivery complications, certain methods of labor induction or cervical ripening could be used in outpatient settings
• Vogel et al. (Cochrane Database Syst Rev., 2017) compared methods of labor induction or cervical ripening in outpatient settings, measuring their effectiveness, maternal satisfaction, healthcare costs and, where information is available, safety.

METHODS:

• Performed meta-analysis, incorporating randomized controlled trials (RCT)
• Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy
• Researchers included women who received treatment at home or sent home after treatment and initial monitoring in hospital
  • Most recent Cochrane review (2013) that compared the same treatment outpatient vs inpatient could not reach a conclusion due to limited data
  • Current approach allows for pooling of patients treated in outpatient setting in studies that were assessing treatment options vs setting
• Main outcomes
  • Vaginal birth not achieved within 24 hours
  • Additional induction agents required
  • Length of hospital stay
  • Use of emergency services
  • Maternal satisfaction
  • Caregiver satisfaction
  • Serious neonatal morbidity or perinatal death (composite outcome will include, for example, seizures, birth asphyxia defined by trialists, neonatal encephalopathy, disability in childhood)
  • Serious maternal morbidity or death (composite outcome will include, for example, uterine rupture, admission to intensive care unit, septicemia)
  • GRADE methods used to assess result quality

RESULTS:

• 5,003 women were pooled from 34 RCTs
• Limited quality data was available and overall evidence was graded low with some moderate quality studies
• Most studies looked at women at term, low risk

Vaginal PGE₂ versus expectant management or placebo

• Fewer women in the vaginal PGE₂ group needed additional induction agents
  • Wide confidence intervals (risk ratio [RR] 0.52, 95% CI 0.27 to 0.99)
• No difference between groups in
  • uterine hyperstimulation (RR 3.76, 95% CI 0.64 to 22.24)
  • caesarean section (RR 0.80, 95% CI 0.49 to 1.31)
  • admission to NICU (RR 0.32, 95% CI 0.10 to 1.03)

Intracervical PGE₂ versus expectant management or placebo

• No clear difference between groups for:
  • Need for additional induction agents (RR 0.98, 95% CI 0.74 to 1.32)
  • Vaginal birth not achieved within 48 to 72 hours (RR 0.83, 95% CI 0.68 to 1.02)
  • Uterine hyperstimulation with FHR changes (RR 2.66, 95% CI 0.63 to 11.25)
  • Cesarean section (RR 0.90, 95% CI 0.72 to 1.12)
  • Babies admitted to NICU (RR 1.61, 95% CI 0.43 to 6.05)

Vaginal misoprostol versus placebo

• One small study reported on the rate of perinatal death with no clear differences between groups
• There were no deaths in the treatment group compared with one stillbirth (reason not reported) in the control group (RR 0.34, 95% CI 0.01 to 8.14)
• There was no clear difference between groups in rates of:
  • Uterine hyperstimulation with FHR changes (RR 1.97, 95% CI 0.43 to 9.00)
  • Cesarean section (RR 0.94, 95% CI 0.61 to 1.46)
  • Babies admitted to NICU (RR 0.89, 95% CI 0.54 to 1.47)

Additional Notes

• Women who received oral misoprostol were more likely to give birth within 24 hours (RR 0.65, 95% CI 0.48 to 0.86) and were less likely to require additional induction agents (RR 0.60, 95% CI 0.37 to 0.97)
• Women who received mifepristone were also less likely to require additional induction agents (average RR 0.59, 95% CI 0.37 to 0.95) but high heterogeneity noted in these studies
• There was no information on vaginal birth within 24, 48 or 72 hours, length of hospital stay, use of emergency services, maternal caregiver satisfaction or serious maternal and neonatal morbidity or deaths as well as maternal or neonatal morbidity in many of the studies

CONCLUSION:

• Induction of labor in the outpatient setting or sending women home after initial treatment in the hospital setting appears to be a management option
• Important adverse events seem rare but evidence my be insufficient to make firm conclusions regarding differences
• Additional induction treatments do not appear to be required

Learn More – Primary Sources:

Pharmacological and mechanical interventions for labour induction in outpatient settings.

Related ObG Topics:

Labor Induction and an Unripe Cervix: Does it Result in More C-sections?

Foley vs Misoprotol:  What is the Most Cost-Effective Way to Induce Labor?

Induction to Prevent Stillbirths for Age 35 and Older: Impact on Cesarean Rates?

The FIAT-M study: Simultaneous or Sequential Foley and Oxytocin for Induction in Multiparous Women