Grand Rounds

What is the Best Labor Induction Method for Multiparous Women?

BACKGROUND AND PURPOSE:

Ripening is indicated if a cervix is unfavorable
Foley balloon (mechanical ripening) is a commonly used approach, as well as the addition of pharmacologic agents
Data is limited on the best approach in multiparous women with only one previous RCT (see ‘Related ObG Topics’ below: FIAT-M study)
Bauer et al. (AJOG 2018) sought to determine the best induction method for for multiparous women with an unfavorable cervix

Randomized controlled trial (RCT)
Participants: Multiparous women, ≥18 years with prior vaginal delivery
- Singleton nonanomalous fetus | ≥34 weeks | Vertex presentation | EFW <4500 g | cervical dilation ≤2 cm on admission to labor and delivery
- >1 prior cesarean or complicated delivery, particularly if a contraindication to vaginal delivery were excluded
Women were randomized into the following groups
- Simultaneous (oxytocin with cervical ripening balloon)
- Sequential (oxytocin following cervical ripening balloon expulsion)
Primary outcome: Delivery within 24 hours of cervical ripening balloon placement
Secondary outcomes
- Induction-to-delivery interval | Time to cervical ripening balloon expulsion | Mode of delivery | Adverse maternal or neonatal outcomes

180 patients were included
Baseline demographic and obstetric characteristics were similar between groups
When compared to the sequential group, women in the simultaneous group
- Were more likely to deliver within 24 hours vs the sequential group (87.8% vs 73.3%; P=0.02)
- Had a shorter induction-to-delivery interval (12.5 h vs 16.3 h; P=0.01)
- Had greater cervical dilation at cervical ripening balloon expulsion (4 cm vs 3.5 cm; P=0.001)
There were no differences in mode of delivery, chorioamnionitis, or adverse maternal or neonatal outcomes

Simultaneous administration of oxytocin and cervical ripening balloon lead to a greater success for induced labor compared to sequential administration
Authors note that they used all delivery within 24 hours, rather than vaginal delivery
- Vaginal delivery was not itself statistically significant but time to vaginal delivery was improved in the simultaneous group
The authors recommend that “The simultaneous use of oxytocin with cervical ripening balloon should be incorporated into the management for multiparous women who require cervical ripening while undergoing induction of labor.”

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