BACKGROUND AND PURPOSE:

• McDonagh et al. (Obstetrics & Gynecology, 2021) compared cervical ripening in an outpatient vs inpatient setting or different methods used in the outpatient setting

METHODS:

• Systematic review and meta-analysis
• Data sources
  • Databases and reference lists through August 2020
• Study inclusion criteria
  • RCTs and cohort studies
  • Include analysis of outpatient cervical ripening using prostaglandins and mechanical methods in pregnant women at or beyond 37 weeks of gestation
• Study design
  • Data abstraction and risk of bias assessment were conducted by two reviewers
  • Random effects models were used for meta-analysis of results from two or more studies
• Primary outcomes
  • Birth-related outcomes (e.g. total time from admission to vaginal birth, cesarean rate)
  • Neonatal harms (e.g. mortality, infection)
  • Maternal harms (e.g. hemorrhage, infection)

RESULTS:

• 30 RCTs and 10 cohort studies: 9,618 pregnancies
  • Weighted mean age: 28.8 years
  • Weighted BMI: 26.7
• Quality of evidence: Low or insufficient strength of evidence
• Incidence of cesarean delivery
  • No difference found for inpatient vs outpatient setting  
    • Ripening method did not alter outcome
    • Most evidence was available was for single-balloon catheters and dinoprostone
• Harms were inconsistently reported or inadequately defined
• There were no differences in
  • Neonatal infection for inpatient vs outpatient dinoprostone
  • Birth trauma for inpatient vs outpatient single balloon catheter
  • Shoulder dystocia for outpatient dinoprostone vs placebo
  • Maternal infection for outpatient vs inpatient single-balloon catheters OR outpatient prostaglandins vs placebo
  • Postpartum hemorrhage for outpatient catheter vs inpatient dinoprostone
• Evidence on misoprostol, hygroscopic dilators, and other outcomes (eg, perinatal mortality and time to vaginal birth) was insufficient

CONCLUSION:

• Outpatient cervical ripening (with single-balloon catheter or dinoprostone) did not increase the incidence of cesarean delivery in women with low-risk pregnancies
• There was no significant difference in incidence of adverse outcomes between the inpatient and outpatient samples
• Limitations of this study include low certainty of evidence that would allow for “definitive conclusions” and in addition
  • Not all possible harms were included
  • Generalizability may be limited to 30 year olds, singleton fetuses, cephalic presentation, and no major comorbidities
  • Not all methods were sufficiently covered, specifically double-balloon catheters, hygroscopic dilators, misoprostol, or different prostaglandin doses and routes of administration
• The authors conclude

The finding that outpatient cervical ripening with dinoprostone and single-balloon catheters did not impose increased risk of cesarean delivery, with at least no strong signals of clinically important increased risk of harms, may be encouraging for women who are interested in outpatient cervical ripening

Learn More – Primary Sources:

Outpatient Cervical Ripening A Systematic Review and Meta-analysis

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