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To compare the effectiveness, safety and patient satisfaction of a double balloon catheter (DB) with a synthetic osmotic cervical dilator (OD) for pre-induction cervical ripening in an outpatient setting. This is a prospective, dual-center pilot study including 94 patients with an unripe cervix (Bishop Score <6) near term; 50 patients received the DB and 44 patients the OD. The primary outcomes were the difference in BishopScore (BS) and cervical shortening. Pain perception at insertion and during the cervical ripening period was evaluated by a visual analogue scale and patient satisfaction by a predefined questionnaire. The use of DB was associated with a significantly higher increase in BS (median 3) compared to OD (median 2; p=0.002) and resulted in significantly greater cervical shortening (median −14 mm vs. −9 mm; p=0.003). There were no serious adverse events at placement of devices or during the cervical ripening. There were no significant differences in perinatal outcomes. Pain perception during cervical ripening was significantly higher (p<0.001), and patient satisfaction regarding sleep, relaxing time and performing desired daily activities were significantly lower in patients with DB compared to patients with OD (p<0.001). DB was superior to OD regarding cervical ripening based on BS and on sonographic measurement of the cervical length. Patients with OD experienced less pain during cervical ripening and were more satisfied with the method compared to patients with DB. [ABSTRACT FROM AUTHOR]

Background: Cervical ripening is a multifactorial outcome, and the association between cervical ripening and vaginal microbiota remains unexplored in term primiparous women. A new sequencing technology, microbiome 2bRAD sequencing (2bRAD-M) that provides a higher level of species discrimination compared to amplicon sequencing. We applied 2bRAD-M to analyze the vaginal microbiota in a population with variations in cervical ripeness and to explore potential microbiota factors influencing cervical ripening. Methods: A total of 30 full-term primigravid women participated in this study, with 15 belonging to the low scoring group of cervical ripeness and 15 to the high scoring group. Clinical information was collected from the participants, and the vaginal microbiota and community structure of both groups were analyzed using 2bRAD-M sequencing. Microbiota diversity and differential analyses were conducted to explore potential factors influencing cervical ripening. Results: A total of 605 species were detected. There was no difference in vaginal microbiota diversity between the two groups, and the vaginal microbial composition was structurally similar. In the two groups, Lactobacillus crispatus and Lactobacillus iners were identified as the two pivotal species through random forest analysis. Concurrent, extensive and close connections between species within the two groups were observed in the correlation analysis, influencing the aforementioned two species. Pairwise comparisons showed that Sphingomonas (P = 0.0017) and three others were abundant in high scoring group, while Alloprevotella (P = 0.0014), Tannerella (P = 0.0033), Bacteroides (P = 0.0132), Malassezia (P = 0.0296), Catonella (P = 0.0353) and Pseudomonas (P = 0.0353) and so on showed higher abundance in low scoring group. Linear discriminant analysis effect size identified 29 discriminative feature taxa. Conclusion: For the first time, vaginal microbiota was sequenced using 2bRAD-M. With a relatively simple structure, a more stable vaginal microbiota is associated with higher cervical ripeness, and certain microorganisms, such as Sphingomonas, may play a beneficial role in cervical ripening. [ABSTRACT FROM AUTHOR]

Objective Our objective was to compare patient perceived control and experience with outpatient versus inpatient cervical ripening. Study Design This is a retrospective mixed-methods analysis of a quality improvement initiative focused on the impact to patients of incorporating outpatient cervical ripening into routine practice. Postpartum inpatients who had elected for outpatient cervical ripening (outpatients) and those who met criteria for outpatient cervical ripening but opted for an inpatient setting (inpatients) were invited to participate in the study. Patients completed the Perceived Control in Childbirth Scale, and scores were compared between outpatient and inpatient groups using Mann–Whitney U test. In addition, semistructured questions elicited feedback prior to hospital discharge, and these qualitative data were analyzed using iterative thematic analysis. Results The study population consisted of 36 outpatients and 38 inpatients. The median score on the Perceived Control in Childbirth Scale was 69 for outpatients and 67 for inpatients (p -value = 0.49), out of a maximum score of 72 (representing the highest level of perceived control). Both groups reported similarly high levels of perceived control, regardless of cervical ripening setting. In the qualitative analysis, pain was the most common theme in both groups. Inpatients reported more distress despite access to stronger pain medications. Outpatients utilized a variety of distraction techniques and expressed gratitude for their setting more than inpatients. Conclusion Outpatient cervical ripening can be a patient-centered solution to obstetric throughput challenges arising from increased numbers of inductions. Those who underwent outpatient cervical ripening had similar perceived control to those who underwent inpatient cervical ripening, suggesting that individual patient preferences are most important in determining the optimal setting for care. The patients' reported experiences identified focus areas for process improvement efforts and future research, including improving patient education regarding expectations and innovating new pain management strategies for cervical ripening. Key Points Patient experiences must inform patient-centered care. Perceived control with cervical ripening was high. Pain with cervical ripening was the most cited theme. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion Registration at Clinical Trials To examine whether cervical ripening with a double balloon device for 6 h is as effective as 12 h in patients with a cervical length ≥ 30 mm measured on transvaginal ultrasound before induction of labor, and to determine whether patients with a long cervix need to have the balloon placed for a longer time.This is a secondary analysis of data from a randomized controlled trial that compared maternal and neonatal outcomes between women undergoing cervical ripening with a double balloon device for 6 h (study group) versus 12 h (control group). In this secondary analysis, we included only patients who had cervical length ≥ 30 mm measured on transvaginal ultrasound on admission. Our primary outcome was a Bishop score change after removal of the device. Secondary outcomes included insertion to delivery interval, mode of delivery, and oxytocin infusion duration.Sixty‐seven women met the inclusion criteria and were included in the analysis: 33 in the 6‐h group and 34 in the 12‐h group. Maternal characteristics were similar between both groups. Bishop score difference between the preinsertion and the postremoval scores were similar in the two groups (2.67 ± 1.8 vs. 2.53 ± 1.69, P = 0.76), while insertion to delivery time was 10 h shorter in the 6‐h group (20.95 vs. 31.21, P = 0.02; mean difference, −10.26 [95% CI, −19.0 to −1.51]). The other secondary outcomes remained similar in both groups.In women undergoing induction of labor who have a cervical length ≥ 30 mm measured on admission transvaginal ultrasound, removing a double balloon device after 6 h achieved similar Bishop score changes as removal after 12 h, but significantly reduced the time to delivery.https://classic.clinicaltrials.gov/ct2/show/NCT03045939. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions Our objective was to compare the performance of the first vaginal examination at 8 versus 4 h after amniotomy following Foley ripening in nulliparous labor induction.A randomized controlled trial was conducted from June 2021 to January 2022. 210 nulliparas at term for labor induction were randomized: 105 each to first vaginal examination at 8 or 4 h after Foley balloon ripening and amniotomy. Titrated oxytocin infusion was routinely commenced after amniotomy to expedite labor. Primary outcomes were the amniotomy‐to‐delivery interval (non‐inferiority hypothesis) and maternal satisfaction with their allocated labor care (superiority hypothesis) within 24 h after delivery. Analyses performed using t‐test, Mann–Whitney U test, and Chi‐squared test as appropriate.The amniotomy‐to‐delivery interval was mean ± standard deviation 8.7 ± 3.4 versus 8.4 ± 3.7, mean difference 0.4 (97.5% CI: −0.7 to 1.5) hours, p = 0.442 within the pre‐specified 2‐hour non‐inferiority margin, and maternal satisfaction score with allocated labor care was median [interquartile range] 8[7.5–10] versus 8[7.0–10], p = 0.248 for 8 versus 4 h arms, respectively. The amniotomy to first vaginal examination intervals was 5.9 ± 2.3 versus 3.6 ± 1.0 h, p < 0.001, and the number of vaginal examinations was 2[1–2.5] versus 3 [2, 3], p < 0.001 for 8 versus 4 h, respectively. The first vaginal examination was less likely to have been performed as scheduled, more likely to be indicated by the urge to bear down, and non‐reassuring cardiotocography for the 8 h arm (p < 0.001). Spontaneous vaginal delivery was significantly more likely and instrumental vaginal delivery less likely, but cesarean rate was not significantly different for the 8 h arm (p = 0.017).A routine first vaginal examination at 8 h compared to 4 h is non‐inferior for the time to birth but does not increase maternal satisfaction although the number of vaginal examinations is fewer. The increase in spontaneous vaginal delivery and reduction in instrumental vaginal delivery rates warrant further powered primary evaluation. [ABSTRACT FROM AUTHOR]

To compare effectiveness and safety of the Cook's balloon with vaginal dinoprostone to induce labor in patients with previous cesarean section. Observational, and retrospective study that included pregnant women at ≥ 37 weeks' gestation, with unfavorable cervix, singleton pregnancy, intact membranes, and a previous cesarean section, who had undergone labor induction in the period 2014–2019. 170 patients (86 balloon-84 dinoprostone) were analyzed. The proportion of women achieving vaginal delivery within 24 h was higher in the dinoprostone than in double-balloon group (RR, 3.24; 95% CI, 1.36–7.72). No significant differences were detected in the first 48 h in vaginal deliveries (P =.749) or in cesarean section rates (P =.634). Nor were there differences in maternal or fetal safety profiles. A body mass index > 35 increased the risk of cesarean section by 1.53 times (P =.017) and a Bishop's test score < 3 by 1.91 times (P =.009). A vaginal delivery following a cesarean section decreased the probability of another cesarean section by 0.46 times (P =.039). Labor induction with vaginal dinoprostone achieves better vaginal delivery rates in the first 24 h vs Cook's balloon. While the difference in uterine rupture rate did not reach significance, this was higher in women receiving prostaglandin. [ABSTRACT FROM AUTHOR]

Objective: The present study aimed to evaluate low‐dose oral misoprostol induction, and compare different methods used in second‐line induction in patients with a Bishop score less than 6. Methods: This retrospective study analyzed the medical history and courses of pregnancy of all patients induced with first‐line of low‐dose oral misoprostol (50 μg every 4 h with a total of 200 μg/24 h) from April 2021 to June 2022 in a university hospital center, and reported outcomes according to the second‐line method of induction. Results: Among 437 labor inductions with low‐dose oral misoprostol, 120 patients required a second‐line induction. Predictive factors of first‐line failure were higher body mass index (P = 0.011), absence of premature rupture of membranes (P = 0.021) and earlier term of pregnancy (P < 0.001). Regarding second methods of induction of labor, time from induction to delivery was shorter in the oxytocin group than the dinoprostone and misoprostol groups (24.0 vs. 41 and 51.0 h, respectively; P < 0.001), and was also significantly shorter in the dinoprostone than the misoprostol group (P = 0.048). Cesarean section rates did not differ between the three groups (P = 0.651). There were no clinically significant differences in adverse events between the groups. Conclusion: Normal body mass index, previous rupture of membranes and later term of induction of labor were the three favoring success factors during first‐line oral misoprostol. In cases of a Bishop score <6, oxytocin may be the best option to reduce duration to delivery, with the same maternal‐fetal outcomes, including a similar rate of vaginal delivery. Synopsis: If a Bishop score was <6 after 24 h oral misoprostol, oxytocin could be the best method to reduce duration to delivery. [ABSTRACT FROM AUTHOR]

Objective Combining pharmacologic agents with mechanical ripening achieves the shortest labor duration, yet there is no clear evidence on route of drug administration in obese individuals. The use of buccal misoprostol has shown greater patient acceptance but remains understudied. Our objective was to evaluate the difference in time to delivery of buccal compared with vaginal misoprostol in combination with a Foley catheter (FC) for induction of labor (IOL) in the obese population. Study Design This was a secondary analysis of a randomized controlled trial comparing identical dosages (25 μg) of buccal and vaginal misoprostol in combination with a FC. The parent trial was an institutional review board-approved, randomized clinical trial conducted from June 2019 through January 2020. Labor management was standardized among participants. Women undergoing IOL at ≥37 weeks with a singleton gestation and cervical dilation ≤2 cm were included. Body mass index (BMI, kg/m 2) was stratified. The primary outcome was time to delivery. Results A total of 215 participants were included. Demographic characteristics were similar between the three groups. Vaginal drug administration achieved a faster median time to delivery than the buccal route among patients with a body mass index greater than or equal to 30 kg/m 2 (vaginal misoprostol–FC: 21.3 hours vs. buccal misoprostol–FC: 25.2 hours, p = 0.006). There was no difference in the cesarean delivery rate between the two groups. Furthermore, patients with a BMI greater than or equal to 30 kg/m 2 receiving vaginal misoprostol delivered 1.2 times faster than women who received buccal misoprostol after censoring for cesarean delivery and adjusting for parity (hazard ratio: 1.2, 95% confidence interval: 1.1–1.7). There were no significant differences in maternal and neonatal outcomes. Conclusion We found that vaginal misoprostol was superior to buccal misoprostol when combined with a FC among individuals with a BMI greater than or equal to 30 kg/m 2. Vaginal misoprostol should be the preferred route of drug administration for term IOL in this population. Key Points Vaginal misoprostol was superior to buccal route among patients with obesity. There was no difference in the cesarean delivery rate between the two groups. Vaginal misoprostol should be the preferred route of administration among patients with obesity. [ABSTRACT FROM AUTHOR]

Objective: To evaluate vaginal delivery in obese women who underwent cervical ripening at term using a dinoprostone vaginal insert or a cervical ripening balloon (CRB), and to assess maternal and neonatal morbidity according to the method. Methods: A prospective cohort study including obese women with a live singleton fetus in cephalic presentation who required cervical ripening at term (≥37 weeks) for maternal and/or fetal disease using a dinoprostone vaginal insert or a CRB. The primary outcome was vaginal delivery. Secondary outcomes were a favorable cervix (Bishop score >6) after 24 h, the time from device insertion to delivery, and composite maternal and neonatal morbidity. Results: In total, 135 consecutive women were analyzed (107 CRB, 79.3%; 28 dinoprostone vaginal insert, 20.7%). Vaginal delivery (86 [80.4%] after CRB vs 19 [67.9%] after dinoprostone vaginal insert; P = 0.248), favorable cervix within 24 h after device placement (52 [48.6%] vs 17 [60.7%]; P = 0.264), and maternal morbidity (12 [11.2%] vs 4 [14.3%]; P = 0.646) were similar between the groups. The time from device insertion to delivery also did not differ between the groups. Neonatal morbidity was significantly higher after the dinoprostone vaginal insert (11 [39.3%] vs 20 [18.7%]; P = 0.030). Cervical ripening using the dinoprostone vaginal insert, compared with the CRB, was significantly associated with neonatal morbidity (adjusted odds ratio 4.00, 95% confidence interval 1.34–12.5), but not with maternal morbidity (adjusted odds ratio 1.23, 95% confidence interval 0.30–4.38). Conclusions: Vaginal delivery, a favorable cervix after 24 h, the time from device insertion to delivery, and maternal morbidity did not significantly differ between the CRB and the dinoprostone vaginal insert for cervical ripening in obese women at term. Nevertheless, neonatal morbidity was significantly associated with the dinoprostone vaginal insert, compared with the CRB, among obese women who required cervical ripening at term. Synopsis: Neonatal morbidity was associated with vaginal dinoprostone, compared with a CRB, among obese women at term, without a difference in vaginal delivery and maternal morbidity. [ABSTRACT FROM AUTHOR]

Abstract Background Cervical ripening is a multifactorial outcome, and the association between cervical ripening and vaginal microbiota remains unexplored in term primiparous women. A new sequencing technology, microbiome 2bRAD sequencing (2bRAD-M) that provides a higher level of species discrimination compared to amplicon sequencing. We applied 2bRAD-M to analyze the vaginal microbiota in a population with variations in cervical ripeness and to explore potential microbiota factors influencing cervical ripening. Methods A total of 30 full-term primigravid women participated in this study, with 15 belonging to the low scoring group of cervical ripeness and 15 to the high scoring group. Clinical information was collected from the participants, and the vaginal microbiota and community structure of both groups were analyzed using 2bRAD-M sequencing. Microbiota diversity and differential analyses were conducted to explore potential factors influencing cervical ripening. Results A total of 605 species were detected. There was no difference in vaginal microbiota diversity between the two groups, and the vaginal microbial composition was structurally similar. In the two groups, Lactobacillus crispatus and Lactobacillus iners were identified as the two pivotal species through random forest analysis. Concurrent, extensive and close connections between species within the two groups were observed in the correlation analysis, influencing the aforementioned two species. Pairwise comparisons showed that Sphingomonas (P = 0.0017) and three others were abundant in high scoring group, while Alloprevotella (P = 0.0014), Tannerella (P = 0.0033), Bacteroides (P = 0.0132), Malassezia (P = 0.0296), Catonella (P = 0.0353) and Pseudomonas (P = 0.0353) and so on showed higher abundance in low scoring group. Linear discriminant analysis effect size identified 29 discriminative feature taxa. Conclusion For the first time, vaginal microbiota was sequenced using 2bRAD-M. With a relatively simple structure, a more stable vaginal microbiota is associated with higher cervical ripeness, and certain microorganisms, such as Sphingomonas, may play a beneficial role in cervical ripening.

Objective: In this study, we aimed to evaluate the factors associated with insufficient cervical ripening in a controlled-release dinoprostone vaginal delivery system (Propess). Materials and methods: This retrospective cohort study included 103 pregnant women who used Propess for labor induction. The outcomes were the factors associated with insufficient cervical ripening, defined as a Bishop score ≤6 on the morning after Propess administration. Results: Forty-nine participants had insufficient cervical ripening, and 54 had sufficient cervical ripening. Univariate analysis of these two groups showed that maternal age ≥35 years, early-term delivery (gestational age between 37 and 38 weeks), and Bishop scores at insertion ≤1 were significantly higher in the insufficient cervical ripening group. Multivariate logistic analysis showed that maternal age ≥35 years (adjusted odds ratio: 3.08, 95% confidence interval: 1.29–7.36, p = 0.011) and early-term delivery (adjusted odds ratio: 3.17, 95% confidence interval: 1.23–8.20, p = 0.017) were independent factors associated with poor Propess efficacy. Parity, pre-pregnancy body mass index, body mass index at delivery, and indications for labor induction were not associated with insufficient cervical ripening. Conclusions: In our study, older maternal age and early-term delivery were independent predictors of insufficient cervical ripening with Propess. More effective delivery management can be achieved by considering induction protocols tailored to individual maternal factors for patients with factors associated with poor Propess efficacy.

Objective: Pregnancy outcomes are an important factor in women’s quality of life, and negative experiences have adverse effects on the overall health of the mother and the family. This study was designed and implemented to compare the effects of two drugs, hyoscine and dexamethasone, on cervical ripening and effacement during childbirth. Methods: This study was a double-blind randomized clinical trial of 150 patients divided into three groups. The researchers, in the early stage (latent) of labor, gave 8 mg of dexamethasone intravenously to the first group, 20 mg of hyoscine butyl bromide to the second group, and 8 mg of dexamethasone along with 20 mg of hyoscine butyl bromide to the third group. Findings: Among the quantitative variables studied (length of labor induction, duration of active stage, first stage and second stage of labor, placental expulsion time, 5- and 10-min Apgar and Bishop score), active stage duration (P = 0.000) and 5-min Apgar (P = 0.042) had statistical differences among the three groups. In addition, the type of delivery (P = 0.003) and the percentage of fetal distress (P = 0.001) in the studied groups had a statistically significant difference, and also, in the third group, the cesarean rate was less than the other two groups. Conclusion: Simultaneous injection of hyoscine and dexamethasone in primiparous women can reduce the duration of the active stage of labor without obstetric complications, so its use in the latent stage is suggested.

Wenjie Liu, Li Guo, Lizhen Feng, Jie Wang, Miao Zhang, Xiaobin Fan Department of Obstetrics and Gynecology, Xi’an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi’an, 710018, People’s Republic of ChinaCorrespondence: Xiaobin Fan, Email liuwj0709@163.comObjective: To evaluate factors predictive of the success of a slow-release dinoprostone vaginal insert for cervical ripening.Methods: This retrospective study included 187 women who received dinoprostone vaginal inserts for cervical ripening. The participants were divided into two groups: the transvaginal delivery group (n = 87) and cesarean section termination group (n = 100). The correlation between the parameters present before cervical ripening with dinoprostone slow release and its success, as well as complications and adverse outcomes, was analyzed. Cesarean section predictors and area under the curve (AUC) were compared between the two Groups.Results: There were statistical differences between the two groups in body mass index (BMI), height, cervical Bishop score, cephalic position, time of medication use, and fetal head position at the time of medication use (P< 0.05). The optimal thresholds for identifying cesarean section in dinoprostone vaginal insert for cervical ripening were 162.5 for height (AUC = 0.61), 10.65 cm for amniotic fluid index (AUC = 0.6), S-2.5 for cephalic position (AUC = 0.61), 5.5 for bishop score of cervix (AUC = 0.65). The height, amniotic fluid index, cephalic position, and Bishop score of the cervix were included in the same model. The AUC value of the combined model was higher than the AUC value of the single factor.Conclusion: The combined model was a better predictor of cesarean section in dinoprostone vaginal inserts for cervical ripening and labor induction. The success of cervical ripening with a dinoprostone slow-release vaginal insert can be predicted by the factors that can be recognized at admission.Keywords: dinoprostone, cervical ripening, labor induction, predictive model

Background: One in four labors are induced. The process of cervical ripening can be lengthy and pre‐labor hospitalization is required. Outpatient cervical ripening can be an attractive alternative. Objectives: To evaluate the efficacy and safety of outpatient cervical ripening with a balloon catheter compared with inpatient balloon catheter or prostaglandin E2 (PGE2). Search Strategy: The PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases were searched from their inception to October 15, 2022. Selection Criteria: Randomized controlled trials comparing the outpatient balloon catheter with inpatient balloon catheter or inpatient PGE2 for term cervical ripening. Data Collection and Analysis: Bayesian network meta‐analysis was performed. The primary outcome was the cesarean delivery rate. The secondary outcomes included instrumental delivery, the time from intervention‐to‐birth, oxytocin augmentation, total hospital duration, and maternal/neonatal adverse events. Main Results: Twenty‐nine randomized controlled trials with a total of 6004 participants were identified. No difference in the cesarean delivery rate was revealed among the three interventions. Compared with inpatient balloon catheter, outpatient balloon catheter had shorter total hospital duration (mean difference −8.58, 95% confidence interval −17.02 to −1.10). No differences were revealed in the time from intervention‐to‐birth, instrumental delivery, postpartum hemorrhage, 5‐min Apgar score less than 7, umbilical cord arterial pH less than 7.1, and neonatal intensive care unit admission among the three interventions. Conclusions: Outpatient balloon catheter in low‐risk term pregnancies is an available option that could be considered for cervical ripening. The safety and effectiveness are comparable to inpatient cervical ripening methods. Synopsis: Outpatient balloon catheter had shorter total hospital duration compared with inpatient balloon catheter, and could be considered as an available option for cervical ripening. [ABSTRACT FROM AUTHOR]

Introduction: Several studies have shown that late- and post-term pregnancies are associated with an increased risk of perinatal morbidity and mortality. In this case, induction of labor is the recommended approach. For full-term pregnancies, various methods exist to prepare the cervix and/or commence labor. Prostaglandins serve the dual purpose of cervical ripening and labor induction, blurring the distinction between the two processes. The aim of this research was to evaluate the effect of maternal age and body mass index (BMI) on oral misoprostol induction of labor for late-term pregnancies. Methods: This was a retrospective cross-sectional study (ClinicalTrial ID: NCT06184139), including only late-term pregnancies in healthy nulliparous women carrying a single cephalic fetus with normal birthweight who underwent induction of labor with oral misoprostol. We used the oral misoprostol regimen proposed by the World Health Organization (WHO) for induction of labor in term singleton pregnancies in women who have not had a previous cesarean delivery and a Bishop score <7. The regimen was oral misoprostol in aqueous solution at the low dose of 25 μg every 2 h until a Bishop score ≥7, labor, or for a maximum of 8 doses. Results: One hundred and four pregnant women underwent induction of labor with oral misoprostol for late-term pregnancy on the 290th day of gestation. Study population was divided in two groups based on age (<35 and ≥35 years) and obesity (BMI <30 and ≥30). No statistically significant differences were recorded between younger and older women. Obese women reported a longer time between the last dose of misoprostol and cervical dilation of 6 cm (p = 0.01), a longer time between the last dose of misoprostol and delivery (p = 0.04), and a higher rate of grade II vaginal lacerations (p = 0.02). Conclusions: Maternal BMI is a factor negatively influencing the efficacy of oral misoprostol for induction of labor in late-term pregnancy. [ABSTRACT FROM AUTHOR]

Objective Saline vaginal douching prior to intravaginal prostaglandin application might increase the vaginal pH, leading to improvement of prostaglandin bioavailability, by which the outcomes of labor induction can be greatly improved. Thus, we aimed to evaluate the effect of vaginal washing with normal saline before insertion of vaginal prostaglandin for labor induction. Study Design A systematic search was done in PubMed, Cochrane Library, Scopus, and ISI Web of Science from inception to March 2022. We selected randomized controlled trials (RCTs) that compared vaginal washing using normal saline versus no vaginal washing in the control group before intravaginal prostaglandin insertion during labor induction. We used RevMan software for our meta-analysis. Our main outcomes were the duration of intravaginal prostaglandin application, duration from intravaginal prostaglandin insertion to active phase of labor, duration from intravaginal prostaglandin insertion till total cervical dilatation, labor induction failure rate, incidence of cesarean section (CS), and rates of neonatal intensive care unit (NICU) admission and fetal infection postdelivery. Results Five RCTs were retrieved with a total number of 842 patients. Duration of prostaglandin application, duration from prostaglandin insertion to active phase of labor, and time interval from prostaglandin insertion to total cervical dilatation were significantly shorter among vaginal washing group (p < 0.05). Vaginal douching prior to prostaglandin insertion significantly decreased the incidence of failed labor induction (p < 0.001). After the removal of reported heterogeneity, vaginal washing was linked to a significant decline in CS incidence (p = 0.04). In addition, the rates of NICU admission and fetal infection were significantly lower in the vaginal washing group (p < 0.001). Conclusion Vaginal washing with normal saline before intravaginal prostaglandin insertion is a useful and easily applicable method for labor induction with good outcomes. Key Points Induction of labor is frequently used in the obstetrics field. We assessed vaginal washing impact before prostaglandin insertion for labor induction. Vaginal washing is an easily applicable method for labor induction with good outcomes. [ABSTRACT FROM AUTHOR]

Background: Modern-day obstetrics recommend induction of labor by medical or mechanical methods where continuation of pregnancy causes detrimental effect to the health of mother or fetus. One of the prerequisites for successful vaginal delivery includes a favorable or ripe cervix. We undertook the present study to find out the safety and efficacy of mifepristone for pre-induction cervical ripening and its effect on Bishop's score in term pregnancy. Methods: A total of 100 patients with term pregnancy were enrolled for this study. 200 mg of mifepristone was administered orally, and efficacy of mifepristone was assessed based on improvement in modified Bishop's score at 48 h. If there was inadequate improvement in Bishop's score after 48 h, additional intracervical cerviprime was administered for induction. Results: Out of 100 patients, 50 women delivered vaginally after administration of mifepristone. Twenty-four patients delivered vaginally within 48 h of administration of mifepristone. We observed the Bishop's score of 6 or more at 48 h in 69% participants. Fifty patients required additional intracervical cerviprime. Thirty participants underwent cesarean section. Mean Modified Bishop's score at 0 h was 1.87 and improved to 6.92 after 48 h after mifepristone. A statistically significant difference was found with mean Bishop's score with p value < 0.005. Conclusion: In our study, we found that mifepristone is a safe and effective cervical ripening agent in term pregnancy with unfavorable cervix. It is well tolerated and leads to significant cervical ripening with improvement in Bishop's score favoring vaginal delivery. [ABSTRACT FROM AUTHOR]

introduction: Chemical and herbal medicines are used to facilitate vaginal delivery and reduce cesarean section. Unripe cervix is associated with many complications. Since chemical drugs may be associated with maternal and fetal complications, the present study was performed with aim to determine the effect of flaxseed on cervical ripening and delivery outcome. Methods: This randomized clinical trial study was conducted in 2018-2021 on 120 primiparous women referred to a midwifery office in Rafsanjan city. The samples were randomly divided into intervention and control groups. Then, 28 packets of 10 gr of flaxseed powder were provided to the intervention group, so that from the 37th week of pregnancy until delivery, they eat one packet in a glass of warm water every morning as fasting. The control group received no intervention. The study tool was a demographic and obstetric information questionnaire, and the two groups were compared in terms of cervical ripening and maternal and neonatal outcomes. Data analysis was done using SPSS software (version 22) and independent t and chi-square statistical tests. P

Abstract Background Previous studies had found that the mechanical methods were as effective as pharmacological methods in achieving vaginal delivery. However, whether balloon catheter induction is suitable for women with severe cervical immaturity and whether it will increase the related risks still need to be further explored. Research aim To evaluate the efficacy and safety of Foley catheter balloon for labor induction at term in primiparas with different cervical scores. Methods A total of 688 primiparas who received cervical ripening with a Foley catheter balloon were recruited in this study. They were divided into 2 groups: Group 1 (Bishop score ≤ 3) and Group 2 (3

Background: Previous studies had found that the mechanical methods were as effective as pharmacological methods in achieving vaginal delivery. However, whether balloon catheter induction is suitable for women with severe cervical immaturity and whether it will increase the related risks still need to be further explored. Research aim: To evaluate the efficacy and safety of Foley catheter balloon for labor induction at term in primiparas with different cervical scores. Methods: A total of 688 primiparas who received cervical ripening with a Foley catheter balloon were recruited in this study. They were divided into 2 groups: Group 1 (Bishop score ≤ 3) and Group 2 (3 < Bishop score < 7). Detailed medical data before and after using of balloon were faithfully recorded. Results: The cervical Bishop scores of the two groups after catheter placement were all significantly higher than those before (Group 1: 5.49 ± 1.31 VS 2.83 ± 0.39, P<0.05; Group 2: 6.09 ± 1.00 VS 4.45 ± 0.59, P<0.05). The success rate of labor induction in group 2 was higher than that in group 1 (P<0.05). The incidence of intrauterine infection in Group 1 was higher than that in Group 2 (18.3% VS 11.3%, P<0.05). Conclusion: The success rates of induction of labor by Foley catheter balloon were different in primiparas with different cervical conditions, the failure rate of induction of labor and the incidence of intrauterine infection were higher in primiparas with severe cervical immaturity. [ABSTRACT FROM AUTHOR]

Objective: To analyze the influence of the resting interval after removal of a double‐balloon for cervical ripening and oxytocin administration on the time to onset of active labor in singleton pregnancies. Methods: A retrospective cohort study of women who required a cervical ripening with double‐balloon was conducted between January 2019 and December 2022. We collected data for cervical ripening balloon insertion and removal, oxytocin administration, suspicious or pathological cardiotocographic trace, mode of delivery, maternal and neonatal complications, neonatal outcomes. Proportional hazards model comparing resting interval between double‐balloon cervical ripening removal and oxytocin administration. Results: A total of 403 singleton pregnancies were recruited and 213 pregnant women experienced a rest of 12 h between cervical balloon removal and oxytocin administration (resting group). Oxytocin was administered immediately after balloon removal in 190 women (non‐resting group). Median insertion‐to‐active labor interval and insertion‐to‐delivery interval were significantly shorter in the non‐resting group: 18.5 versus 24.0 h, HR 2.59 (CI 95%: 1.97–3.41) and 24.0 versus 29.0 h, HR 2.38 (CI 95%: 1.85–3.05) respectively. Bishop score change and mode of delivery between were similar in both groups. No differences in maternal nor neonatal complications between both groups were found. Conclusions: Oxytocin administration immediately after removal of a double‐balloon for cervical ripening compared with 12 h delayed interval resulted in a shortened time from insertion to active labor onset and to delivery interval without increasing maternal or neonatal adverse outcomes. Synopsis: In a retrospective study of 403 singleton pregnancies, administering oxytocin immediately after double‐balloon removal reduced labor onset time without increasing complications. [ABSTRACT FROM AUTHOR]

introduction: Chemical and herbal medicines are used to facilitate vaginal delivery and reduce cesarean section. Unripe cervix is associated with many complications. Since chemical drugs may be associated with maternal and fetal complications, the present study was performed with aim to determine the effect of flaxseed on cervical ripening and delivery outcome. Methods: This randomized clinical trial study was conducted in 2018-2021 on 120 primiparous women referred to a midwifery office in Rafsanjan city. The samples were randomly divided into intervention and control groups. Then, 28 packets of 10 gr of flaxseed powder were provided to the intervention group, so that from the 37th week of pregnancy until delivery, they eat one packet in a glass of warm water every morning as fasting. The control group received no intervention. The study tool was a demographic and obstetric information questionnaire, and the two groups were compared in terms of cervical ripening and maternal and neonatal outcomes. Data analysis was done using SPSS software (version 22) and independent t and chi-square statistical tests. P<0.05 was considered statistically significant. Results: At admission time, the two groups had statistically significant differences in cervical ripening, and it was higher in the intervention group (p=0.01). Also, the first stage duration of labor was shorter in the intervention group (p=0.03). The two groups had no statistically significant difference in terms of other delivery outcomes, including admission cause, induction and strengthening of labor pains, the second stage duration, fetal distress, meconium passing, type of delivery, first and fifth minute Apgar scores, and postpartum hemorrhage (p<0.05). Conclusion: The use of flaxseed increases the probability of cervical ripening and shortens the first stage and the course of childbirth. [ABSTRACT FROM AUTHOR]

Objective: To analyze the predictive value of cervical Bishop score combined with cervical ultrasound elastography and serological markers for cervical ripening. Methods: 178 pregnant women who were registered at Peking University Third Hospital from January 2022 to June 2022 and underwent induced labor were selected and divided into a successful labor induction group of 158 cases and a failed labor induction group of 20 cases. Cervical ultrasound elastography indexes, serological markers (relaxin, estradiol, estriol, progesterone), cervical Bishop score before induction of labor were collected and analyzed. Compare the differences in the above indicators between two groups, and use the receiver operator characteristic curve (ROC curve) to analyze the value of combined detection in evaluating cervical ripening. Results: The elastic contrast index (ECI), external cervical os (EOS) and relaxin levels of the failed labor induction group were lower than in the successful labor induction group, and the cervical length was longer than that in the successful labor induction group (P＜0.05). There was no significant difference in the levels of progesterone, estradiol and estriol between the two groups (P＞0.05). The combination of cervical Bishop score, ultrasound elastography indicators (ECI, EOS, cervical length), and serum relaxin had the highest evaluation value for cervical ripening, with an area under the ROC curve of 0.940. Conclusions: The cervical Bishop score combined with cervical ultrasound elastography and relaxin can improve the accuracy of predicting cervical ripening. [ABSTRACT FROM AUTHOR]

The uterine cervix is one of the key factors involved in ensuring a proper track of gestation and labor. At the end of the gestational period, the cervix undergoes extensive changes, which can be summarized as a transformation from a non-favorable cervix to one that is soft and prone to dilation. During a process called cervical ripening, fundamental remodeling of the cervical extracellular matrix (ECM) occurs. The cervical ripening process is a derivative of many interlocking and mutually driving biochemical and molecular pathways under the strict control of mediators such as inflammatory cytokines, nitric oxide, prostaglandins, and reactive oxygen species. A thorough understanding of all these pathways and learning about possible triggering factors will allow us to develop new, better treatment algorithms and therapeutic goals that could protect women from both dysfunctional childbirth and premature birth. This review aims to present the possible role of the NLRP3 inflammasome in the cervical ripening process, emphasizing possible mechanisms of action and regulatory factors. [ABSTRACT FROM AUTHOR]

Objective: To clarify whether the duration from cervical ripening induction to labor onset is prolonged when epidural analgesia is administered following application of dinoprostone vaginal inserts vs. cervical ripening balloon. Methods: This retrospective study included mothers with singleton deliveries at a single center between 2020–2021. Nulliparous women who underwent labor induction and requested epidural analgesia during labor after 37 weeks of gestation were included. The duration from cervical ripening induction to labor onset was compared between women using a dinoprostone vaginal insert and those using a cervical ripening balloon and between women who received epidural analgesia before and after labor onset. Results: In the dinoprostone vaginal insert group, the duration was significantly shorter in the subgroup that received epidural analgesia after labor onset (estimated median, 545 [95% confidence interval: 229–861 min]) than the subgroup that received it before labor onset (estimated median, 1,570 [95% confidence interval: 1,226–1,914] min, p = 0.004). However, in the cervical ripening balloon group, the difference between subgroups was not significant. The length of labor among the groups was also not significantly different. Conclusion: Epidural analgesia as labor relaxant adversely affected the progression of uterine cervical ripening when dinoprostone vaginal inserts were used, whereas it did not affect cervical ripening when a mechanical cervical dilatation balloon was used. The present results are significant for choosing the appropriate ripening method. [ABSTRACT FROM AUTHOR]

Objective: To compare cervical ripening time with the use of vaginal Misoprostol plus Hyoscine-N-Butylbromide, with vaginal Misoprostol alone. Design: A double-blind randomized controlled trial with Pan-African Clinical Trials Registry (PACTR) approval number PACTR202112821475292 Setting: Federal Medical Centre, Asaba, Nigeria. Participants: A total of 126 eligible antenatal patients for cervical ripening were enrolled. Interventions: Participants in Group A had 25µg of vaginal misoprostol with 1ml of intramuscular placebo, and those in Group B had 25µg of vaginal misoprostol with 20mg of Intramuscular Hyoscine (1 ml). Oxytocin infusion was used when indicated, and the labour was supervised as per departmental protocol. Main outcome measure: Cervical ripening time Results: The mean cervical ripening time was statistically significantly shorter in the hyoscine group (8.48±4.36 hours) than in the placebo group (11.40±7.33 hours); p-value 0.02, 95% CI 0.80-5.05. There was no statistically sig)nificant difference in the mean induction-delivery interval in Group A (7.38±5.28 hours) compared to Group B (7.75±5.04 hours), with a value of 0.54. The mode of delivery was comparable. However, women in Group B (53, 84.1%) achieved more vaginal deliveries than women in Group A (50, 79.4%); p-value 0.49. Thirteen women in Group A (20.6%) had a caesarean section, while ten women (15.9%) in Group B had a caesarean section (p-value 0.49, RR 0.94, CI 0.80-1.11). Adverse maternal and neonatal outcomes were not statistically significant between the two groups. Conclusion: Intramuscular hyoscine was effective in reducing cervical ripening time when used as an adjunct to vaginal Misoprostol, with no significant adverse maternal or neonatal outcome. [ABSTRACT FROM AUTHOR]

Introduction: Obesity is an increasing public health concern worldwide and can lead to more complications in pregnancy and childbirth. Women with obesity more often require induction of labor for various indications. The aim of this study is to assess which method of induction of labor is safest and most effective in women with obesity. Material and methods: This is a secondary analysis of two randomized controlled trials about induction of labor. Women with a term singleton pregnancy in cephalic presentation, an unfavorable cervix, intact membranes and without a previous cesarean section were randomly allocated to cervical priming with a Foley catheter or vaginal prostaglandin‐E2‐gel (PROBAAT‐I) or a Foley catheter or oral misoprostol (PROBAAT‐II). The inclusion and exclusion criteria for the studies were identical. Induction methods were compared in women with obesity (body mass index ≥30.0). Main outcomes were cesarean section and postpartum hemorrhage (blood loss >1000 mL). Results: A total of 2664 women, were included in the trials, 517 of whom were obese: 254 women with obesity received a Foley catheter, 176 oral misoprostol and 87 prostaglandin E2 (PGE2). A cesarean section was performed in 29.1% of women allocated to Foley vs 22.2% in the misoprostol and 23.0% in the PGE2 groups. Comparisons between groups revealed no statistically significant differences: the relative risk [RR] was 1.31 (95% confidence interval [CI] 0.94–1.84) in the Foley vs misoprostol group and 1.27 (95% CI 0.83–1.95) in the Foley vs PGE2 group. The rates of postpartum hemorrhage were comparable (10.6%, 11.4% and 6.9%, respectively; P = 0.512). In women with obesity, more often a switch to another method occurred in the Foley group, (20.1% vs 6.3% in misoprostol vs 1.1% in the PGE2 group; P < 0.001). The risk of a failed Foley placement was higher in women with obesity than in women without obesity (8.3% vs 3.2%; adjusted odds ratio 3.12, 95% CI 1.65–5.90). Conclusions: In women with obesity we found a nonsignificant trend towards an increased rate of cesarean sections in the group induced with a Foley catheter compared to oral misoprostol; however, the study lacked power for this subgroup analysis. The finding of a higher risk of failed placement of a Foley catheter in women with obesity can be used in shared decision making. [ABSTRACT FROM AUTHOR]

Collagen is an essential constituent of the uterine extracellular matrix that provides biomechanical strength, resilience, structural integrity, and the tensile properties necessary for the normal functioning of the uterus. Cross-linking is a fundamental step in collagen biosynthesis and is critical for its normal biophysical properties. This step occurs enzymatically via lysyl oxidase (LOX) or non-enzymatically with the production of advanced glycation end-products (AGEs). Cross-links found in uterine tissue include the reducible dehydro-dihydroxylysinonorleucine (deH-DHLNL), dehydro-hydroxylysinonorleucine (deH-HLNL), and histidinohydroxymerodesmosine (HHMD); and the non-reducible pyridinoline (PYD), deoxy-pyridinoline (DPD); and a trace of pentosidine (PEN). Collagen cross-links are instrumental for uterine tissue integrity and the continuation of a healthy pregnancy. Decreased cervical cross-link density is observed in preterm birth, whereas increased tissue stiffness caused by increased cross-link density is a pathogenic feature of uterine fibroids. AGEs disrupt embryo development, decidualization, implantation, and trophoblast invasion. Uterine collagen cross-linking regulators include steroid hormones, such as progesterone and estrogen, prostaglandins, proteoglycans, metalloproteinases, lysyl oxidases, nitric oxide, nicotine, and vitamin D. Thus, uterine collagen cross-linking presents an opportunity to design therapeutic targets and warrants further investigation in common uterine disorders, such as uterine fibroids, cervical insufficiency, preterm birth, dystocia, endometriosis, and adenomyosis. [ABSTRACT FROM AUTHOR]

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information. [ABSTRACT FROM AUTHOR]

This review assessed the efficacy and safety of pharmacologic agents (prostaglandins, oxytocin, mifepristone, hyaluronidase, and nitric oxide donors) and mechanical methods (single- and double-balloon catheters, laminaria, membrane stripping, and amniotomy) and those generally considered under the rubric of complementary medicine (castor oil, nipple stimulation, sexual intercourse, herbal medicine, and acupuncture). A substantial body of published reports, including 2 large network meta-analyses, support the safety and efficacy of misoprostol (PGE1) when used for cervical ripening and labor induction. Misoprostol administered vaginally at doses of 50 μg has the highest probability of achieving vaginal delivery within 24 hours. Regardless of dosing, route, and schedule of administration, when used for cervical ripening and labor induction, prostaglandin E2 seems to have similar efficacy in decreasing cesarean delivery rates. Globally, although oxytocin represents the most widely used pharmacologic agent for labor induction, its effectiveness is highly dependent on parity and cervical status. Oxytocin is more effective than expectant management in inducing labor, and the efficacy of oxytocin is enhanced when combined with amniotomy. However, prostaglandins administered vaginally or intracervically are more effective in inducing labor than oxytocin. A single 200-mg oral tablet of mifepristone seems to represent the lowest effective dose for cervical ripening. The bulk of the literature assessing relaxin suggests this agent has limited benefit when used for this indication. Although intracervical injection of hyaluronidase may cause cervical ripening, the need for intracervical administration has limited the use of this agent. Concerning the vaginal administration of nitric oxide donors, including isosorbide mononitrate, isosorbide, nitroglycerin, and sodium nitroprusside, the higher incidence of side effects with these agents has limited their use. A synthetic hygroscopic cervical dilator has been found to be effective for preinduction cervical ripening. Although a pharmacologic agent may be administered after the use of the synthetic hygroscopic dilator, in an attempt to reduce the interval to vaginal delivery, concomitant use of mechanical and pharmacologic methods is being explored. Combining the use of a single-balloon catheter with dinoprostone, misoprostol, or oxytocin enhances the efficacy of these pharmacologic agents in cervical ripening and labor induction. The efficacy of single- and double-balloon catheters in cervical ripening and labor induction seems similar. To date, the combination of misoprostol with an intracervical catheter seems to be the best approach when balancing delivery times with safety. Although complementary methods are occasionally used by patients, given the lack of data documenting their efficacy and safety, these methods are rarely used in hospital settings. [ABSTRACT FROM AUTHOR]

Background: Previous studies that suggest a shorter time from cervical ripening balloon placement to delivery with shorter total balloon placement time have excluded patients with prior cesarean deliveries. Objective: To evaluate, in patients with a prior history of cesarean delivery undergoing cervical ripening with a double-balloon catheter, whether planned removal of device after 6 vs 12 hours would result in shorter time to vaginal delivery. Study Design: A before-and-after study was performed after a practice change occurred November 2020, shortening the planned time of double-balloon catheter placement for cervical ripening from 12 to 6 hours. Data were collected via retrospective electronic chart review. Primary outcome was time from balloon placement to vaginal delivery. Secondary outcomes included rates of cesarean delivery, maternal intraamniotic infection, and uterine rupture. Kaplan–Meier curves compared median times to delivery between the groups. A Cox proportional-hazards model was used to adjust for time of balloon placement, number of previous vaginal deliveries, and co-medications used. Results: From November 2018 to November 2022, 189 analyzable patients with a prior history of cesarean delivery received a double-balloon catheter for cervical ripening during their trial of labor. Patients were separated into pre- and postpolicy change groups (n=91 and 98, respectively). The median time to vaginal delivery for the pregroup was 28 hours (95% CI: 26, 35) and 25 hours (95% CI: 23, 29) for those in the postgroup (P value .052). After adjusting for dilation at time of balloon placement, number of previous vaginal deliveries, and co-medication, the estimated hazard ratio for successful vaginal delivery postpolicy change was 1.89 (95% CI: 1.27, 2.81). There were no differences in rates of secondary outcomes. Conclusion: In patients with prior cesarean delivery undergoing mechanical cervical ripening with a double-balloon catheter, planned removal at 6 hours compared to 12 hours may result in higher chances of successful vaginal delivery and possibly a shorter time to delivery, without increasing rates of cesarean delivery and intraamniotic infection.

Background: Cervical ripening is crucial for induction. However, its influencing factors, mechanistic understanding, and effective risk stratification are still challenging. Recent research suggested that microorganisms and their metabolites in vaginal spaces correlate to preterm birth. However, it remains unclear whether the cervicovaginal metabolome is related to the natural physiological process of cervical maturation. Objective: We aimed to analyze the cervicovaginal metabolome in women with favorable induction cervix and those unfavorable for induction when delivering at term. Study design: Cervicovaginal swabs were collected between 40 and 41 weeks gestation from the following 2 different groups of patients: Ripe group (n = 25) which was favorable for the induction cervix and Unripe group which was unfavorable for the induction cervix (n = 25). Samples were tested using untargeted metabolomics analysis and analyzed by a bioinformatics platform. The correlation analysis between the metabolome and the previously acquired microbiome was also performed. Results: A total of 629 metabolites were identified in cervicovaginal fluid. The cervicovaginal metabolome was significantly different between the women with the ripe cervix and those with the unripe cervix, especially within each stratum of the same CST. Metabolites within the amino acid, carbohydrate, and dipeptide pathways may play a role in this distinction. Thirty-four metabolites were significantly upregulated, and the remaining fourteen were significantly downregulated in the Unripe group with an unripe cervix unfavorable for induction. Statistical modeling identified Arachidonic Acid and Nicotinate associated with the risk of cervical maturation disorder (AUC 0.87) in negative ion mode. A combination of Choline and d-Mannose identified a risk of cervical maturation disorder (AUC 0.80) in positive ion mode, improved by Lactobacillus relative abundance (AUC 0.89). Conclusion: These data suggested that the cervicovaginal space was metabolically active during pregnancy and significantly altered among the women with the mature and immature cervix. Combining the genera-level phylotypes and metabolites could build better cervix maturity prediction models. By using cervicovaginal fluid samples, we demonstrated the potential of multi-data type integration for developing composite models toward understanding the contribution of the vaginal environment to the remodeling of cervix during term pregnancy.

Background: Labor induction is a common and essential procedure in obstetrics. Various new formulations of prostaglandins are currently being used for labor induction. Trials are being conducted regularly using new formulations to see the efficacy and outcome of labor induction. Materials and Methods: Prospective observational study was conducted to compare the clinical outcome of dinoprostone pessary (DP) and intracervical dinoprostone gel (DG) on induction of labor. The objectives were to study the efficacy on induction-to-delivery duration, to compare the time taken from application to initiation of labor, and the number of applications required. The study also compared the need for oxytocin augmentation, cesarean rate, and neonatal outcomes after delivery. Results: In the DP group, 86.7% of patients required single application and 68.4% of patients in the DG group required double application. In 91.6% of patients in the DG group and 68.3% of patients in the DP group labor were initiated in

Objective: To compare pre and post Foley’s catheter Bishop Score during labour induction. Methods: This study was a retrospective study conducted at the Aga Khan University Hospital Karachi, Pakistan after approval from ethical review board. All women who underwent induction of labour with Foley’s Catheter at gestation of 37 weeks or more from September 2014-October 2015 were included. Data was entered and analyzed in Statistical Package for Social Sciences (SPSS) version 19.0. The comparison between pre and post Foley’s catheter Bishop Score during labour induction will be calculated by Wilcoxon sign test. Results: There were 981 cases of inductions of labour, 749 (76.3%) received Foley’s catheter, in combination with prostaglandins and oxytocin. About 68% were vaginal deliveries while 32% underwent C-section. Two third of women had bishop <4. Overall, Bishop score improved significantly in all patients with the catheter however, maximum benefit was seen in patients where the catheter was placed for 10-12 hours. Conclusion: Foley’s is the better and safer option. In view of our results, It has been recommended to keep the Foley’s for 10-12 hours to get significant improvement in bishop score. [ABSTRACT FROM AUTHOR]

To determine whether maternal colonization with Group B Streptococcus increases the risk for infectious morbidity following transcervical Foley catheter-assisted cervical ripening. A retrospective cohort study comparing infectious morbidity and other clinical outcomes by Group B Streptococcus colonization status between all women with singleton pregnancies who underwent Foley catheter-assisted cervical ripening labor induction at a single tertiary medical center during 2011–2021. Multivariable logistic regression explored the relationship between Group B Streptococcus colonization to adverse outcomes while adjusting for relevant clinical variables. A total of 4,409 women were included of whom 886 (20.1 %) were considered Group B Streptococcus carriers and 3,523 (79.9 %) were not. Suspected neonatal sepsis rate was similar between Group B Streptococcus carriers and non-carriers (5.2 vs. 5.0 %, respectively, p=0.78). Neonatal sepsis was confirmed in 7 (0.02 %) cases, all born to non-carriers. Group B Streptococcus carriers had a higher rate of maternal bacteremia compared to non-carriers (1.2 vs. 0.5 %, respectively, p=0.01). Group B Streptococcus colonization was independently associated with maternal bacteremia (adjusted odds ratio 3.05; 95 %CI 1.39, 6.66). Group B Streptococcus colonization among women undergoing Foley catheter-assisted cervical ripening does not seem to increase the risk for neonatal infection. However, higher rates of maternal bacteremia were detected. [ABSTRACT FROM AUTHOR]

Objective: To investigate the predictive value of obstetric findings when using dinoprostone (prostaglandin E2 [PGE2]) vaginal inserts for cervical ripening, and to assess the optimal cervical‐ripening method between PGE2 vaginal insert and/or cervical dilators. Methods: This prospective observational study enrolled pregnant women who underwent cervical ripening for labor induction in 37–41 week' gestation in 2020. In evaluation 1, optimal obstetric findings predictive of rapid cervical ripening using PGE2 were assessed. In evaluation 2, the duration from PGE2 administration to labor onset and perinatal outcomes were compared between cases in which only PGE2 was used and cases that were treated with PGE2 after mechanical cervical dilators (Dilapan®) for extremely immature cervical ripening (uterine cervical os <2 cm). Results: In evaluation 1, uterine dilatation before the use of a PGE2 vaginal insert was mostly correlated with the time from PGE2 administration to labor onset (r = −0.428, p < 0.001). When the uterine cervical os dilatation was ≥2 cm, a shorter time‐to‐labor onset was found. In addition, os dilatation, effacement, and station at the time of PGE2 vaginal insert removal also significantly progressed. In evaluation 2, the median duration from PGE2 administration to labor onset was 1740 min in cases where only PGE2 was used, and 610 min in those where PGE2 was used after mechanical cervical dilators (p = 0.011). Conclusion: PGE2 vaginal inserts are relatively effective when the uterine cervical os is ≥2 cm in diameter. However, in cases of extremely immature cervical‐ripening, it was feasible to use PGE2 vaginal inserts before mechanical cervical dilatation. [ABSTRACT FROM AUTHOR]

The purpose of this prospective cohort study is to identify the predictive factors for vaginal delivery among women (n = 146) who underwent cervical ripening using a dinoprostone insert (PG) alone (13.7%), cervical ripening balloon (CRB) alone (52.7%), oral misoprostol (M) alone (4.1%), or repeated methods (R, 29.5%) for gestational diabetes mellitus (GDM) at term, and to analyze maternal and neonatal morbidity outcomes according to the method for cervical ripening. After cervical ripening, vaginal delivery occurred in 84.2% (n = 123) and was similar among groups (90.0% after PG, 83.1% after CRB, 83.3% after M, and 83.7% after R; p = 0.89). After a multivariable logistic regression analysis adjusted for potential confounders, the internal cervical os being open before cervical ripening was a predictor of vaginal delivery (adjusted odds ratio (OR) of 4.38, 95% confidence index (CI) of 1.62–13.3, p = 0.03), and previous cesarean delivery was a predictor of cesarean delivery (aOR of 7.67, 95% CI of 2.49–24.00, p < 0.01). Birthweight was also significantly associated with cesarean delivery (aOR of 1.15, 95% CI of 1.03–1.31, p = 0.02). The rates of maternal and neonatal morbidity outcomes were 10.9% (n = 16) and 19.9% (n = 29), respectively, and did not differ according to the mode of delivery and to the method used for cervical ripening. Identifying these specific high-risk women (previous cesarean delivery and internal cervical os being closed before cervical ripening) for cesarean delivery among women who underwent cervical ripening for GDM at term is important and practical for all physicians to make a decision in partnership with women. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare twice-daily versus once-daily administration of intravaginal PGE2 for induction of labor at term. Efficacy, safety, and patient satisfaction were evaluated. For this single-center, randomized, comparative, open-label, two-arm, and parallel study, pregnant women with term singleton live pregnancies ≥ 37 weeks of gestation, medical indications for induction of labor, and Bishop score ≤ 6 were randomized to either the control group (induction of labor with PGE2 gel with repeat dose after 24 h) or the experimental group (repeat dose after 12 h). The primary outcome was induction-to-delivery interval time. Secondary outcomes were maternal and neonatal outcomes and patient satisfaction. In total, 246 women were randomized to the control (n = 121) or experimental groups (n = 125). The mean time for initiation of induction to delivery was 9.4 h shorter in the experimental group compared to controls (p = 0.007). For control vs experimental, there were no differences in tachysystole (19/121, 15.7 % vs 21/124, 16.9 %, respectively; p = 0.79), cesarean section rate (18/121, 14.9 % vs 28/124, 22.6 % respectively; p = 0.12), or other main obstetrical or neonatal outcomes. Patients in the experimental group reported higher satisfaction with their induction (48/96, 50 % with once-daily vs 60/86, 69.8 % with twice-daily; p = 0.010). Among women admitted for induction of labor at term, closer interval of vaginal PGE2 administration was associated with a significantly shorter induction-to-delivery time without increasing maternal or neonatal morbidity. Furthermore, the reduction in induction time was associated with improved patient experience of delivery. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy and safety of cervical ripening and induction of labor with prostaglandin E1 among primiparas, multiparas and grand multiparas. Study design: This was a retrospective cohort study. Results: Between January and December 2017, 1713 women underwent cervical ripening and induction of labor with prostaglandin E1: 523 were primiparas, 656 were multiparas, and 534 were grand multiparas. Four hundred and seventy-nine (91.6%) primiparas delivered vaginally as did 640 (97.6%) multiparas and 521 (97.6%) grand multiparas. Forty-four (8.4%) primiparas underwent cesarean delivery compared to 16 (2.4%) multiparas and 13(2.4%) grand multiparas. Induction to delivery interval was significantly longer in primiparas (29.7 ± 22.8 h). There were no cases of uterine rupture, and the rates of postpartum hemorrhage and endometritis were similar among the three groups. Neonatal outcomes including Apgar score < 7 and umbilical artery pH < 7.1 were not significantly different between the groups. Conclusion: Using prostaglandin E1 for cervical ripening and labor induction is efficient and safe in primiparas, multiparas and grand multiparas. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of misoprostol only, Foley's catheter only, and combined misoprostol plus Foley's catheter for second-trimester pregnancy terminations. Methods: This retrospective study comprised 146 patients who underwent second-trimester pregnancy termination. Patients were divided into three groups: group 1 (n=62), misoprostol alone; group 2 (n=35), Foley catheter alone; and group 3 (n=49), combined group (Misoprostol plus Foley's catheter). The primary outcome in our study was determined by comparing the induction-abortion interval between methods. Secondary outcomes were termination in the first 24 h, complications including surgical removal of the placenta, and uterine rupture. Results: According to the termination methods, the total termination time of the cases, the duration of hospital stays, and the termination rates in the first 24 h did not show statistically significant differences according to the procedures performed (p>0.05). The doses of misoprostol in nullipara and multiparous cases were statistically significantly higher in those who received misoprostol alone than those who received Foley + Misoprostol (respectively p=0.029; p=0.002). It was found that misoprostol dose was statistically significantly lower in those with a history of cesarean delivery (p=0.004). Conclusion: Although the methods used in second trimester pregnancy terminations are not superior to each other in terms of efficiency, the combined method may be preferred in reducing the side effects associated with misoprostol, including a severe condition such as uterine rupture, in those with a history of cesarean section. [ABSTRACT FROM AUTHOR]

Accidental rupture of membranes (acROM), an insertion-related complication of the balloon catheter for labor induction, may prolong the duration of ruptured membranes. Prolonged rupture of membranes is associated with an increased risk of intra-uterine infection with possibly neonatal infection as result. Little is known about safety profiles of different catheters regarding the occurrence of these complications. This study compares the incidence of neonatal early-onset sepsis (EOS) and acROM in women receiving either silicone or latex balloon catheters. A retrospective cohort study was performed including 2200 women (silicone balloon catheter, n = 1100 vs. latex balloon catheter, n = 1100). The primary outcomes were the incidence of acROM, and suspected and proven neonatal EOS. Secondary outcomes were: prolonged rupture of membranes, intrapartum fever, pre- or postnatal neonatal exposure to antibiotics, and perinatal outcomes. A subgroup analysis was performed between women with and without acROM. No statistically significant difference with regard to suspected or proven EOS was seen between the silicone and latex groups. The acROM rate was significantly higher in the silicone group compared to the latex group (2.9 % and 0.3 %, p < 0.01). Prolonged rupture of membranes was significantly more common in the silicone group compared to the latex group (5.0 % and 2.4 %, p < 0.01), as was the use of intrapartum antibiotics (12.7 % and 9.6 %, p = 0.02). Neonates were significantly more often exposed to pre- or postnatal antibiotics in the silicone group compared to the latex group (17.6 % and 13.6 %, p = 0.01). Subgroup analysis showed significantly more suspected and proven neonatal EOS when catheter-insertion was complicated with acROM (11.4 % and 20.0 %), compared to cases without acROM (3.8 % and 2.5 %), irrespective of the type of catheter used. The use of silicone balloon catheters for labor induction results in higher rates of acROM, prolonged rupture of membranes and use of intrapartum antibiotics, compared to latex balloon catheters. No statistically significant differences were found in the occurrence of suspected or proven neonatal EOS, however neonates from the silicone group were more often exposed to pre- or postnatal antibiotics. When acROM occurs, irrespective of type of catheter used, suspected and proven neonatal EOS was seen more often. [ABSTRACT FROM AUTHOR]

We evaluated quantitative cervicovaginal foetal-fibronectin as a predictor of cervical ripening and labour duration in late-term pregnant women with an unfavourable cervix. This was an analytical cross-sectional study wherein 152 women, with late-term pregnancy and unfavourable cervix, at 41weeks3days gestational age, had pre-induction quantitative cervicovaginal foetal-fibronectin determined using ELISA. Data were compared in nulliparas and multiparas at a significance level < 0.05. The mean age of late-term pregnant women was 30.4 ± 4.3 years. Median cervicovaginal foetal-fibronectin levels in nulliparous and multiparous women were 45.35 ng/ml and 46.93 ng/ml respectively(p = 0.289). The correlation between foetal-fibronectin levels and cervical ripening duration was poor in nulliparous(r = 0.014) and multiparous(r = 0.024) women. The Youden's foetal-fibronectin cut-off level had a sensitivity of 53.5% and specificity of 71.6% in predicting cervical ripening duration of > 12 hours in late-term pregnancy with an area under the ROC curve of 0.634. Quantitative cervicovaginal foetal-fibronectin is a poor correlate and predictor of cervical ripening and induced labour duration in late-term pregnancy. What is already known on this subject? Cervicovaginal foetal fibronectin is useful in the prediction of preterm delivery but its role in prolonged pregnancy is unclear. What the results of this study add? Cervicovaginal foetal fibronectin is a poor correlate and predictor of cervical ripening and induced labour duration in late-term pregnancy What the implications are of these findings for clinical practice and/or further research? Cervicovaginal fibronectin should not be used to predict ease and success of cervical ripening and induction of labour in women with late-term pregnancy. [ABSTRACT FROM AUTHOR]

Objectives: Labor induction is one of the most common procedures in modern obstetrics. One in five pregnant women and 30-40% of women delivering vaginally undergo this procedure. If the cervical status is unfavorable, a ripening process is used prior to induction to shorten the duration of oxytocin administration and maximize the possibility of vaginal birth. The aim of this study was to compare the duration of labor induced with dinoprostone vaginal insert to spontaneous labor. Material and methods: It was a retrospective study conducted between May 2019 and February 2021 in the tertiary reference center, the Obstetrics and Perinatology Department of the Jagiellonian University Hospital in Krakow. The research group involved 182 patients in singleton pregnancy at term, qualified for cervical ripening procedure. The control group consisted of 178 patients that were delivering spontaneously and admitted to the delivery ward in the first stage of labor. Statistical analysis was performed to compare the duration of labor between groups. To find factors affecting the procedure we compared different models consisting of maternal and fetal characteristics. Results: Successful vaginal delivery in the dinoprostone group was achieved in the group of 88% of patients. There was no significant difference in labor duration between the groups: 315 minutes in the study group and 300 min in the control group. Only being primipara was a factor related to longer labor in both groups. Conclusions: Pre-induction with dinoprostone insert and additional foley catheter, if indicated, does not make labor longer in comparison with spontaneous labor. [ABSTRACT FROM AUTHOR]

Introduction: Termination of pregnancy through curettage in the first trimester requires cervical ripening (CR) which can be induced by medicinal or mechanical methods. In the pharmaceutical method, vaginal administration of misoprostol, as well as vaginal trinitroglycerin (TNG), has been shown to induce effective CR. This study was conducted with the aim of comparing vaginal misoprostol and vaginal TNG in the CR of women candidates for the first-trimester curettage. Materials and Methods: This double-blind clinical trial study was conducted on 168 pregnant women with a gestational age of less than 14 weeks who were candidates for curettage. Participants were randomly divided into two groups receiving vaginally either TNG (400 µgr)(n=87) or misoprostol (400 µgr) (n=81). Then, the state of CR and the need for mechanical dilatation were compared between the two groups. Also, the presence of any side effects caused by drug use was determined. Results: The percentage of CR in the misoprostol group (67.9%) was significantly higher than in the TNG group (32.2%) (P0.001). Generally, the rate of complications in the TNG group (35.6%) was significantly higher compared with the misoprostol group (13.6%) (P>0.001). Conclusion: Vaginally Misoprostol is more effective than vaginally TNG on CR of first-trimester curettage as well as it significantly reduces the need for mechanical dilatation of the cervix.

Background: Hysteroscopy is a valuable surgical technique, but some complications are related to cervical dilatation. Sublingual trinitroglycerin (TNG) is a vasodilator that can facilitate cervical dilation. In our study, we compared its effectiveness to that of misoprostol. Methods: This randomized controlled trial study was conducted on 199 women of reproductive age who were referred to Rasoul Akram Hospital. Patients were randomly divided into two groups: TNG and misoprostol. Next, they were examined for clinical and practical indicators of cervical preparation. The data was analyzed using SPSS software. Results: Demographic characteristics exhibited no significant differences between the groups. The mean size of the largest dilator inserted without resistance showed not statistically significant difference between the TNG and misoprostol groups (6.26 ± 1.95 vs. 6.57 ± 2.05; p = 0.20). Side effects were reported in 66 (33.2%) of the women studied. The misoprostol group experienced a significantly higher rate of side effects (53.7%) compared to the TNG group (14.4%; p < 0.001). The most frequently observed side effect in the TNG group was headache, which occurred at a statistically significantly higher rate than in the misoprostol group (p = 0.04). On the other hand, uterine bleeding before hysteroscopy was significantly lower in the TNG group compared to the misoprostol group (p < 0.001). Conclusions: There was no statistically significant difference in the mean size of the largest dilator inserted without resistance between the TNG and misoprostol groups. Additionally, TNG experienced significantly fewer side effects than sublingual misoprostol group, with headache being the most prominent side effect. Sublingual TNG can be used to improve cervical preparation before hysteroscopy. Clinical Trial Registration: The study has been registered on https://trialsearch.who.int/Trial2.aspx?TrialID=IRCT20191123045476N4 (registration number: IRCT20191123045476N4).

HIGHLIGHTS • Oral misoprostol is more effective than vaginal misoprostol in cervical ripening as a part of induction of labor. • Oral misoprostol is as safe as vaginal misoprostol. ABSTRACT Objective: To compare Bishop score changes and labor event between oral and vaginal misoprostol in pregnancy beyond 41 weeks. Materials and Methods: A total of 52 pregnant women with more than 41 weeks of gestation, had a Bishop score less than 5, and were undergoing induction labor were randomly divided into two groups: oral and vaginal misoprostol. In the oral misoprostol group, participants were given 25 mg of misoprostol in a solution with a concentration of 1 ug/ml every 2 hours. In the vaginal misoprostol group, a 25 mg misoprostol tablet was inserted into the posterior fornix every 6 hours. The two groups were compared in terms of Bishop score during the first 6 hours, changes in Bishop score, labor at term events, neonatal outcomes, complications, and side effects after the administration of misoprostol. Results: The oral group showed significantly higher changes in Bishop score compared to the vaginal group (5.5 vs 3.6; p=0.0001). The median interval times for induction of labor at term, induction at stage II, and induction at birth were found to be shorter in the oral misoprostol group compared to the vaginal group (7.3 hours vs 10.6 hours, 14.0 hours vs 16.8 hours, and 14.6 hours vs 17.6 hours; p=0.002, 0.003, 0.002). Labor at term occurred much more frequently in the oral group (53.8% vs 15.4%). Additionally, the oral misoprostol group had a 3.5 times higher likelihood of experiencing labor at term within the first 6 hours after the initial administration compared to the vaginal group (OR 3.5, 95% CI 1.33-9.23). Conclusion: Oral administration of misoprostol for cervical ripening has been demonstrated to be more effective than vaginal administration, greater bishop score changes while maintaining an equivalent level of safety.

Background: Suction evacuation is the most common surgical method of first-trimester pregnancy termination and cervical dilatation is the most critical step. Misoprostol is increasingly being used as a cervical priming agent before suction evacuation although the ideal dosage and route of administration is not yet agreed upon. Objective: The present study aimed to compare the efficacy, side effects and acceptability of the sublingual vs. vaginal route of administration of misoprostol. Methodology: 120 women seeking first-trimester termination of pregnancy between 6 to 12 weeks of gestation were randomized to receive 400mcg of misoprostol either sublingually or vaginally. Women in the two groups were comparatively evaluated for cervical dilatation before a surgical abortion, operative blood loss, time duration of surgery, adverse effects and overall satisfaction with the route of administration. Result: Successful dilatation of more than 8mm was achieved in 41(68.3%) women in the sublingual group and 23(38 %) in the vaginal group (p

The aim of this study was to evaluate the effect of maternal age and body mass index (BMI) on induction of labor with oral misoprostol for premature rupture of membrane (PROM) at term. We have conducted retrospective cross-sectional study, including only term (37 weeks or more of gestation) PROM in healthy nulliparous women with a negative vaginal-rectal swab for group B streptococcus, a single cephalic fetus with normal birthweight, and uneventful pregnancy that were induced after 24 h from PROM. Ninety-one patients were included. According to the multivariate logistic regression, age and BMI odds ratio (OR) for induction success were 0.795 and 0.857, respectively. The study population was divided into two groups based on age (

Abstract Background The aim of this study was to estimate predictors for vaginal birth following balloon catheter induction of labor (IOL) in women with one previous cesarean section (CS) and an unfavorable cervix. Methods This 4-year retrospective cohort study was conducted in Longhua District Central Hospital in Shenzhen China, between January 2015 and December 2018. Patients with one previous CS and a current singleton-term pregnancy who underwent balloon catheter cervical ripening and IOL were enrolled. Univariate analysis was used to identify predictive factors associated with vaginal birth after cesarean section (VBAC). Binary logistic regression was further used to identify which factors were independently associated with the outcome measure. The primary outcome was VBAC, which was a successful trial of labor after cesarean delivery (TOLAC) following IOL. Results A total of 69.57% (208/299) of the women who planned for IOL had VBAC. In the final binary logistic regression equation, lower fetal weight ( 6 (OR 1.94; CI 1.37, 2.76) remained independently associated with an increased chance of VBAC. Conclusions The influencing factors of VBAC following IOL were fetal weight, BMI, and Bishop score after cervical ripening. Adequate individualized management and assessment of the IOL may help improve the VBAC rate.