Am J Perinatol
DOI: 10.1055/s-0041-1732379
Original Article

Maternal and Neonatal Outcomes in Nulliparous Participants Undergoing Labor Induction by Cervical Ripening Method

1   Department of Obstetrics and Gynecology, Columbia University, New York, New York
,
Elisa T. Bushman
2   Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
,
Madeline M. Rice
3   The George Washington University Biostatistics Center, Washington, District of Columbia
,
William A. Grobman
4   Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
,
Uma M. Reddy
5   The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
,
Robert M. Silver
6   Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
,
Yasser Y. El-Sayed
7   Department of Obstetrics and Gynecology, Stanford University, Stanford, California
,
Dwight J. Rouse
8   Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
,
George R. Saade
9   Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
,
John M. Thorp Jr.
10   Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
,
Suneet P. Chauhan
11   Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas
,
Maged M. Costantine
12   Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
,
Edward K. Chien
13   Department of Obstetrics and Gynecology, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio
,
Brian M. Casey
14   Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
,
Sindhu K. Srinivas
15   Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
,
Geeta K. Swamy
16   Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
,
Hyagriv N. Simhan
17   Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
,
for the Eunice Kennedy Shriver National Institute of Child Health Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network › Author Affiliations
Funding Supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; grant nos.: HD40512, U10 HD36801, HD27869, HD34208, HD68268, HD40485, HD40500, HD53097, HD40560, HD40545, HD27915, HD40544, HD34116, HD68282, HD87192, HD68258, and HD87230) and the National Center for Advancing Translational Sciences (UL1TR001873). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Abstract

Objective This study aimed to evaluate maternal and neonatal outcomes by method of cervical ripening for labor induction among low-risk nulliparous individuals.

Study Design This is a secondary analysis of a multicenter randomized trial of labor induction at 39 weeks versus expectant management in low-risk nulliparous participants. Participants undergoing cervical ripening for labor induction in either group were included. Participants were excluded for preripening membrane rupture, abruption, chorioamnionitis, fetal demise, or cervical dilation ≥3.5 cm. Cervical ripening was defined by the initial method used: prostaglandin only (PGE; referent), Foley with concurrent prostaglandin (Foley-PGE), Foley only (Foley), and Foley with concurrent oxytocin (Foley-oxytocin). Coprimary outcomes were adverse maternal and neonatal composites. Secondary outcomes included cesarean delivery and length of labor and delivery (L&D) stay. Multivariable analysis was used to adjust for patient characteristics.

Results Of 6,106 participants included in the trial, 2,376 (38.9%) met criteria for this analysis. Of these, 1,247 (52.4%) had cervical ripening with PGE, 290 (12.2%) had Foley-PGE, 385 (16.2%) had Foley, and 454 (19.1%) had Foley-oxytocin. The maternal composite outcome was similar among participants who received Foley-PGE (24.1%, adjusted relative risk [aRR] = 1.21, 95% confidence interval [CI]: 0.96–1.52), Foley (21.3%, aRR = 1.16, 95% CI: 0.92–1.45), or Foley-oxytocin (19.4%, aRR = 1.04, 95% CI: 0.83–1.29), compared with PGE (19.7%). The neonatal composite outcome was less frequent in participants who received the Foley-PGE (2.4%, aRR = 0.35, 95% CI: 0.16–0.75) or Foley (3.6%, aRR = 0.51, 95% CI: 0.29–0.89) but did not reach statistical significance for participants who received Foley-oxytocin (4.6%, aRR = 0.63, 95% CI: 0.40–1.01) compared with PGE only (6.8%). Participants who received Foley-PGE or Foley-oxytocin had a shorter L&D stay (adjusted mean difference = −1.97 hours, 95% CI: −3.45 to −0.49 and −5.92 hours, 95% CI: −7.07 to −4.77, respectively), compared with PGE.

Conclusion In term low-risk nulliparous participants, Foley alone or concurrent with PGE is associated with a lower risk of adverse neonatal outcomes than with PGE alone. Length of L&D stay was the shortest with concurrent Foley-oxytocin.

Key Points

  • Adverse maternal outcomes are similar among different methods of cervical ripening in low-risk women.

  • Adverse neonatal outcomes are less frequent with use of Foley alone or in combination with PGE.

  • The use of Foley alone, or in combination with other agents, appears to be beneficial.

* A list of other members of the NICHD MFMU Network is available in the [Supplementary Appendix] (available in the online version).


Supplementary Material



Publication History

Received: 08 February 2021

Accepted: 17 June 2021

Publication Date:
05 August 2021 (online)

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