Labor and Delivery Outcomes with the Sequential Use of Misoprostol Followed by Cervical Foley Catheter

Abstract

Objective Studies demonstrate shorter time to delivery with concurrent use of misoprostol and cervical Foley catheter. However, concurrent placement may not be feasible. If misoprostol is used to start an induction, little is known regarding the benefit of sequentially using Foley catheter. We examine obstetrical outcomes in women with Foley catheter placed after misoprostol compared with those only requiring misoprostol.

Study Design Retrospective cohort study of singleton pregnancies, intact membranes, and an unfavorable cervix (Bishop score of ≤6 and dilation ≤2 cm) undergoing term induction May 2013 to June 2015. We compared obstetrical outcomes between women receiving misoprostol alone versus those that had a Foley catheter placed after misoprostol. Outcomes are mode of delivery, time to delivery, chorioamnionitis, admission to neonatal intensive care unit, and maternal morbidity. Chi-square and Fisher's exact tests were used for categorical variables, Mann–Whitney U-tests compared continuous variables.

Results Among 364 women, 281 began induction with misoprostol alone. A total of 135 (48%) subsequently had a Foley catheter placed. Characteristics were similar between the groups, although nulliparity and cervical dilation <1 cm at start of induction were more likely to have subsequent Foley catheter. Women with Foley catheter placement after misoprostol had a longer median time to delivery (15 vs. 11 hours, p < 0.001), twofold higher rate of cesarean (42 vs. 26%, odds ratio: 2.1, 95% confidence interval: 1.26–3.44, p = 0.004), and increased risk of neonatal intensive care unit (NICU) admission (21 vs. 11%, p = 0.024). There was a nonsignificant increased risk of chorioamnionitis (12 vs. 7%, p = 0.1) and maternal morbidity (15 vs. 8%, p = 0.08) in the misoprostol followed by Foley catheter group.

Conclusion In women receiving misoprostol for induction, nulliparas and those with dilation <1 cm are more likely to have subsequent Foley catheter placement. Sequential use of cervical Foley catheter after misoprostol is associated with longer labor, higher cesarean rate, and increased NICU admission. Requirement of Foley catheter after misoprostol confers higher risk and may guide counseling.

Key Points

• Little is known regarding efficacy of misoprostol followed by cervical Foley catheter.

• Nulliparas and dilation <1 cm increases need for Foley after misoprostol.

• Complications were more common in women requiring Foley after misoprostol.

Keywords

Induction - cervical ripening - misoprostol - Foley - neonatal morbidity

Publication History

Received: 03 January 2020

Accepted: 26 May 2020

Article published online:
28 June 2020

• References

• 1 The American College of Obstetricians and Gynecologists. Induction of labor. ACOG practice bulletin 107. Obstet Gynecol 2009; 114: 386-397
• 2 Jozwiak M, Bloemenkamp KW, Kelly AJ, Mol BW, Irion O, Boulvain M. Mechanical methods for induction of labour. Cochrane Database Syst Rev 2012; (03) CD001233
• 3 Thomas J, Fairclough A, Kavanagh J, Kelly AJ. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database Syst Rev 2014; (06) CD003101
• 4 Alfirevic Z, Kelly AJ, Dowswell T. Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database Syst Rev 2009; (04) CD003246
• 5 Ten Eikelder ML, Mast K, van der Velden A, Bloemenkamp KW, Mol BW. Induction of labor using a foley catheter or misoprostol: a systematic review and meta-analysis. Obstet Gynecol Surv 2016; 71 (10) 620-630
• 6 Jozwiak M, ten Eikelder M, Oude Rengerink K. et al; PROBAAT Study Group. Foley catheter versus vaginal misoprostol: randomized controlled trial (PROBAAT-M study) and systematic review and meta-analysis of literature. Am J Perinatol 2014; 31 (02) 145-156
• 7 Levine LD, Downes KL, Elovitz MA, Parry S, Sammel MD, Srinivas SK. Mechanical and pharmacologic methods of labor induction: a randomized controlled trial. Obstet Gynecol 2016; 128 (06) 1357-1364
• 8 Carbone JF, Tuuli MG, Fogertey PJ, Roehl KA, Macones GA. Combination of Foley bulb and vaginal misoprostol compared with vaginal misoprostol alone for cervical ripening and labor induction: a randomized controlled trial. Obstet Gynecol 2013; 121 (2 Pt 1): 247-252
• 9 Ande AB, Ezeanochie CM, Olagbuji NB. Induction of labor in prolonged pregnancy with unfavorable cervix: comparison of sequential intracervical Foley catheter-intravaginal misoprostol and intravaginal misoprostol alone. Arch Gynecol Obstet 2012; 285 (04) 967-971
• 10 Kehl S, Weiss C, Dammer U. et al. Double-balloon catheter and sequential oral misoprostol versus oral misoprostol alone for induction of labour at term: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2016; 204: 78-82