Office-based ambulatory cervical ripening prior to inpatient induction of labor - MDedge
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EDITORIAL
Office-based ambulatory cervical ripening
prior to inpatient induction of labor
There is growing literature to support the use of ambulatory cervical ripening
(CR) for low-risk women—initiating CR in the office, sending the patient
home to complete the first phase of the CR process, and then admitting her
to the labor unit for additional CR or induction of labor
Robert L. Barbieri, MD
Chair Emeritus, Department of Obstetrics and Gynecology
Interim Chief, Obstetrics
Brigham and Women’s Hospital
Kate Macy Ladd Distinguished Professor of Obstetrics,
Gynecology and Reproductive Biology
Harvard Medical School
Boston, Massachusetts
F
or women with a Bishop morning or is sent home in the effectiveness of ambulatory versus
score ≤6, CR is an important morning to return for IOL in the eve- inpatient Foley catheter CR.1 A total of
first step in planned induc- ning or at night. A secondary benefit 130 women with a Bishop scoreEDITORIAL Streptococcus group B infection, and Ausbeck and colleagues ran- by direct visualization using a vagi- HIV infection. Prostaglandin CR was domly assigned 126 nulliparous nal speculum. After placement of not used if the woman had a previous women with a Bishop score
In another study of outpatient CR Two systematic reviews and baseline Bishop score of 2.9, had with the Cook double-balloon cath- meta-analyses reported that out- Dilapan-S placed for approximately eter, 695 women with a Bishop score comes were similar when using the 15 hours prior to oxytocin IOL. The
EDITORIAL 425 women at 37 to 42 weeks’ gesta- outpatient CR with oral misopro- birthing unit. If they had no regular tion were assigned randomly to out- stol (100 µg) or placebo.23 Fol- contractions they were discharged patient or inpatient CR.18 All women lowing administration of the oral home. For nulliparous women, the had CTG monitoring for 20 minutes misoprostol, the women had 2 hours time from intervention to delivery in before and after vaginal placement of CTG monitoring. The treatment the misoprostol group was 4.9 days, of the PGE2 gel. The PGE2 dose was was repeated daily for up to 3 days and 8.1 days in the control group. For 2 mg for nulliparous and 1 mg for if there was no change in the cervix. parous women, the times from inter- parous women. The cesarean deliv- If labor occurred, the patient was vention to delivery in the two groups ery rates were similar in the outpa- admitted to the labor unit for oxy- were 3.8 and 6.9 days, respectively. tient and inpatient groups—22.3% tocin IOL. The times from first dose and 22.9%, respectively. Among the of misoprostol or placebo to deliv- women randomized to outpatient ery were 46 and 84 hours (P
Safety of office-based Two systematic reviews have misoprostol, the transcervical bal-
ambulatory CR among reported that, compared with bal- loon catheter is associated with a low
low-risk women loon CR, misoprostol CR is associ- rate of uterine tachysystole. It may
Safety is a complex concept with ated with an increased risk of uterine be a preferred method for outpatient
experts often disagreeing on what tachysystole.33-34 In a large retrospec- CR. If placement of a transcervi-
level of safety is required to accept a tive study, compared with inpatient cal balloon catheter is challenging,
new medical procedure. Establish- CR, outpatient CR with dinoprostone for example when the patient has
ing the safety of office-based ambu- vaginal insert was not associated a tightly closed cervix, oral miso-
latory CR among low-risk women with an increased risk of newborn prostol ambulatory CR may be an
would require a very large cohort or admission to the neonatal intensive option if CTG monitoring is available
randomized studies with at least a care unit or a low Apgar score at in the office.
thousand participants. Only a few 5 minutes after birth.35 During the COVID pandemic,
large studies focused on the safety of many in-person office visits have
CR have been reported. Sciscione and transitioned to virtual visits with
colleagues reported a large observa- Will you consider the patient in their home. Histori-
tional study of inpatient transcervi- office-based CR in your cally, most cases of CR have been
cal Foley catheter for CR involving obstetric practice? performed on labor and deliv-
1,905 women.31 They reported no As reviewed in this editorial, evolv- ery units. It may be time for your
adverse outcomes among term, sin- ing data suggest that it is feasible to practice to consider office-based
gleton, uncomplicated pregnancies. initiate CR in the office ambulatory ambulatory CR for low-risk women
They calculated that the 95% con- setting prior to admission to the planning an IOL. Office-based
fidence interval (CI) for an adverse labor unit for additional CR or IOL. ambulatory CR is a win for labor
event was between 0.0% and 0.2%. In Many women prefer to complete CR nurses who generally prefer to man-
a meta-analysis of 26 studies includ- at home after initiation in the office, age laboring patients rather than
ing 5,563 women, the risk of chorio- rather than have CR in a labor unit or patients undergoing prolonged in-
amnionitis during IOL was equivalent hospital setting.36 The transcervical hospital CR. Outpatient CR is also
with pre-IOL Foley catheter CR (7.2%) balloon catheter has the most pub- a win for low-risk patients who
or prostaglandin CR (7.2%) (relative lished data supporting the feasibility prefer to be at home rather than
risk, 0.96; 95% CI, 0.66–1.38).32 of ambulatory CR. Compared with in a labor unit. ●
References
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mdedge.com/obgyn Vol. 33 No. 3 | March 2021 | OBG Management 13EDITORIAL
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