Outpatient labor induction-Exploring future potential by assessing eligibility in a historical cohort.

INTRODUCTION: Labor induction rates have increased over the last decades, and in many high-income countries, more than one in four labors are induced. Outpatient management of labor induction has been suggested in low-risk pregnancies to improve women's birth experiences while also promoting a more efficient use of healthcare resources. The primary aim of this paper was to assess the proportion of women in a historical cohort that would have been eligible for outpatient labor induction with oral misoprostol. Second, we wanted to report safety outcomes and assess efficacy outcomes for mothers and infants in pregnancies that met the criteria for outpatient care. MATERIAL AND METHODS: Criteria for outpatient labor induction with oral misoprostol were applied to a historical cohort of women with induction of labor at two Norwegian tertiary hospitals in the period January 1, through July 31, 2021. The criteria included low-risk women with an unscarred uterus expecting a healthy, singleton baby in cephalic position at term. The primary outcome was the proportion of women eligible for outpatient labor induction. Secondary outcomes included reasons for ineligibility and, for eligible women, safety and efficacy outcomes. RESULTS: Overall, 29.7% of the 1320 women who underwent labor induction in a singleton term pregnancy met the criteria for outpatient labor induction. We identified two serious adverse events that potentially could have occurred outside the hospital if the women had received outpatient care. The mean duration from initiation of labor induction to administration of the last misoprostol was 22.4 h. One in 14 multiparous women gave birth within 3 h after the last misoprostol dose. CONCLUSIONS: In this historical cohort, three in ten women met the criteria for outpatient management of labor induction with oral misoprostol. Serious adverse events were rare. The average time span from the initiation of labor induction to the last misoprostol was nearly 24 h. This suggests a potential for low-risk women with an induced labor to spend a substantial period of time at home before labor onset. However, larger studies testing or evaluating labor induction with oral misoprostol as an outpatient procedure are needed to draw conclusions.

Induction of labor and nulliparity: A nationwide clinical practice pilot evaluation.

INTRODUCTION: Induction of labor has become an increasingly common obstetric procedure, but in nulliparous women or women with a previous cesarean section, it can pose a clinical challenge. Despite an overall expansion of medical indications for labor induction, there is little international consensus regarding the criteria for induction, or for the recommended methods among nulliparous women. In this light, we assessed variations in the practice of induction of labor among 21 birth units in a nationwide cohort of women with no prior vaginal birth. MATERIAL AND METHODS: We carried out a prospective observational pilot study of women with induced labor and no prior vaginal birth, across 21 Norwegian birth units. We registered induction indications, methods and outcomes from 1 September to 31 December 2018 using a web-based case record form. Women were grouped into "Nulliparous term cephalic", "Previous cesarean section" and "Other Robson" (Robson groups 6, 7, 8 or 10). RESULTS: More than 98% of eligible women (n=1818) were included and a wide variety of methods was used for induction of labor. In nulliparous term cephalic pregnancies, cesarean section rates ranged from 11.1% to 40.6% between birth units, whereas in the previous cesarean section group, rates ranged from 22.7% to 67.5%. The indications "large fetus" and "other fetal" indications were associated with the highest cesarean rates. Failed inductions and failure to progress in labor contributed most to the cesarean rates. Uterine rupture occurred in two women (0.11%), both in the previous cesarean section group. In neonates, 1.6% had Apgar <7 at 5 minutes, and 0.4% had an umbilical artery pH <7.00. CONCLUSIONS: Cesarean rates and applied methods for induction of labor varied widely in this nationwide cohort of women without a prior vaginal birth. Neonatal outcomes were similar to those of normal birth populations. Results could indicate the need to move towards more standardized induction protocols associated with optimal outcomes for mother and baby.

A comparison of misoprostol vaginal insert and misoprostol vaginal tablets for induction of labor in nulliparous women: a retrospective cohort study.

BACKGROUND: Since Misoprostol Vaginal Insert (MVI - Misodel ®) was approved for labor induction in Europe in 2013, to date, no study has been published comparing MVI to Misoprostol vaginal tablets (MVT). The aim of this study, performed as part of a quality improvement project, was to compare the efficacy and safety of 200 µg MVI versus 25 µg MVT for labor induction in nulliparous women. METHODS: This retrospective cohort study included 171 nulliparous singleton term deliveries induced with MVI (n = 85) versus MVT (n = 86) at Oslo University Hospital Rikshospitalet, Norway, from November 2014 to December 2015. Primary outcomes were time from drug administration to delivery in hours and minutes and the rate of cesarean section (CS). Results were adjusted for Bishop Score and pre-induction with balloon catheter. RESULTS: Median time from drug administration to delivery was shorter in the MVI group compared to the MVT group (15 h 43 min versus 19 h 37 min, p = 0.011). Adjusted for confounding factors, mean difference was 6 h 3 min (p = 0.002). The risk of CS was 67% lower in the MVI group compared to the MVT group (11.8% versus 23.3%, OR = 0.33; adjusted 95% CI 0.13-0.81). Adverse neonatal outcomes did not differ between the groups. CONCLUSIONS: In a setting of routine obstetric care, MVI seems to be a more efficient labor induction agent than MVT, and with a lower CS rate and no increase in adverse infant outcomes.