My Opinion: Outpatient cervical ripening for select patients may be on the horizon, but we're not there yet.
Kacey Eichelberger, MD
Dr Eichelberger is Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Carolina Greenville School of Medicine/Greenville Health System.
Annâs question is certainly a reasonable one, and echoes with refrains familiar to most delivery providers. As she approaches the birth of her child, she draws upon the positive experience of a trusted friend who underwent outpatient cervical ripening and presumably had a positive birth experience. Those of us privileged enough to deliver babies encounter such personal requests day in and day out: âI was thinking I may want to deliver in the tub . . . what do you think?â âWill you wait to cut the cord until it stops pulsing?â âIâd like to give birth at home . . . is that okay?â
Part of our job as womenâs healthcare providers is to help patients navigate the vast and often murky waters between personal narrative, traditional practice patterns, and, for lack of a better word, scientific evidence. Two basic questions serve as a helpful starting point when considering requests that veer away from our otherwise ânormativeâ practice patterns: Does it work? and Is it safe?
From a purely biologic standpoint, most would presume that cervical ripening should be equally as effective in the outpatient and inpatient settings. However, there is always a chance that unmeasured variables affect the performance of an intervention in one environment over another. To this end, Sciscione and colleagues conducted a randomized controlled trial (RCT) of preinduction cervical ripening with a Foley catheter, in which 61 women were randomized to outpatient ripening and 50 to traditional inpatient.1 The primary outcome of the studyâmean change in Bishop scoreâwas no different between the 2 study groups. That is to say, Foley catheter ripening worked as well in an outpatient setting as it did in an inpatient one. In 2014, Wilkinson and colleagues published the results of their large RCT, in which 827 women were randomized to outpatient versus inpatient cervical ripening with PGE2.2 There was no significant difference between the 2 study groups in the primary outcome, total oxytocin use, or cesarean section rate.
Now the question, is it safe? In the Wilkinson trial mentioned above, 47% of women randomized to the outpatient PGE2 arm did not ultimately receive the intervention, and of those 215 women who did have the prostaglandin placed, 47 (21.8%) remained inpatient for abnormal fetal heart rate (FHR) tracing, labor, or personal request. Indeed, only 103 of 411 women (25%) randomized to the outpatient arm ultimately received the intervention and remained at home through the designated ripening period. This is consistent with existing data on inpatient ripening with prostaglandins, which carries with it the known risk of tachysystole and FHR abnormalities. The safety data are stronger for outpatient mechanical ripening: Sciscione reviewed the records of more than 1900 women who underwent inpatient pre-induction ripening with Foley catheters, and identified no adverse outcomes among that cohort.3
Finally, what do the authorities say? The American College of Obstetricians and Gynecologists hedges, saying that outpatient ripening by mechanical means may be appropriate for select patients.4 The Cochrane Review, too, is inconclusive, noting that the data are limited, and âit is not yet possible to determine whether induction of labour is effective and safe in outpatient settings.â5 Finally, our own hospital system, with almost 7000 deliveries annually, has not yet agreed that evidence is sufficient to change practice recommendations.
Ultimately, Ann, the data on safety and feasibility of outpatient cervical ripening with prostaglandins are not convincing, and I would not recommend their use outside the research setting. While I believe the data on safety and feasibility of mechanical dilation are very promising, that practice falls outside our current practice guidelines.
"So, Ann, what can we do to make your inpatient ripening experience as comfortable for you as possible?
1. Sciscione AC, Muench M, Pollack M, Jenkins TM, Tidlon-Burton J, Colmorgen GH. Transcervical Foley catheter for preinduction cervical ripening in an outpatient versus inpatient setting. Obstet Gynecol. 2001;98(5, Pt 1):751â756.
2. Wilkinson C, Bryce R, Adelson P, Turnbull D. A randomised controlled trial of outpatient compared with inpatient cervical ripening with prostaglandin Eâ (OPRA study). BJOG. 2015;122(1):94â104.
3. Sciscione AC, Bedder CL, Hoffman MK, Ruhstaller K, Shlossman PA. The timing of adverse events with Foley catheter preinduction cervical ripening; implications for outpatient use. Am J Perinatol. 2014;31(9):781â786.
4. ACOG Committee on Practice BulletinsâObstetrics. Induction of Labor: ACOG Practice Bulletin No. 107. Obstet Gynecol. 2009;114(2 Pt 1):386â397.
5. Kelly AJ, Alfirevic Z, Ghosh A. Outpatient versus inpatient induction of labour for improving birth outcomes. Cochrane Database Syst Rev. 2013;11:CD007372.