My Opinion: Outpatient cervical ripening should be offered to select women
Lauren D Demosthenes, MD
Dr Demosthenes is Assistant Clinical Professor, Department of Obstetrics and Gynecology, Greenville Health System, South Carolina.
Ann is a 25-year-old who presents at 41 weeksâ gestation for her routine and uncomplicated prenatal visit. On exam, her cervix is closed and soft. Her Bishop score is 5. You offer her cervical ripening and induction of labor and she agrees to this plan. In fact, her best friend in another state just went through the same thing last month. She tells you that the woman went home after her cervical ripening and returned for induction the next morning. Ann would really like this option, as she is much more comfortable at home.
Approximately 25% of women in the United States undergo induction of labor.1 In women with an unfavorable cervix, usually defined as a Bishop score of â¤6, cervical ripening is used to facilitate the process of cervical softening, thinning, and dilation. This leads to a shorter induction-to-delivery time and a lower probability of a failed induction. Cervical ripening can be accomplished either pharmacologically or mechanically. Pharmacologic agents include synthetic prostaglandin E1 (PGE1) and E2 (PGE2). Risks include tachysystole with possible fetal heart rate concerns. Mechanical dilation most often is performed with a Foley catheter or other balloon catheter, which is inserted through the unfavorable cervix. Risks include a very low likelihood of postpartum fever and post-insertion bleeding.
In an era of patient-centered care, providing safe, high-quality, cost-conscious options for patients has never been more important. It is our responsibility as caregivers to offer reasonable choices that have the potential to enhance the patient experience. Evidence shows that outpatient cervical ripening is appropriate in selected patients. Indeed, the American College of Obstetricians and Gynecologists states in its Practice Bulletin on induction of labor that outpatient cervical ripening, particularly mechanical methods, may be appropriate in carefully selected patients.1
A randomized, double-blind placebo-controlled study published in 2009 looked at outpatient oral misoprostol for prolonged pregnancies and found that patients receiving misoprostol had a significantly shorter time interval from study entry to onset of spontaneous labor and to delivery when compared with the placebo group. Although there were no significant differences in maternal or fetal morbidity, the study was not powered to determine safety in the outpatient setting. So we found out that pharmacologic ripening works but could not conclude that it is safe.2
In comparing mechanical to pharmacologic cervical ripening, use of a Foley and pharmacologic cervical ripening have demonstrated similar efficacy.3,4 For outpatient versus inpatient cervical ripening, a Foley catheter also has been shown to be equally effective in both settings, with a high satisfaction rate in women in the outpatient arm of the study. In addition, outpatient management resulted in a reduction in length of hospital stay, which is beneficial for both patient and hospital.5
But what about safety? A more recent retrospective cohort study published in 2014 built upon this work to provide more information about the safety of outpatient management. Over 3 Â½ years, 1905 patients met criteria for outpatient cervical ripening. Patients were monitored for 2 hours after Foley bulb placement then allowed to go home and return at 0600 the following morning. No adverse obstetric events were reported to the use of the Foley catheter in the cervical ripening phase. The authors concluded that utilization of a Foley catheter for cervical ripening is an ideal outpatient option.6
In light of these data regarding length of hospital stay, patient satisfaction, safety, and potential cost savings in the outpatient setting, we should consider offering this option to our carefully selected patients.
âSo yes, Ann, you can go home to your own bed the night before your induction.â
1. ACOG Committee on Practice BulletinsâObstetrics. Induction of Labor: ACOG Practice Bulletin No. 107. Obstet Gynecol. 2009;114(2 Pt 1):386â397.
2. Gaffaney C, Saul L, Rumney P, Morrison E, Thomas S, Nageotte M, Wing D. Outpatient oral misoprostol for prolonged pregnancy: a pilot investigation. Am J Perinatol. 2009;26:673â678.
3. Gelber S, Sciscione A. Mechanical methods of cervical ripening and labor induction. Clin Obstet Gynecol. 2006;49(3):642â657.
4. Vaknin Z, Kurzweil Y, Sherman D. Foley catheter balloon vs locally applied prostaglandins for cervical ripening and labor inductions: a systematic review and metaanalysis. Am J Obstet Gynecol. 2010;203(5):418â429.
5. 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.
6. Sciscione AC, Bedder C, Hoffman MK, Ruhstaller K, Sholssman PA. The timing of adverse events with Foley catheter preinduction cervical ripening: implications for outpatient use. Am J Perinatol. 2014;31:781â786.