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Meta-Analysis
. 2017 Sep 13;9(9):CD007701.
doi: 10.1002/14651858.CD007701.pub3.

Pharmacological and mechanical interventions for labour induction in outpatient settings

Joshua P Vogel  1 , Alfred O Osoti, Anthony J Kelly, Stefania Livio, Jane E Norman, Zarko Alfirevic
Affiliations
Meta-Analysis

Pharmacological and mechanical interventions for labour induction in outpatient settings

Joshua P Vogel et al. Cochrane Database Syst Rev. .

Abstract

Background: Induction of labour is carried out for a variety of indications and using a range of methods. For women at low risk of pregnancy complications, some methods of induction of labour or cervical ripening may be suitable for use in outpatient settings.

Objectives: To examine pharmacological and mechanical interventions to induce labour or ripen the cervix in outpatient settings in terms of effectiveness, maternal satisfaction, healthcare costs and, where information is available, safety.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016) and reference lists of retrieved studies.

Selection criteria: We included randomised controlled trials examining outpatient cervical ripening or induction of labour with pharmacological agents or mechanical methods. Cluster trials were eligible for inclusion.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed evidence using the GRADE approach.

Main results: This updated review included 34 studies of 11 different methods for labour induction with 5003 randomised women, where women received treatment at home or were sent home after initial treatment and monitoring in hospital.Studies examined vaginal and intracervical prostaglandin E₂ (PGE₂), vaginal and oral misoprostol, isosorbide mononitrate, mifepristone, oestrogens, amniotomy and acupuncture, compared with placebo, no treatment, or routine care. Trials generally recruited healthy women with a term pregnancy. The risk of bias was mostly low or unclear, however, in 16 trials blinding was unclear or not attempted. In general, limited data were available on the review's main and additional outcomes. Evidence was graded low to moderate quality. 1. Vaginal PGE₂ versus expectant management or placebo (5 studies)Fewer women in the vaginal PGE₂ group needed additional induction agents to induce labour, however, confidence intervals were wide (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.27 to 0.99; 150 women; 2 trials). There were no clear differences between groups in uterine hyperstimulation (with or without fetal heart rate (FHR) changes) (RR 3.76, 95% CI 0.64 to 22.24; 244 women; 4 studies; low-quality evidence), caesarean section (RR 0.80, 95% CI 0.49 to 1.31; 288 women; 4 studies; low-quality evidence), or admission to a neonatal intensive care unit (NICU) (RR 0.32, 95% CI 0.10 to 1.03; 230 infants; 3 studies; low-quality evidence).There was no information on vaginal birth within 24, 48 or 72 hours, length of hospital stay, use of emergency services or maternal or caregiver satisfaction. Serious maternal and neonatal morbidity or deaths were not reported. 2. Intracervical PGE₂ versus expectant management or placebo (7 studies) There was no clear difference between women receiving intracervical PGE₂ and no treatment or placebo in terms of need for additional induction agents (RR 0.98, 95% CI 0.74 to 1.32; 445 women; 3 studies), vaginal birth not achieved within 48 to 72 hours (RR 0.83, 95% CI 0.68 to 1.02; 43 women; 1 study; low-quality evidence), uterine hyperstimulation (with FHR changes) (RR 2.66, 95% CI 0.63 to 11.25; 488 women; 4 studies; low-quality evidence), caesarean section (RR 0.90, 95% CI 0.72 to 1.12; 674 women; 7 studies; moderate-quality evidence), or babies admitted to NICU (RR 1.61, 95% CI 0.43 to 6.05; 215 infants; 3 studies; low-quality evidence). There were no uterine ruptures in either the PGE₂ group or placebo group.There was no information on vaginal birth not achieved within 24 hours, length of hospital stay, use of emergency services, mother or caregiver satisfaction, or serious morbidity or neonatal morbidity or perinatal death. 3. Vaginal misoprostol versus placebo (4 studies)One small study reported on the rate of perinatal death with no clear differences between groups; there were no deaths in the treatment group compared with one stillbirth (reason not reported) in the control group (RR 0.34, 95% CI 0.01 to 8.14; 77 infants; 1 study; low-quality evidence).There was no clear difference between groups in rates of uterine hyperstimulation with FHR changes (RR 1.97, 95% CI 0.43 to 9.00; 265 women; 3 studies; low-quality evidence), caesarean section (RR 0.94, 95% CI 0.61 to 1.46; 325 women; 4 studies; low-quality evidence), and babies admitted to NICU (RR 0.89, 95% CI 0.54 to 1.47; 325 infants; 4 studies; low-quality evidence).There was no information on vaginal birth not achieved within 24, 48 or 72 hours, additional induction agents required, length of hospital stay, use of emergency services, mother or caregiver satisfaction, serious maternal, and other neonatal, morbidity or death.No substantive differences were found for other comparisons. One small study found that women who received oral misoprostol were more likely to give birth within 24 hours (RR 0.65, 95% CI 0.48 to 0.86; 87 women; 1 study) and were less likely to require additional induction agents (RR 0.60, 95% CI 0.37 to 0.97; 127 women; 2 studies). Women who received mifepristone were also less likely to require additional induction agents (average RR 0.59, 95% CI 0.37 to 0.95; 311 women; 4 studies; I² = 74%); however, this result should be interpreted with caution due to high heterogeneity. One trial each of acupuncture and outpatient amniotomy were included, but few review outcomes were reported.

Authors' conclusions: Induction of labour in outpatient settings appears feasible and important adverse events seem rare, however, in general there is insufficient evidence to detect differences. There was no strong evidence that agents used to induce labour in outpatient settings had an impact (positive or negative) on maternal or neonatal health. There was some evidence that compared to placebo or no treatment, induction agents administered on an outpatient basis reduced the need for further interventions to induce labour, and shortened the interval from intervention to birth.We do not have sufficient evidence to know which induction methods are preferred by women, the interventions that are most effective and safe to use in outpatient settings, or their cost effectiveness. Further studies where various women-friendly outpatient protocols are compared head-to-head are required. As part of such work, women should be consulted on what sort of management they would prefer.

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Conflict of interest statement

Joshua P Vogel: none known.

Alfred O Osoti: none known.

Anthony J Kelly: none known.

Stefania Livio: none known.

Jane E Norman: Jane Norman was an investigator on two trials included in this review (Bollapragada 2006b; Osman 2006); the reports from these trials were independently assessed by two other review authors. Jane Norman has received a grant of GBP 11,000 (paid to her institution) from the Chief Scientist's Office, Scottish Executive, for an epidemiological study entitled: "Ferguson EF, Norman JE, Chalmers J, Shanks E, Finlayson A. Investigation of the beneficial and adverse effects of induction of labour." Jane Norman has received a number of research grants (paid to her institution) to support research into improving perinatal outcome ‐ none specifically related to immediate versus deferred delivery. Jane has also received small amounts of money for speaking at meetings about prematurity but not immediate versus deferred delivery.

Zarko Alfirevic: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 1 Additional induction agents required.
1.2
1.2. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 2 Epidural.
1.3
1.3. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 3 Uterine hyperstimulation (FHR changes unclear).
1.4
1.4. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 4 Caesarean section.
1.5
1.5. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 5 Apgar score < 7 at 5 minutes.
1.6
1.6. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 6 NICU admission.
1.7
1.7. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 7 Chorioamnionitis.
1.8
1.8. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 8 Indicator of 'progress' in labour ‐ Cervix unchanged at follow up (not pre‐specified).
1.9
1.9. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 9 'Spontaneous labour' within 48 hours.
1.10
1.10. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 10 Indicator of 'progress' in labour ‐ Admitted to hospital for labour.
1.11
1.11. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 11 Time to birth ‐ Gestational age at birth (weeks).
1.12
1.12. Analysis
Comparison 1 Intravaginal PGE₂ gel versus placebo or expectant management, Outcome 12 Time to birth ‐ Gestational age on admission (days).
2.1
2.1. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 1 Additional induction agent required (induction with oxytocin or other means).
2.2
2.2. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 2 Additional induction agents required (further prostaglandin required).
2.3
2.3. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 3 Uterine rupture.
2.4
2.4. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 4 Birth not achieved in 48 to 72 hours.
2.5
2.5. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 5 Oxytocin augmentation.
2.6
2.6. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 6 Uterine hyperstimulation (with FHR changes).
2.7
2.7. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 7 Assisted (instrumental) vaginal birth.
2.8
2.8. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 8 Caesarean section.
2.9
2.9. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 9 Apgar score < 7 at 5 minutes.
2.10
2.10. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 10 NICU admission.
2.11
2.11. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 11 Postpartum haemorrhage (> 500 mL).
2.12
2.12. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 12 Chorioamnionitis.
2.13
2.13. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 13 Endometritis.
2.14
2.14. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 14 Side effects ‐ Maternal side effects.
2.15
2.15. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 15 Time to birth ‐ Interval from intervention to birth (days).
2.16
2.16. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 16 Time to birth ‐ Gestational age at birth (weeks).
2.17
2.17. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 17 Indicator of 'progress' in labour ‐ Induction for gestational age > 42 weeks.
2.18
2.18. Analysis
Comparison 2 Intracervical PGE₂ versus placebo, Outcome 18 Time to birth ‐ Birth within 48 hours of treatment (all births).
3.1
3.1. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 1 Serious neonatal morbidity or death.
3.2
3.2. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 2 Epidural.
3.3
3.3. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 3 Uterine hyperstimulation (with FHR changes).
3.4
3.4. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 4 Uterine hyperstimulation (without FHR changes).
3.5
3.5. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 5 Assisted (instrumental) vaginal birth.
3.6
3.6. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 6 Caesarean section.
3.7
3.7. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 7 Apgar score < 7 at 5 minutes.
3.8
3.8. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 8 NICU admission.
3.9
3.9. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 9 Perinatal death.
3.10
3.10. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 10 Neonatal infection.
3.11
3.11. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 11 Indicator of 'progress' in labour ‐ Oxytocin dose used (mU).
3.12
3.12. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 12 Indicator of 'progress' in labour ‐ Number of medication dose.
3.13
3.13. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 13 Indicator of 'progress' in labour ‐ Number of women requiring dosing on day 2.
3.14
3.14. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 14 Indicator of 'progress' in labour ‐ Number of women requiring induction on day 3.
3.15
3.15. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 15 Indicator of 'progress' in labour ‐ Days to admission (all) (days).
3.16
3.16. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 16 Indicator of 'progress' in labour ‐ Days to admission (subgroups by parity) (days).
3.17
3.17. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 17 Indicator of 'progress' in labour ‐ Gestational age at labour (weeks).
3.18
3.18. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 18 Indicator of 'progress' in labour ‐ Days to admission (parous) (weeks).
3.19
3.19. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 19 Indicator of 'progress' in labour ‐ Days to PROM (days).
3.20
3.20. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 20 Time to birth ‐ Interval from intervention to vaginal birth (days).
3.21
3.21. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 21 Time to birth ‐ Days to birth (all) (days).
3.22
3.22. Analysis
Comparison 3 Vaginal misoprostol versus placebo, Outcome 22 Time to birth ‐ Days to birth (subgroups by parity) (days).
4.1
4.1. Analysis
Comparison 4 Vaginal misoprostol 25 µg versus 50 µg, Outcome 1 Additional induction agents required (oxytocin).
4.2
4.2. Analysis
Comparison 4 Vaginal misoprostol 25 µg versus 50 µg, Outcome 2 Uterine hyperstimulation.
4.3
4.3. Analysis
Comparison 4 Vaginal misoprostol 25 µg versus 50 µg, Outcome 3 Caesarean section.
4.4
4.4. Analysis
Comparison 4 Vaginal misoprostol 25 µg versus 50 µg, Outcome 4 NICU admission.
4.5
4.5. Analysis
Comparison 4 Vaginal misoprostol 25 µg versus 50 µg, Outcome 5 Interval from treatment to birth (in days, all births).
5.1
5.1. Analysis
Comparison 5 Intracervical PGE₂ versus vaginal misoprostol, Outcome 1 Uterine hyperstimulation (with or without FHR changes).
5.2
5.2. Analysis
Comparison 5 Intracervical PGE₂ versus vaginal misoprostol, Outcome 2 Caesarean section.
5.3
5.3. Analysis
Comparison 5 Intracervical PGE₂ versus vaginal misoprostol, Outcome 3 Apgar score < 7 after 5 minutes.
5.4
5.4. Analysis
Comparison 5 Intracervical PGE₂ versus vaginal misoprostol, Outcome 4 Admission to NICU.
5.5
5.5. Analysis
Comparison 5 Intracervical PGE₂ versus vaginal misoprostol, Outcome 5 Indicator of 'progress' in labour ‐ Interval from administration to admission (hours).
5.6
5.6. Analysis
Comparison 5 Intracervical PGE₂ versus vaginal misoprostol, Outcome 6 Indicator of 'progress' in labour ‐ Labour or SROM during ripening.
5.7
5.7. Analysis
Comparison 5 Intracervical PGE₂ versus vaginal misoprostol, Outcome 7 Time to birth ‐ Birth within 24 hours.
5.8
5.8. Analysis
Comparison 5 Intracervical PGE₂ versus vaginal misoprostol, Outcome 8 Time to birth ‐ Birth within 48 hours (cumulative).
6.1
6.1. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 1 Vaginal delivery not achieved within 24 hours.
6.2
6.2. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 2 Additional induction agents required.
6.3
6.3. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 3 Oxytocin augmentation.
6.4
6.4. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 4 Uterine hyperstimulation (with FHR changes).
6.5
6.5. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 5 Uterine hyperstimulation (FHR changes unclear).
6.6
6.6. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 6 Instrumental vaginal birth.
6.7
6.7. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 7 Caesarean section.
6.8
6.8. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 8 Apgar score < 7 at 5 minutes.
6.9
6.9. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 9 Neonatal intensive care unit admission.
6.10
6.10. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 10 Postpartum haemorrhage.
6.11
6.11. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 11 Chorioamnionitis.
6.12
6.12. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 12 Endometritis.
6.13
6.13. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 13 Indicator of 'progress' in labour ‐ Time from first dose to active labor (hours).
6.14
6.14. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 14 Time to birth ‐ First dose to birth (hours).
6.15
6.15. Analysis
Comparison 6 Oral misoprostol versus placebo, Outcome 15 Indicator of 'progress' in labour ‐ Total doses of medication.
7.1
7.1. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 1 Additional induction agents required.
7.2
7.2. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 2 Serious neonatal morbidity or death.
7.3
7.3. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 3 Oxytocin augmentation.
7.4
7.4. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 4 Epidural.
7.5
7.5. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 5 Assisted (instrumental) vaginal birth.
7.6
7.6. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 6 Caesarean section.
7.7
7.7. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 7 Apgar score < 7 at 5 minutes.
7.8
7.8. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 8 NICU admission.
7.9
7.9. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 9 Perinatal death.
7.10
7.10. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 10 Uterine scar separation.
7.11
7.11. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 11 Chorioamnionitis.
7.12
7.12. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 12 Indicator of 'progress' in labour ‐ Labour or ripe cervix in 48 hours.
7.13
7.13. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 13 Indicator of 'progress' in labour ‐ Cervix unchanged after 24/48 hours.
7.14
7.14. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 14 Indicator of 'progress' in labour ‐ Spontaneous labour within 72 hours.
7.15
7.15. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 15 Indicator of 'progress' in labour ‐ Spontaneous labour within 48 hours.
7.16
7.16. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 16 Indicator of 'progress' in labour ‐ Oxytocin requirements (IU).
7.17
7.17. Analysis
Comparison 7 Mifepristone versus placebo, Outcome 17 Indicator of 'progress' in labour ‐ Interval between day 1 and start of labour (hours).
8.1
8.1. Analysis
Comparison 8 Oestrogens versus placebo, Outcome 1 Oxytocin augmentation.
8.2
8.2. Analysis
Comparison 8 Oestrogens versus placebo, Outcome 2 Assisted (instrumental) vaginal birth.
8.3
8.3. Analysis
Comparison 8 Oestrogens versus placebo, Outcome 3 Caesarean section.
8.4
8.4. Analysis
Comparison 8 Oestrogens versus placebo, Outcome 4 NICU admission.
8.5
8.5. Analysis
Comparison 8 Oestrogens versus placebo, Outcome 5 Chorioamnionitis.
8.6
8.6. Analysis
Comparison 8 Oestrogens versus placebo, Outcome 6 Endometritis.
9.1
9.1. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 1 Vaginal birth not achieved in 24/48 hours.
9.2
9.2. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 2 Additional induction agents required.
9.3
9.3. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 3 Maternal satisfaction.
9.4
9.4. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 4 Maternal satisfaction.
9.5
9.5. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 5 Perinatal death.
9.6
9.6. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 6 Neonatal trauma (long bone fracture, collarbone fracture, basal skull fracture, brachial plexus palsy, facial nerve palsy, phrenic nerve palsy, or subdural haemorrhage).
9.7
9.7. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 7 Neonatal convulsions in the first 24 hours.
9.8
9.8. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 8 Tracheal ventilation > 24 hours.
9.9
9.9. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 9 Neonatal ICU admission for 5 or more days.
9.10
9.10. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 10 Neonatal transfer.
9.11
9.11. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 11 Maternal death.
9.12
9.12. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 12 Severe postpartum haemorrhage.
9.13
9.13. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 13 Deep vein thrombosis.
9.14
9.14. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 14 Oxytocin augmentation.
9.15
9.15. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 15 Epidural.
9.16
9.16. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 16 Uterine hyperstimulation (with FHR changes).
9.17
9.17. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 17 Uterine hyperstimulation (FHR changes unclear).
9.18
9.18. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 18 Assisted (instrumental) vaginal birth.
9.19
9.19. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 19 Caesarean section.
9.20
9.20. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 20 Apgar score < 7 at 5 minutes.
9.21
9.21. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 21 NICU (or SCBU) admission.
9.22
9.22. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 22 Postpartum haemorrhage (> 500 mL).
9.23
9.23. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 23 Neonatal infection.
9.24
9.24. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 24 Side effects ‐ Maternal side effect ‐ nausea.
9.25
9.25. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 25 Side effects ‐ Maternal side effect ‐ headache.
9.26
9.26. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 26 Side effects ‐ Maternal side effects ‐ severe headache.
9.27
9.27. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 27 Indicator of 'progress' in labour ‐ Admitted in established labour within 24 hours.
9.28
9.28. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 28 Indicator of 'progress' in labour ‐ Bishop score > 6 or active labour at 36 hours.
9.29
9.29. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 29 Time to birth ‐ Time in hours from admission to birth (all women).
9.30
9.30. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 30 Indicator of 'progress' in labour ‐ Bishop score on admission after treatment.
9.31
9.31. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 31 Indicator of 'progress' in labour ‐ Change in Bishop score.
9.32
9.32. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 32 Time to birth ‐ Interval from onset of labour to birth (hours).
9.33
9.33. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 33 Indicator of 'progress' in labour ‐ Cervix unchanged after 48 hours.
9.34
9.34. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 34 Time to birth ‐ Interval from admission to vaginal birth (hours).
9.35
9.35. Analysis
Comparison 9 Vaginal isosorbide mononitrate (IMN) versus placebo, Outcome 35 Total cost of care package (GBP).
10.1
10.1. Analysis
Comparison 10 Acupuncture versus routine care, Outcome 1 Additional induction agents required.
10.2
10.2. Analysis
Comparison 10 Acupuncture versus routine care, Outcome 2 Caesarean section.
11.1
11.1. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 1 Maternal satisfaction ‐ I look back positively on the treatment I received.
11.2
11.2. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 2 Maternal satisfaction ‐ In retrospect, I would have preferred another treatment than received.
11.3
11.3. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 3 Augmentation, induction or both.
11.4
11.4. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 4 Epidural, opioids or both for pain relief.
11.5
11.5. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 5 Instrumental vaginal birth.
11.6
11.6. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 6 Caesarean section.
11.7
11.7. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 7 Apgar < 7 at 5 minutes.
11.8
11.8. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 8 Neonatal intensive care unit admission.
11.9
11.9. Analysis
Comparison 11 Outpatient amniotomy for induction versus routine care, Outcome 9 Duration of birth (hours).
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References

References to studies included in this review

Agarwal 2012 {published data only}
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Attanayake 2014 {published data only}
    1. Attanayake K, Goonewardene M. Outpatient cervical ripening with vaginal isosorbide mononitrate in uncomplicated singleton pregnancies at 39 weeks gestation: A double blind randomized controlled trial. Sri Lanka Journal of Obstetrics and Gynaecology 2014;36(Suppl 1):28, Abstract no: FC 10.5. - PubMed
Bollapragada 2006a {published data only}
    1. Bollapragada S, Mackenzie F, Norrie J, Petrou S, Reid M, Greer I, et al. IMOP: randomised placebo controlled trial of outpatient cervical ripening with isosorbide mononitrate (IMN) prior to induction of labour ‐ clinical trial with analyses of efficacy, cost effectiveness and acceptability. BMC Pregnancy and Childbirth 2006;6:25. [DOI: 10.1186/1471-2393-6-25] - DOI - PMC - PubMed
    1. Bollapragada SS, MacKenzie F, Norrie J, Petrou S, Reid M, Greer IA, et al. Randomized placebo controlled trial of outpatient cervical ripening with isosorbide mononitrate (IMN) prior to induction of labour ‐ clinical trial with analyses of efficacy, cost effectiveness and acceptability. The IMOP study [abstract]. Journal of Obstetrics and Gynaecology 2007;27(Suppl 1):S22. - PubMed
    1. Bollapragada SS, MacKenzie F, Norrie JD, Eddama O, Petrou S, Reid M, et al. Randomised placebo‐controlled trial of outpatient (at home) cervical ripening with isosorbide mononitrate (IMN) prior to induction of labour‐clinical trial with analyses of efficacy and acceptability. The IMOP study. BJOG: an international journal of obstetrics and gynaecology 2009;116(9):1185‐95. - PubMed
    1. Eddama O, Petrou S, Schroeder L, Bollapragada SS, Mackenzie F, Norrie J, et al. The cost‐effectiveness of outpatient (at home) cervical ripening with isosorbide mononitrate prior to induction of labour. BJOG: an international journal of obstetrics and gynaecology 2009;116(9):1196‐203. - PubMed
    1. Reid M, Lorimer K, Norman JE, Bollapragada SS, Norrie J. The home as an appropriate setting for women undertaking cervical ripening before the induction of labour. Midwifery 2011;27(1):30‐5. - PubMed
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Frydman 1992 {published data only}
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Gaffaney 2009 {published data only}
    1. Gaffaney CA, Saul LL, Rumney PJ, Morrison EH, Thomas S, Nageotte MP, et al. Outpatient oral misoprostol for prolonged pregnancies: a pilot investigation. American Journal of Perinatology 2009;26(9):673‐7. - PubMed
Ghanaie 2013 {published data only}
    1. Ghanaie MM, Mirblouk F, Godarzi R, Shakiba M. Effect of outpatient isorbide mononitrate on success of labor induction. Journal of Babol University of Medical Sciences 2013;15(2):12‐7.
Giacalone 1998 {published data only}
    1. Giacalone PL, Targosz V, Laffargue F, Boog G, Faure JM. Cervical ripening with mifepristone before labor induction: a randomized study. Obstetrics and Gynecology 1998;92(4 Pt 1):487‐92. - PubMed
Gittens 1996 {published data only}
    1. Gittens L, Schenkel C, Strassberg S, Apuzzio J. Vaginal birth after cesarean section: comparison of outpatient use of prostaglandin gel to expectant management. American Journal of Obstetrics and Gynecology 1996;174(1 Pt 2):354.
Habib 2008 {published data only}
    1. Habib SM, Emam SS, Saber AS. Outpatient cervical ripening with nitric oxide donor isosorbide mononitrate prior to induction of labor. International Journal of Gynaecology and Obstetrics 2008;101(1):57‐61. - PubMed
Hage 1993 {published data only}
    1. Hage P, Shaw J, Zarou D, Fleisher J, Wehbeh H. Double blind randomized trial to evaluate the role of outpatient use of PGE2 in cervical ripening. American Journal of Obstetrics and Gynecology 1993;168(1 Part 2):430.
Harper 2006 {published data only}
    1. Harper TC, Coeytaux RR, Chen W, Campbell K, Kaufman JS, Moise KJ, et al. A randomized controlled trial of acupuncture for initiation of labor in nulliparous women. Journal of Maternal‐Fetal and Neonatal Medicine 2006;19(8):465‐70. - PubMed
Incerpi 2001 {published data only}
    1. Incerpi M, Fassett M, Kjos S, Tran S, Wing D. Vaginally administered misoprostol for outpatient labor induction in pregnancies with diabetes mellitus [abstract]. American Journal of Obstetrics and Gynecology 2001;184(1):S120. - PubMed
    1. Incerpi MH, Fassett MJ, Kjos SL, Tran SH, Wing DA. Vaginally administered misoprostol for outpatient cervical ripening in pregnancies complicated by diabetes mellitus. American Journal of Obstetrics and Gynecology 2001;185(4):916‐9. - PubMed
Kipikasa 2005 {published data only}
    1. Kipikasa JH, Adair CD, Williamson J, Breen JM, Medford LK, Sanchez‐Ramos L. Use of misoprostol on an outpatient basis for postdate pregnancy. International Journal of Gynaecology and Obstetrics 2005;88(2):108‐11. - PubMed
Larmon 2002 {published data only}
    1. Larmon JE, Magann EF, Dickerson GA, Morrison JC. Outpatient cervical ripening with prostaglandin E2 and estradiol. Journal of Maternal‐Fetal and Neonatal Medicine 2002;11(2):113‐7. - PubMed
Lelaidier 1994 {published data only}
    1. Lelaidier C, Baton C, Benifla JL, Fernandez H, Bourget P, Frydman R. Mifepristone for labour induction after previous caesarean section. British Journal of Obstetrics and Gynaecology 1994;101(6):501‐3. - PubMed
Lien 1998 {published data only}
    1. Lien JM, Morgan MA, Garite TJ, Kennedy KA, Sassoon DA, Freeman RK. Antepartum cervical ripening: applying prostaglandin e2 gel in conjunction with scheduled nonstress tests in postdate pregnancies. American Journal of Obstetrics and Gynecology 1998;179(2):453‐8. - PubMed
Lyons 2001 {published data only}
    1. Lyons C, Rumney P, Huang W, Morrison E, Thomas S, Nageotte M, et al. Outpatient cervical ripening with oral misoprostol post‐term: induction rates decreased. American Journal of Obstetrics and Gynecology 2001;184(1):S116.
Magann 1998 {published data only}
    1. Magann E, Chauhan SP, Nevils BG, McNamara MF, Kinsella MJ, Morrison JC. Management of pregnancies beyond forty‐one weeks' gestation with an unfavorable cervix. American Journal of Obstetrics and Gynecology 1998;178(6):1279‐87. - PubMed
McKenna 1999 {published data only}
    1. McKenna DS, Costa SW, Samuels P. Prostaglandin E2 cervical ripening without subsequent induction of labor. Obstetrics and Gynecology 1999;94(1):11‐4. - PubMed
McKenna 2004 {published data only}
    1. McKenna DS, Ester JB, Proffitt M, Waddell KR. Misoprostol outpatient cervical ripening without subsequent induction of labor: a randomized trial. Obstetrics and Gynecology 2004;104(3):579‐84. - PubMed
Meyer 2005 {published data only}
    1. Meyer M, Pflum J. Outpatient administration of misoprostol decreases induction time. American Journal of Obstetrics and Gynecology 2002;187(6 Pt 2):S167.
    1. Meyer M, Pflum J, Howard D. Outpatient misoprostol compared with dinoprostone gel for preinduction cervical ripening: a randomized controlled trial. Obstetrics and Gynecology 2005;105(3):466‐72. - PubMed
Newman 1997 {published data only}
    1. Newman M, Newman R. Multiple‐dose PGE2 cervical ripening on an outpatient basis: safety and efficacy. American Journal of Obstetrics and Gynecology 1997;176(1 Pt 2):S112.
O'Brien 1995 {published data only}
    1. O'Brien JM, Mercer B, Cleary N, Sibai BM. Efficacy of outpatient induction with low dose intravaginal prostaglandin E2: A randomized, double‐blind, placebo‐controlled trial. American Journal of Obstetrics and Gynecology 1995;172:424. - PubMed
    1. O'Brien JM, Mercer BM, Cleary NT, Sibai BM. Efficacy of outpatient induction with low‐dose intravaginal prostaglandin E2: A randomized, double blind, placebo‐controlled trial. American Journal of Obstetrics and Gynecology 1995;173(6):1855‐9. - PubMed
Oboro 2005 {published data only}
    1. Oboro VO, Tabowei TO. Outpatient misoprostol cervical ripening without subsequent induction of labor to prevent post‐term pregnancy. Acta Obstetricia et Gynecologica Scandinavica 2005;84(7):628‐31. - PubMed
Rayburn 1999 {published data only}
    1. Rayburn W, Lucas M, Gittens L, Goodwin TM, Baxi L, Gall S, et al. Attempted vaginal birth after cesarean section: a multicenter comparison of outpatient prostaglandin E2 gel with expectant management. Primary Care Update for Ob/Gyns 1998;5(4):182‐3. - PubMed
    1. Rayburn WF, Gittens LN, Lucas MJ, Gall SA, Martin ME. Weekly administration of prostaglandin e2 gel compared with expectant management in women with previous cesareans Prepidil gel study group. Obstetrics and Gynecology 1999;94(2):250‐4. - PubMed
Rijnders 2011 {published data only}
    1. ISRCTN47736435. Costs and effects of amniotomy at home for induction of post term pregnancy. isrctn.com/ISRCTN47736435 (first received 9 January 2006).
    1. Rijnders MEB. A randomised controlled trial of amniotomy at home for induction between 292 and 294 days gestation. Interventions in Midwife Led Care in the Netherlands to Achieve Optimal Birth Outcomes: Effects and Women's Experiences. Amsterdam: University of Amsterdam, 2011.
Sawai 1991 {published data only}
    1. Sawai SK, Williams MC, O'Brien WF, Angel JL, Mastrogiannis DS, Johnson L. Sequential outpatient application of intravaginal prostaglandin E2 gel in the management of postdates pregnancies. Obstetrics and Gynecology 1991;78(1):19‐23. - PubMed
    1. Williams MG, O'Brien WF, Sawai SK, Knuppel RA. Outpatient cervical ripening in the postdates pregnancy. Proceedings of 10th Annual Meeting of Society of Perinatal Obstetricians; 1990 Jan 23‐27; Houston, Texas, USA. 1990:533.
Sawai 1994 {published data only}
    1. Sawai SK, O'Brien WF, Mastrogiannis DS, Krammer J, Mastry MG, Porter GW. Patient‐administered outpatient intravaginal prostaglandin E2 suppositories in post‐date pregnancies: a double‐blind, randomized, placebo‐controlled study. Obstetrics and Gynecology 1994;84(5):807‐10. - PubMed
    1. Sawai SK, O'Brien WF, Mastrogiannis MS, Mastry MG, Porter GW, Johnson L. Outpatient prostaglandin E2 suppositories in postdates pregnancies. American Journal of Obstetrics and Gynecology 1992;166(1 Pt 2):400.
Schmitz 2014 {published data only}
    1. Schmitz T, Closset E, Fuchs F, Maillard F, Rozenberg P, Anselem O, et al. Outpatient cervical ripening with nitric oxide (NO) donors for prolonged pregnancy in nullipara: the NOCETER randomized, multicentre, double‐blind, placebo‐controlled trial. American Journal of Obstetrics and Gynecology 2014;210(1 Suppl):S19.
    1. Schmitz T, Fuchs F, Closset E, Rozenberg P, Winer N, Perrotin F, et al. Outpatient cervical ripening by nitric oxide donors for prolonged pregnancy: a randomized controlled trial. Obstetrics and Gynecology 2014;124(6):1089‐97. - PubMed
Stenlund 1999 {published data only}
    1. Stenlund PM, Bygdeman M, Ekman G. Induction of labor with mifepristone (RU 486). A randomized double‐blind study in post‐term pregnant women with unripe cervices. Acta Obstetricia et Gynecologica Scandinavica Supplement 1994;73(161):Abstract FP50.
    1. Stenlund PM, Ekman G, Aedo AR, Bygdeman M. Induction of labour with mifepristone ‐ a randomized double‐blind study versus placebo. Acta Obstetricia et Gynecologica Scandinavica 1999;78:793‐8. - PubMed
Stitely 2000 {published data only}
    1. Stitely ML, Browning J, Fowler M, Gendron RT, Gherman RB. Outpatient cervical ripening with intravaginal misoprostol. Obstetrics and Gynecology 2000;96(5 Pt 1):684‐8. - PubMed

References to studies excluded from this review

Adewole 1993 {published data only}
    1. Adewole IF, Franklin O, Matiluko AA. Cervical ripening and induction of labour by breast stimulation. African Journal of Medicine and Medical Sciences 1993;22(4):81‐6. - PubMed
Damania 1988 {published data only}
    1. Damania KR, Nanavati MS, Dastur NA, Daftary SN. Breast stimulation for cervical ripening. Journal of Obstetrics and Gynaecology of India 1988;58:663‐5.
Damania 1992 {published data only}
    1. Damania KK, Natu U, Mhatre PN, Mataliya M, Mehta AC, Daftary SN. Evaluation of two methods employed for cervical ripening. Journal of Postgraduate Medicine 1992;38(2):58‐9. - PubMed
Di Lieto 1989 {published data only}
    1. Lieto A, Miranda L, Ardito P, Favale P, Albano G. Changes in the bishop score induced by manual nipple stimulation. A cross‐over randomized study. Clinical and Experimental Obstetrics and Gynecology 1989;16(1):26‐9. - PubMed
Doany 1997 {published data only}
    1. Doany W. Outpatient management of postdate pregnancy with intravaginal prostaglandin E2 and membrane stripping. American Journal of Obstetrics and Gynecology 1996;174(1Pt 2):351.
    1. Doany W, McCarty J. Outpatient management of the uncomplicated postdate pregnancy with intravaginal prostaglandin E2 gel and membrane stripping. Journal of Maternal‐Fetal Medicine 1997;6(2):71‐8. - PubMed
Dorfman 1987 {published data only}
    1. Dorfman P, Lasserre MN, Tetau M. Preparation for childbirth by homeopathy [Preparation a l'accouchement par homeopathie: experimentation en double insu versus placebo]. Cahiers de Biothérapie 1987;94:77‐81.
Elliott 1984 {published data only}
    1. Elliott JP, Flaherty JF. The use of breast stimulation to prevent postdate pregnancy. American Journal of Obstetrics and Gynecology 1984;149(6):628‐32. - PubMed
    1. Elliott JP, Flaherty JF. The use of breast stimulation to ripen the cervix in term pregnancies. American Journal of Obstetrics and Gynecology 1983;145(5):553‐6. - PubMed
Evans 1983 {published data only}
    1. Evans MI, Dougan MB, Moawad AH, Evans WJ, Bryant‐Greenwood GD, Greenwood FC. Ripening of the human cervix with porcine ovarian relaxin. American Journal of Obstetrics and Gynecology 1983;147(4):410‐4. - PubMed
Garry 2000 {published data only}
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Griffin 2003 {published data only}
    1. Griffin C. Outpatient cervical ripening using sequential oestrogen ‐ a randomised controlled pilot study. Australian and New Zealand Journal of Obstetrics and Gynaecology 2003;43:183.
Herabutya 1992 {published data only}
    1. Herabutya Y, Prasertsawat PO, Tongyai T, Isarangura N, Ayudthya N. Prolonged pregnancy: the management dilemma. International Journal of Gynaecology and Obstetrics 1992;37(4):253‐8. - PubMed
Kadar 1990 {published data only}
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Krammer 1995 {published data only}
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Magann 1999 {published data only}
    1. Magann EF, Chauhan SP, McNamara MF, Bass JD, Estes CM, Morrison JC. Membrane stripping vs dinoprostone vaginal insert in the management of pregnancies beyond 41 weeks with unfavorable cervix. American Journal of Obstetrics and Gynecology 1998;178(1 Pt 2):S30.
    1. Magann EF, Chauhan SP, McNamara MF, Bass JD, Estes CM, Morrison JC. Membrane sweeping versus dinoprostone vaginal insert in the management of pregnancies beyond 41 weeks with an unfavorable cervix. Journal of Perinatology 1999;19(2):88‐91. - PubMed
Manidakis 1999 {published data only}
    1. Manidakis G, Sifakis S, Orfanoudaki E, Mikelakis G, Prokopakis P, Magou M, et al. Prostaglandin versus stripping of membranes in management of pregnancy beyond 40‐41 weeks [abstract]. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1999;86:S79‐S80.
Moghtadaei 2007 {published data only}
    1. Moghtadaei P. A randomized trial comparing outpatient vaginal isosorbide‐mononitrate versus extra‐amnion saline infusion with concurrent oxytocin for cervical ripening and labor induction in nulliparous women. American Journal of Obstetrics and Gynecology 2007;197(6 Suppl 1):S103.
Ohel 1996 {published data only}
    1. Ohel G, Rahav D, Rothbart H, Ruach M. Randomised trial of outpatient induction of labor with vaginal PGE2 at 40‐41 weeks of gestation versus expectant management. Archives of Gynecology and Obstetrics 1996;258(3):109‐12. - PubMed
Rayburn 1988 {published data only}
    1. Rayburn W, Gosen R, Ramadei C, Woods R, Scott J Jr. Outpatient cervical ripening with prostaglandin E2 gel in uncomplicated postdate pregnancies. American Journal of Obstetrics and Gynecology 1988;158(6 Pt 1):1417‐23. - PubMed
Rezk 2014 {published data only}
    1. Rezk M, Sanad Z, Dawood R, Masood A, Emarh M, Halaby AA. Intracervical foley catheter versus vaginal isosorbid mononitrate for induction of labor in women with previous one cesarean section. Journal of Clinical Gynecology and Obstetrics 2014;3(2):55‐61.
Salamalekis 2000 {published data only}
    1. Salamalekis E, Vitoratos N, Kassanos D, Loghis C, Batalias L, Panayotopoulos N, et al. Sweeping of the membranes versus uterine stimulation by oxytocin in nulliparous women: a randomized controlled trial. Gynecologic and Obstetric Investigation 2000;49(4):240‐3. - PubMed
Salmon 1986 {published data only}
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Spallicci 2007 {published data only}
    1. Spallicci MD, Chiea MA, Singer JM, Albuquerque PB, Bittar RE, Zugaib M. Use of hyaluronidase for cervical ripening: a randomized trial. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2007;130(1):46‐50. - PubMed
    1. Spallicci MDB, Bittar RE. Randomized double blind study of ripening the cervix with hyaluronidase in term gestations [Estudo clinico aleatorizado com grupo controle e mascaramento duplo da maturacao do colo uterino pela hialuronidase em gestacoes a termo]. Revista Brasileira de Ginecologia e Obstetricia 2003;25(1):67.
Voss 1996 {published data only}
    1. Voss DH, Cumminsky KC, Cook VD, Nethers MS, Spinnato JA, Gall SA. Effect of three concentrations of intracervical prostaglandin E2 gel for cervical ripening. Journal of Maternal‐Fetal Medicine 1996;5(4):186‐93. - PubMed
Ziaei 2003 {published data only}
    1. Ziaei S, Rosebehani N, Kazeminejad A, Zafarghandi S. The effects of intramuscular administration of corticosteroids on the induction of parturition. Journal of Perinatal Medicine 2003;31(2):134‐9. - PubMed

References to studies awaiting assessment

Ascher‐Walsh 2000 {published data only}
    1. Ascher‐Walsh C, Burke B, Baxi L. Outpatient management of prolonged pregnancy with misoprostol (mp): a randomized double‐blind placebo controlled study, prelim data. American Journal of Obstetrics and Gynecology 2000;182(1 Pt 2):S20.
Mostaghel 2009 {published data only}
    1. Mostaghel N, Nakhai F. Outpatient vaginal misoprostol and its effect on post‐term pregnancy. International Journal of Gynaecology and Obstetrics 2009;107(Suppl 2):S586.
Thakur 2005 {published data only}
    1. Thakur V, Dorman E, Sanu L, Harrington K. Mifepristone is an effective ripening agent in postdates primips with cervical length ≥ 2.5cm, but mode of delivery correlates with birthweight: a randomised, placebo controlled double blind study. Ultrasound in Obstetrics & Gynecology 2005;26:452.

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