Outpatient
preinduction cervical ripening has always been debated. With nearly 1 in 4
pregnancies scheduled for induction of labor and 50% of these women having
unfavorable cervix interest in this has grown. Those clinician and researchers in
favor of it vouch that it offers many advantage like decreased hospitalization
time, conserving resources due to decreased labor room staffing, and improving patient
satisfaction.
While
clinicians against it advocate its use only in specific, well planned situation
with valid indication. The reason behind it is lack of large scale data
reporting experience behind it. There are also no large scale trials to back up
the regime. Studies found in literature involve term pregnancies of living
fetuses with some means of continuous monitoring of uterine activity and the
fetal heart rate for the first few hours. Also there exist no studies comparing
the mechanical vs various drug therapies for cervical ripening.
Samuel A. Cosgrove Memorial Lecture on May 17,
2016 took a detailed look at doing cervical ripening on an outpatient basis for
low-risk patients.
Dr. Anthony C. Sciscione, DO, Christiana
Care Health Services, Newark, DE was in favor of outpatient cervical ripening
and he mostly shared his experiences with Foleys catheter.
He stressed that outpatient ripening has
a very high rate of patient satisfaction and patients were willing to make
extra trip to hospital. Studies also showed that in-patients have a very high
level of anxiety and outpatients were more stress free.
A small randomized trial at Christiana care
was carried out to see if patients can manage Foleys catheter in outpatient
setting. Women who were low risks, with
stable vital signs, adequate amniotic fluid had a catheter placed in and randomized
to 2 groups inpatient (n=50) and
outpatient (n=61) and observed for 2 hours. The outpatient group was discharged
with proper instructions and advised to return next day 6 AM. Dr. Sciscione did
not really observed any difference between the two groups.
While Dr. William F. Rayburn, MD, MBA, University of
New Mexico, Albuquerque, NM, scrutinized it because of lack of concrete and
meticulous research behind it . He urged the audience that they should not postulate
that all outpatient inductions are safe. He argued that Up to Date does not recommend
it except in research settings and ACOG practice bulletin and leading textbook
do not mention it. A review of literature found less than 10% of literature on
this subject.
He quoted “What we all would agree with
here, I assume, is that whatever we do with this procedure, we want to add as
little, or ideally, no additional risk to the mother and the fetus, so we’ve
got to have sufficient experience to really say that.”
In researching for the debate he only
found two additional clinical trial to the one conducted by Dr. Sciscione. The
total number of patients receiving outpatient balloon cervical ripening was only
141.
While adverse effects were rare, no consensus was reached on what
constitutes unacceptable risk.
The studies found that compared with placebo,
PGE2 (vaginal or intracervical) and misoprostol (oral or vagina) are effective.
But good benefits were documented with Foleys balloon catheter too.
He also commented on the difficulties
faced by patients in transporting to and from hospitals and lack of monitoring
at home.
In the end he stressed the need of having
large randomized trial or meta-analysis to really exclude excess risk here and
determine what works and what does not.
References:
http://www.acogdailynews.com/value-of-outpatient-cervical-ripening-debated/
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