Evidence-Based Approaches to Labor Induction

Abstract

ABSTRACT Importance The induction rate continues to increase in the United States placing pressure on the health care system with increasing cost and time spent on labor and delivery. Most labor induction regimens have evaluated uncomplicated singleton-term gestations. Unfortunately, the optimal labor regimens of medically complicated pregnancies have not been well described. Objective The aim of this study was to review the current available evidence regarding the various labor induction regimens and understand the evidence that exists for induction regimens in complicated pregnancies. Evidence Acquisition Data were acquired by a literature search on PubMed, ClinicalTrials.gov, the Cochrane Review database, the most recent American College of Obstetricians and Gynecologists practice bulletin on labor induction, and a review of the most recent edition on widely used obstetric texts for key words related to labor induction. Results Many heterogeneous clinical trials exist examining various labor induction regimens such as prostaglandin only, oxytocin only, or a combination of mechanical dilation with prostaglandins or oxytocin. Several Cochrane systematic reviews have been performed, which suggest a combination of prostaglandins and mechanical dilation results in an improved time to delivery when compared with single-use methods. Evaluating pregnancies complicated by maternal or fetal conditions, there exist retrospective cohorts describing significantly different labor outcomes. Although a few of these populations have planned or active clinical trials, most do not have an optimal labor induction regimen described. Conclusions and Relevance Most induction trials are significantly heterogeneous and limited to uncomplicated pregnancies. A combination of prostaglandins and mechanical dilation may result in improved outcomes. Complicated pregnancies have significantly different labor outcomes; however, almost none have well-described labor induction regimens. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to describe the various inpatient cervical ripening regimens available in the United States; discuss the evidence on the current inpatient cervical ripening regimens available for several maternal medical conditions (obesity, hypertensive disorders of pregnancy, advanced maternal age, and others); and explain current inpatient cervical ripening regimens available for several fetal medical conditions (preterm gestations, fetal growth restriction, and others).