With penetration, the lower uterine segment is stimulated. This stimulation results in a local release of prostaglandins. Female orgasms have been shown to include uterine contractions, and human semen contains prostaglandins, which are responsible for cervical ripening.
Only one study of 28 women resulted in minimally useful data, so the role of sexual intercourse as a method of promoting labor initiation remains uncertain.
Breast massage and nipple stimulation have been shown to facilitate the release of oxytocin from the posterior pituitary gland. The most commonly prescribed technique involves gently massaging the breasts or applying warm compresses to the breasts for one hour, three times a day. Oxytocin is released, and studies have demonstrated an abnormal fetal heart rate FHR tracing similar to that occurring in oxytocin challenge testing in higher-risk pregnancies. This abnormal rate may be caused by a reduction in placental perfusion and fetal hypoxia.
Acupuncture involves the insertion of very fine needles into designated locations with the purpose of preventing or curing disease. This energy flows along 12 meridians, with designated points along these meridians. Each point is given a name and a number and is associated with a specific organ system or function. In Western medicine, it is thought that acupuncture and transcutaneous nerve stimulation TENS may stimulate the release of prostaglandins and oxytocin.
Most of the studies involving acupuncture were poorly designed and do not meet the rigorous criteria for analysis set forth by the Cochrane reviewers. All mechanical modalities share a similar mechanism of action—namely, some form of local pressure that stimulates the release of prostaglandins. Hygroscopic dilators absorb endocervical and local tissue fluids, causing the device to expand within the endocervix and providing controlled mechanical pressure.
The products available include natural osmotic dilators e. The main advantages of using hygroscopic dilators include outpatient placement and no FHR-monitoring requirements. The technique for placing hygroscopic dilators is described in Table 2. A sterile gauze pad is placed in the vagina to maintain the position of the dilators. Information from Adair CD. Nonpharmacologic approaches to cervical priming and labor induction.
Clin Obstet Gynecol ; — Balloon devices provide mechanical pressure directly on the cervix as the balloon is filled. A Foley catheter 26 Fr or specifically designed balloon devices can be used. The technique is described in Table 3.
The catheter is introduced into the endocervix by direct visualization or blindly by locating the cervix with the examining fingers and guiding the catheter over the hand and fingers through the endocervix and into the potential space between the amniotic membrane and the lower uterine segment.
Additional steps that may be taken: Apply pressure by adding weights to the catheter end. Constant pressure: attach 1 L of intravenous fluids to the catheter end and suspend it from the end of the bed.
Saline infusion 12 : Inflate catheter with 40 mL of sterile water or saline. Remove six hours later or at the time of spontaneous expulsion or rupture of membranes whichever occurs first. Information from references 7 , and 12 through Currently, several RCTs are comparing use of a balloon device with administration of an extra-amniotic saline infusion, laminaria, or prostaglandin E 2 PGE 2.
Results from these trials indicate that each of these methods is effective for cervical ripening and each has comparable cesarean-section delivery rates in women with an unfavorable cervix. The membranes are stripped by inserting the examining finger through the internal cervical os and moving it in a circular direction to detach the inferior pole of the membranes from the lower uterine segment.
The Cochrane reviewers concluded that stripping of the membranes alone does not seem to produce clinically important benefits, but when used as an adjunct does seem to be associated with a lower mean dose of oxytocin needed and an increased rate of normal vaginal deliveries.
It is hypothesized that amniotomy increases the production of, or causes a release of, prostaglandins locally. Risks associated with this procedure include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding from placenta previa or low-lying placenta, and possible fetal injury. The technique for performing amniotomy is described in Table 4.
A pelvic examination is performed to evaluate the cervix and station of the presenting part. A cervical hook is inserted through the cervical os by sliding it along the hand and fingers hook side toward the hand.
The nature of the amniotic fluid is recorded clear, bloody, thick or thin, meconium. Information from references 7 and Only two well-controlled trials studied the use of amniotomy alone, and the evidence did not support its use for induction of labor. Prostaglandins act on the cervix to enable ripening by a number of different mechanisms.
They alter the extracellular ground substance of the cervix, and PGE 2 increases the activity of collagenase in the cervix. They cause an increase in elastase, glycosaminoglycan, dermatan sulfate, and hyaluronic acid levels in the cervix. A relaxation of cervical smooth muscle facilitates dilation. Finally, prostaglandins allow for an increase in intracellular calcium levels, causing contraction of myometrial muscle.
Currently, two prostaglandin analogs are available for the purpose of cervical ripening, dinoprostone gel Prepidil and dinoprostone inserts Cervidil. Prepidil contains 0. The techniques for gel and pessary placement are described in Tables 5 and 6 , respectively. Patient is afebrile. No active vaginal bleeding is present. Fetal heart rate tracing is reassuring.
Patient gives informed consent. Bring gel to room temperature before application, per manufacturer's instructions. Monitor fetal heart rate and uterine activity continuously starting 15 to 30 minutes before gel introduction and continuing for 30 to minutes after gel insertion. If the cervix is uneffaced, use the mm endocervical catheter to introduce the gel into the endocervix just below the level of the internal os.
If the cervix is 50 percent effaced, use the mm endocervical catheter. After application of the gel, the patient should remain recumbent for 30 minutes before being allowed to ambulate. End points for ripening include strong uterine contractions, a Bishop score of 8, or a change in maternal or fetal status. After the publication of the ARRIVE study [ 12 ] whose authors proved that induction of birth after the 39th week of pregnancy does not increase the percentage of CS compared to the expectant management , the assessment of the cervix at admission becomes an even more important predictive element in relation to vaginal delivery due to marginalization of gestational age.
Earlier induction of labor in patients with clinical data such as low Bishop score or long cervix in ultrasonographic cervical measurement [ 7 ] arguing for a low chance of spontaneous birth may reduce the number of maternal complications [ 11 ]. In our study, we did not consider the differences between different methods of delivery preinduction, but we only focused on the population effect of their use.
Group A was heterogeneous in terms of the methods used. The type of preinduction may also affect perinatal results. In this study, PGE1 prostaglandin misoprostol was used as a vaginal insert with constant release for 24 hours. The Foley catheter used in our study, whose history dates back to the 19th century, is also not the only mechanical method used in cervical ripening. Studies indicate that the combination of mechanical method with vaginal prostaglandins does not bring additional benefits such as reduction time to vaginal delivery or reduction in cesarean section rate [ 16 ].
Minimising the risk of hyperstimulation is a basic advantage of mechanical methods in delivery preinduction, it enables their use also in outpatient settings, and current evidence available in the literature indicates the safety of such a procedure [ 17 ].
The probability of this complication was 3. All deliveries in the study were subject to continuous CTG monitoring, because induced deliveries are not physiological in the meaning of Polish law [ 20 ].
The confounding factor in this study may be related to the difference in the percentage of epidural analgesia EA between groups. Some literature data indicate that EA correlates with increases neonatal care unit admission of newborns OR 1.
However, literature data do not indicate an increased risk of acidosis in children born during deliveries with EA [ 22 ]. The immature cervix and the need for delivery pre-induction is a risk factor for cesarean sections. The need for preinduction does not impair neonatological results.
The data that support the findings of this study are openly available in OSF Storage at doi: This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Academic Editor: Marco Scioscia. Received 23 May Revised 05 Aug Accepted 12 Aug Published 01 Sep Abstract Cervical assessment on the Bishop scale prior to induction of labor IOL is one of the strongest prognostic criteria in relation to the success of the procedure. Introduction Induction of labor IOL is one of the most common procedures performed in modern obstetrics.
Material and Methods It was a retrospective observational study. Results The demographic characteristics of the groups are presented in Table 1. Group A Group B value Age years Table 1. Table 2. References D. Drews, H. Huras, P. Journal of Perinatal Medicine, Vol. Suffecool, Katarzyna, Rosenn, Barak M. Journal of Perinatal Medicine. Copy to clipboard. Log in Register. Volume 42 Issue 2. This issue. All issues. Articles in the same Issue frontmatter. Evaluation of the role of first-trimester obstetric ultrasound in the detection of major anomalies: a systematic review.
Austrian Newborn Screening Program: a perspective of five decades. Cervical strain determined by ultrasound elastography and its association with spontaneous preterm delivery. Risk factors for unfavorable pregnancy outcome in women with adverse childhood experiences. Using small dosages appears to reduce adverse outcomes.
Very large trials are needed to evaluate rare adverse outcomes. Extra-amniotic saline infusion is an effective method which appears to reduce the risk of uterine hyperstimulation that occurs with the use of exogenous uterotonics.
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