Medications and mechanical interventions for induction of labour in outpatient settings

Vogel JP, Osoti AO, Kelly AJ, Livio S, Norman JE, Alfirevic Z

What is the issue?

Induction of labour (starting labour artificially) is often needed for medical reasons, such as when women have passed their due dates. Different induction methods can be used, such as medications (like prostaglandin E₂, misoprostol or isosorbide mononitrate) or breaking membranes. Inductions are usually carried out in hospital; some methods may be suitable for use with women treated as outpatients, and allowed to go home to wait for labour to progress. We examined the feasibility, effectiveness and safety of outpatient induction, as well as women’s satisfaction and healthcare costs.

Why is this important?

Pregnant women who have reached their due date can be assessed in hospital as outpatients, given the induction treatment followed by monitoring for a short time, and then sent home. Alternatively, they are given the drug or treatment to take at home. Women may be more comfortable waiting for labour to start at home, and outpatient care may be less costly for health services.

What evidence did we find?

This is an updated review that includes six new studies. We included 34 randomised controlled trials involving 5003 pregnant women (search date: November 2016). The women were healthy and at low risk of complications. They were given induction, a fake treatment (placebo) or no treatment. Limited information was available on the outcomes that were of interest, and risk of bias was generally low or unclear. The quality of evidence was judged to be low-quality, with a few moderate-quality findings.

Women at term who were induced as outpatients may be less likely to need further induction, compared to women given placebo or no treatment. Medications like vaginal PGE₂, mifepristone and oral misoprostol appear to be effective. No clear differences were reported for excessive activity of the uterus (hyperstimulation), caesarean section or need for neonatal intensive care.

There were too few women in these trials to determine differences in rare events, such as infant deaths or serious illnesses of mothers or babies. The trials did not report on use of emergency services to return to hospital. Some medications caused side effects (such as headaches). Overall, there was little information on costs of different methods.

What does this mean?

For healthy, low-risk pregnant women at term, outpatient induction and enabling women to return home to wait for labour to start appears to be feasible. Outpatient induction treatments may reduce both need for further drugs and time from treatment to birth. It does not appear to increase the likelihood of needing other interventions in labour. However, there is insufficient evidence to say definitively whether outpatient induction is safe. Future research should focus on which methods women prefer, and are most effective and safe.

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