Methods to induce labour: a systematic review, network meta‐analysis and cost‐effectiveness analysis

Abstract

ObjectivesTo compare the clinical effectiveness and cost‐effectiveness of labour induction methods.MethodsWe conducted a systematic review of randomised trials comparing interventions for third‐trimester labour induction (search date: March 2014). Network meta‐analysis was possible for six of nine prespecified key outcomes: vaginal delivery within 24 hours (VD24), caesarean section, uterine hyperstimulation, neonatal intensive care unit (NICU) admissions, instrumental delivery and infant Apgar scores. We developed a decision‐tree model from a UK NHS perspective and calculated incremental cost‐effectiveness ratios, expected costs, utilities and net benefit, and cost‐effectiveness acceptability curves.Main resultsIn all, 611 studies comparing 31 active interventions were included. Intravenous oxytocin with amniotomy and vaginal misoprostol (≥50 μg) were most likely to achieve VD24. Titrated low‐dose oral misoprostol achieved the lowest odds of caesarean section, but there was considerable uncertainty in ranking estimates. Vaginal (≥50 μg) and buccal/sublingual misoprostol were most likely to increase uterine hyperstimulation with high uncertainty in ranking estimates. Compared with placebo, extra‐amniotic prostaglandin E2 reduced NICU admissions. There were insufficient data to conduct analyses for maternal and neonatal mortality and serious morbidity or maternal satisfaction. Conclusions were robust after exclusion of studies at high risk of bias. Due to poor reporting of VD24, the cost‐effectiveness analysis compared a subset of 20 interventions. There was considerable uncertainty in estimates, but buccal/sublingual and titrated (low‐dose) misoprostol showed the highest probability of being most cost‐effective.ConclusionsFuture trials should be designed and powered to detect a method that is more cost‐effective than low‐dose titrated oral misoprostol.Tweetable abstractNew study ranks methods to induce labour in pregnant women on effectiveness and cost.

Cervical ripening and induction of labour: Inpatient or outpatient, oral misoprostol or Foley catheter?

“…Most of the agents used for ripening of the cervix lead to induction of labour if used in higher concentration, more frequently or for longer durations. Therefore, it has been suggested that cervical ripening and induction of labour should not be studied as separate entities [6,20]. However, an ideal cervical ripening agent may cause structural remodelling of the cervix, making it softer, shorter and partially dilated and favourable for future induction of labour with another method, without stimulating uterine contractions.…”

“…It is more effective than amniotomy with intravenous oxytocin which can result in increased caesarean delivery, especially if the cervix is 'not ripe' [6][7][8][9]. Doses ranging from 20-200µg, with frequencies varying from hourly to six hourly and the administration of up to 12 doses of 50 µg over four days have been reported.…”

“…Doses ranging from 20-200µg, with frequencies varying from hourly to six hourly and the administration of up to 12 doses of 50 µg over four days have been reported. A starting dose of 20 µg of oral misoprostol in solution, titrated against uterine contractions and administered hourly in increasing doses of up to 60 µg, is currently thought to be a safe, cost effective method for induction of labour [6][7][8][9][10]. The hourly dosing regimen has been calculated according to the pharmacokinetics of oral misoprostol.…”

“…The induction delivery interval possibly being slightly longer after low dose oral misoprostol should not be considered as a major drawback. The fact that it is safer than vaginal misoprostol, results in less caesarean delivery and is also effective with an 'unripe' cervix in contrast to amniotomy and intra venous infusions, indicate that it should be the preferred method for induction of labour now [6][7][8][9][10]. The increased occurrence of meconium stained liquor, without any associated evidence of neonatal asphyxia (risk of Apgar < 7 is reduced with oral misoprostol) suggests that the passage of meconium could be due to stimulation of the fetal gut by oral misoprostol [7].…”

Simplifying oral misoprostol protocols for the induction of labour

“…A recently completed UK National Institute of Health Research (NIHR) funded network and cost‐effectiveness analysis included 31 induction regimes evaluated in 611 trials with over 100 000 trial participants. Titrated low‐dose oral misoprostol was identified as likely to be the most cost‐effective method, and also had a favourable safety profile 5, 6. Sublingual or buccal misoprostol had significantly higher rates of hyperstimulation.…”