Research Article| Volume 190, ISSUE 1, P124-128, January 2004

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Randomized trial between two active labor management protocols in the presence of an unfavorable cervix



      The purpose of this study was to compare the efficacy of two protocols for active management of labor at term in the presence of an unfavorable cervix.

      Study design

      Pregnancies that underwent labor induction at ≥37 weeks of gestation with an unfavorable cervix (Bishop score, ≤6) were randomly assigned to receive vaginally either a single dose of sustained-release dinoprostone (Cervidil) with concurrent low-dose oxytocin or multidosing of misoprostol (25 μg every 4 hours) followed by high-dose oxytocin. The primary outcome was the time interval from induction to vaginal delivery. Other parameters included excess uterine activity and cesarean delivery rates.


      A total of 151 patients (dinoprostone, 74 patients; misoprostol, 77 patients) were enrolled. The mean time from the initiation of induction to vaginal delivery was the same in the dinoprostone and misoprostol groups (15.7 hours; 95% CI, 13.7-17.7 hours vs 16.0 hours; 95% CI, 14.1-17.8 hours; P = .34), regardless of parity. The dinoprostone and misoprostol groups did not differ statistically in the percent of patients who were delivered vaginally by 12 hours (36.2% vs 29.7%), 18 hours (63.8% vs 56.3%), and 24 hours (81.0% vs 81.3%). Excess uterine activity was not more common in either group, and hyperstimulation syndrome was absent in all cases. Primary cesarean delivery rates were similar (dinoprostone, 21.6%; misoprostol, 16.9%; relative risk, 1.3; 95% CI, 0.7-2.5), with a failed induction that occurred in one case in each group.


      Sustained-release dinoprostone with concurrent low-dose oxytocin and intermittent misoprostol with delayed high-dose oxytocin are effective alternatives for active management of labor with an unfavorable cervix.


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        • American College of Obstetricians and Gynecologists
        Induction of labor.
        The College, Washington (DC)1999 (Practice bulletin No.: 10)
        • López-Zeno J.A.
        • Peaceman A.M.
        • Adashek J.A.
        • Socol M.L.
        A controlled trial of a program for the active management of labor.
        N Engl J Med. 1992; 326: 450-454
        • Boylan P.
        • Robson M.
        • McParland P.
        Active management of labor 1963–1993.
        Am J Obstet Gynecol. 1993; 168: 295-300
        • Frigoletto Jr., F.D.
        • Lieberman E.
        • Lang J.M.
        • Cohen A.
        • Barss V.
        • Ringer S.
        • et al.
        A clinical trial of active management of labor.
        N Engl J Med. 1995; 333: 745-750
        • Rayburn W.F.
        Pre-induction cervical ripening: basis and method of current practice.
        Obstet Gynecol Surv. 2002; 57: 683-692
        • Rayburn W.F.
        • Wapner R.J.
        • Barss V.A.
        • Spitzberg E.
        • Molina R.D.
        • Mandsager N.
        • et al.
        An intravaginal controlled-release prostaglandin E2 pessary for cervical ripening and initiation of labor at term.
        Obstet Gynecol. 1992; 79: 374-379
        • Hofmeyr G.J.
        • Gulmezoglu A.M.
        Vaginal misoprostol for cervical ripening and labor induction in late pregnancy.
        Cochrane Library. 1999; 2: 1-18
        • Christensen F.
        • Tehranifar M.
        • Gonzalez J.
        • Rappaport V.
        • Gilson G.
        • Rayburn W.F.
        Randomized trial of concurrent oxytocin and sustained-release dinoprostone vaginal insert for labor induction at term.
        Am J Obstet Gynecol. 2002; 186: 61-65
        • Cervidil
        Physician's desk reference. 56th ed. Medical Economics, Montvale (NJ)2002: 1369-1370
        • Cytotec
        Physician's desk reference. 55th ed. Medical Economics, Montvale (NJ)2001: 2291-2293
        • American College of Obstetricians and Gynecologists
        Response to Searle's drug warning on misoprostol.
        The College, Washington (DC)2000 (Committee opinion No.: 248)
        • Sanchez-Ramos L.
        • Peterson D.E.
        • Delke I.
        • Gaudier F.L.
        • Kaunitz A.M.
        Labor induction with prostaglandin E1 misoprostol compared with dinoprostone vaginal insert: a randomized trial.
        Obstet Gynecol. 1998; 91: 401-405
        • Wing D.A.
        • Ortiz-Omphroy G.
        • Paul R.H.
        A comparison of intermittent vaginal administration of misoprostol with continuous dinoprostone for cervical ripening and labor induction.
        Am J Obstet Gynecol. 1997; 177: 612-618
        • Wing D.A.
        • Paul R.H.
        A comparison of differing dosing regimens of vaginally administered misoprostol for cervical ripening and labor induction.
        Am J Obstet Gynecol. 1996; 175: 158-164