Inpatient versus outpatient induction of labour: a systematic review and meta-analysis

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Abstract

Background

As the number of indications for labour induction continue to increase, the focus has shifted to performing these procedures in an outpatient setting. This study aims to systematically review published data from randomized controlled trials that compare outpatient with inpatient labour induction, to ascertain the role of outpatient labour induction for low-risk pregnancies.

Methods

We conducted a systematic review wherein we searched MEDLINE, EMBASE, Biosis Previews®, and International Pharmaceutical Abstracts from inception to January 2020 to identify randomized controlled trials that reported on maternal, fetal and resource-related outcomes following outpatient versus inpatient labour induction. Pooled incidences and mean differences were calculated using random-effects meta-analysis. Risk-of-bias was assessed using the Cochrane Risk of Bias tool. Subgroup analysis was conducted based on the method of induction.

Results

Of the 588 records identified, 12 publications, representing nine independent randomized controlled trials conducted in Australia, Europe and North America, were included. These reported on 2615 cases of labour induction (1320 outpatients versus 1295 inpatients). Overall, apart from a higher number of suspicious fetal heart rate tracings [RR = 1.43 (1.10, 1.86)] and a shorter mean length of hospital stay [MD = 282.48 min (160.23, 404.73) shorter] in the outpatient group, there were no differences in delivery method, adverse outcomes or resource-use between the two arms. On subgroup analysis, when comparing the use of balloon catheters in both arms, those induced as outpatients had fewer caesarean deliveries [RR = 0.52 (0.30, 0.90)], a shorter admission-to-delivery interval [MD = 370.86 min (19.19, 722.54) shorter], and a shorter induction to delivery interval [MD = 330.42 min (120.13, 540.71) shorter].

Conclusion

Outpatient labour induction in resource-rich settings is at least as effective and safe, in carefully selected patient populations, when compared with inpatient labour induction. Whether outpatient labour induction results in lower rates of caesarean deliveries needs to be explored further.

Trial registration

This systematic review was prospectively registered in Prospero ( CRD42019118049).

Related collections

Most cited references 23

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Assessing the quality of medical and health data from the 2003 birth certificate revision: results from two states.

Joyce Martin, Elizabeth Wilson, Michelle Osterman … (2013)

A primary goal of the 2003 revision of the U.S. Standard Certificate of Live Birth was to improve data quality, in part by improving data sources, definitions, and instructions. This report evaluates the quality of selected medical and health data from the 2003 revision of the birth certificate by comparing birth certificate data with information abstracted from hospital medical records. A random sample of records for 600 births that occurred in 2010-2011 in State A, and a convenience sample of 495 births that occurred in State B in 2009 were reviewed. Birth certificate and hospital medical record data were compared for these categories: pregnancy history, prenatal care, gestational age, birthweight, pregnancy risk factors, obstetric procedures, onset of labor, source of payment, characteristics of labor and delivery, fetal presentation, method of delivery, abnormal conditions of the newborn, infant living, and infant breastfed. Levels of missing data, exact agreement, kappa scores, sensitivity, and false discovery rates are presented, where applicable. Exact agreement or sensitivity, was high for a number of items for both states (e.g., number of cesarean deliveries, cephalic presentation, cesarean delivery, and birthweight within 500 grams), but exact agreement or sensitivity was low or extremely low for both states for several items (e.g., total number of prenatal visits, previous preterm birth, meconium staining, and fetal intolerance of labor) (Figure 1). Levels of agreement or sensitivity for most items (e.g., prenatal care beginning in first trimester and source of payment-private insurance) were substantial or moderate. Data quality varied by state, and often, varied widely by hospital.

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Factors and outcomes associated with the induction of labour in Latin America.

, Michelle S. S. Morais, A Faúndes … (2009)

To describe the prevalence of labour induction, together with its risk factors and outcomes in Latin America. Analysis of the 2005 WHO global survey database. Eight selected Latin American countries. All women who gave birth during the study period in 120 participating institutions. Bivariate and multivariate analyses. Indications for labour induction per country, success rate per method, risk factors for induction, and maternal and perinatal outcomes. Of the 97,095 deliveries included in the survey, 11,077 (11.4%) were induced, with 74.2% occurring in public institutions, 20.9% in social security hospitals and 4.9% in private institutions. Induction rates ranged from 5.1% in Peru to 20.1% in Cuba. The main indications were premature rupture of membranes (25.3%) and elective induction (28.9%). The success rate of vaginal delivery was very similar for oxytocin (69.9%) and misoprostol (74.8%), with an overall success rate of 70.4%. Induced labour was more common in women over 35 years of age. Maternal complications included higher rates of perineal laceration, need for uterotonic agents, hysterectomy, ICU admission, hospital stay>7 days and increased need for anaesthetic/analgesic procedures. Some adverse perinatal outcomes were also higher: low 5-minute Apgar score, very low birthweight, admission to neonatal ICU and delayed initiation of breastfeeding. In Latin America, labour was induced in slightly more than 10% of deliveries; success rates were high irrespective of the method used. Induced labour is, however, associated with poorer maternal and perinatal outcomes than spontaneous labour.

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Outpatient Foley catheter versus inpatient prostaglandin E2 gel for induction of labour: a randomised trial

Amanda P Henry, Arushi Madan, Rachel Reid … (2013)

Background Induction of labour (IOL) is one of the commonest obstetric interventions, with significant impact on both the individual woman and health service delivery. Outpatient IOL is an attractive option to reduce these impacts. To date there is little data comparing outpatient and inpatient IOL methods, and potential safety concerns (hyperstimulation) if prostaglandins, the standard inpatient IOL medications, are used in the outpatient setting. The purpose of this study was to assess feasibility, clinical effectiveness and patient acceptability of outpatient Foley catheter (OPC) vs. inpatient vaginal PGE2 (IP) for induction of labour (IOL) at term. Methods Women with an unfavourable cervix requiring IOL at term (N = 101) were randomised to outpatient care using Foley catheter (OPC, n = 50) or inpatient care using vaginal PGE2 (IP, n = 51). OPC group had Foley catheter inserted and were discharged overnight following a reassuring cardiotocograph. IP group received 2 mg/1 mg vaginal PGE2 if nulliparous or 1 mg/1 mg if multiparous. Main outcome measures were inpatient stay (prior to birth, in Birthing Unit, total), mode of birth, induction to delivery interval, adverse reactions and patient satisfaction. Results OPC group had shorter hospital stay prior to birth (21.3 vs. 32.4 hrs, p < .001), IP were more likely to achieve vaginal birth within 12 hours of presenting to Birthing Unit (53% vs. 28%, p = .01). Vaginal birth rates (66% OPC Vs. 71% IP), total induction to delivery time (33.5 hrs vs. 31.3 hrs) and total inpatient times (96 hrs OPC Vs. 105 hrs IP) were similar. OPC group felt less pain (significant discomfort 26% Vs 58%, p = .003), and had more sleep (5.8 Vs 3.4 hours, p < .001), during cervical preparation, but were more likely to require oxytocin IOL (88 Vs 59%, p = .001). Conclusions OPC was feasible and acceptable for IOL of women with an unfavourable cervix at term compared to IP, however did not show a statistically significant reduction in total inpatient stay and was associated with increased oxytocin IOL. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN:12609000420246.

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Author and article information

Contributors

Rohan D’Souza:

ORCID: http://orcid.org/0000-0002-4049-2017

Rohan.DSouza@sinaihealthsystem.ca

Journal

Journal ID (nlm-ta): BMC Pregnancy Childbirth

Journal ID (iso-abbrev): BMC Pregnancy Childbirth

Title: BMC Pregnancy and Childbirth

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2393

Publication date (Electronic): 30 June 2020

Publication date PMC-release: 30 June 2020

Publication date Collection: 2020

Volume: 20

Electronic Location Identifier: 382

Affiliations

[1 ]GRID grid.416166.2, ISNI 0000 0004 0473 9881, Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynaecology, , Mount Sinai Hospital and University of Toronto, ; 600 University Avenue, Toronto, Canada

[2 ]GRID grid.17063.33, ISNI 0000 0001 2157 2938, Faculty of Medicine, , University of Toronto, ; Toronto, Canada

[3 ]Ferring Inc., 200 Yorkland Blvd, Toronto, Canada

[4 ]GRID grid.416166.2, ISNI 0000 0004 0473 9881, Lunenfeld-Tanenbaum Research Institute, , Mount Sinai Hospital, ; 60 Murray Street, Toronto, Canada

[5 ]GRID grid.416166.2, ISNI 0000 0004 0473 9881, Department of Obstetrics & Gynaecology, Division of Maternal-Fetal Medicine, , Mount Sinai Hospital, ; 700 University Avenue, Room 3-908, Toronto, Ontario M5G 1Z5 Canada

Author information

Rohan D’Souza http://orcid.org/0000-0002-4049-2017

Article

Publisher ID: 3060

DOI: 10.1186/s12884-020-03060-1

PMC ID: 7325658

PubMed ID: 32605542

SO-VID: c0183c27-75d1-495c-ab14-be1f9a22a934

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 1 December 2019

Date accepted : 16 June 2020

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100004914, Ferring Pharmaceuticals;

Custom metadata

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: outpatient induction of labour,inpatient induction of labour,cervical ripening,prostaglandins,balloon catheter,systematic review,meta-analysis

Data availability:

ScienceOpen disciplines: Obstetrics & Gynecology

Keywords: outpatient induction of labour, inpatient induction of labour, cervical ripening, prostaglandins, balloon catheter, systematic review, meta-analysis

Inpatient versus outpatient induction of labour: a systematic review and meta-analysis

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Bacterial vaginosis and biofilm

Most cited references 23

Assessing the quality of medical and health data from the 2003 birth certificate revision: results from two states.

Factors and outcomes associated with the induction of labour in Latin America.

Outpatient Foley catheter versus inpatient prostaglandin E2 gel for induction of labour: a randomised trial

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