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Evidence summaries

Vaginal Prostaglandin (Pge2 and Pgf2a) for Induction of Labour at Term

Vaginal PGE2 is effective for induction of labour at term compared with placebo. Level of evidence: "A"

A network meta-analysis 2 assessed the relative effectiveness, safety and cost-effectiveness of labour induction methods. 611 trials were included. The interventions most likely to achieve vaginal delivery within 24 hours were intravenous oxytocin with amniotomy (posterior rank 2; 95% credible intervals (CI) 1 to 9) and higher-dose (≥ 50 µg) vaginal misoprostol (rank 3; 95% CI 1 to 6) (table T1). Compared with placebo, several treatments reduced the odds of caesarean section, but there were considerable uncertainty in treatment rankings. For uterine hyperstimulation, double-balloon catheter had the highest probability of being among the best 3 treatments, whereas vaginal misoprostol (≥ 50 µg) was most likely to increase the odds of excessive uterine activity.

Interventions for failure to achieve vaginal delivery within 24 hours

Active intervention vs placeboOdds ratio95% CI
i.v. oxytocin with amniotomy0.050.07 to 0.32
Vaginal misoprostol ≥ 50 μg0.090.06 to 0.24
Titrated (low-dose) oral misoprostol solution0.100.07 to 0.29
Vaginal misoprostol < 50 μg0.110.09 to 0.32
Buccal/sublingual misoprostol0.110.05 to 0.19
Vaginal PGE2 pessary (normal release)0.110.04 to 0.16
Vaginal PGE2 (gel)0.130.08 to 0.50
Vaginal PGE2 pessary (slow release)0.150.08 to 0.29
Vaginal PGE2 (tablet)0.160.03 to 0.26
Intracervical PGE20.180.09 to 0.38

A Cochrane review [Abstract] 1 included 70 studies with a total of 11 487 women. Overall vaginal PGE2 (tablets, gels and pessaries including sustained release preparations) compared with placebo or no treatment non-significantly reduced the rate of unsuccessful vaginal delivery within 24 hours (RR 0.32, 95% CI 0.02 to 4.83; 2 trials, n=384). The risk of the cervix remaining unfavourable or unchanged was reduced (RR 0.41, 95% CI 0.27 to 0.65; 6 trials, n=567).There was a trend for lower caesarean section rates (RR 0.91, 95% CI 0.81 to 1.02; 36 trials, n=6599) although the risk of uterine hyperstimulation with fetal heart rate changes was increased (RR 3.16, 95% CI 1.67 to 5.98; 15 trials, n=1359).

PGE2 tablet, gel and pessary appear to be equally effective.

    References

    • Thomas J, Fairclough A, Kavanagh J et al. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database Syst Rev 2014;(6):CD003101. [PubMed]
    • Alfirevic Z, Keeney E, Dowswell T et al. Which method is best for the induction of labour? A systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2016;20(65):1-584.[PubMed]

Primary/Secondary Keywords