Episode 4.9 Value Based Care Part 2: Vaginal Delivery (and some other stuff)

In this episode, we discuss management of soft markers of aneuploidy on ultrasound. Also, on update on Makena’s potential withdrawal by the FDA. And finally, we discuss value based care for vaginal induction and delivery, including methods of inductions, routine labs, methods of hemorrhage control, sterilization, etc. 

Links Discussed:

SMFM Consult Series #57: Evaluation and management of isolated soft ultrasound markers for aneuploidy in the second trimester

AWHONN Statement on FDA Committee Recommendation FDA Withdraw of 17p alpha Hydroxyprogesterone Caproate, 17-OHPC (Makena)

Summary of Cervidil Literature


MP vs DP. Risk of abruption in women with preeclampsia. 403 patients. 

Conclusion: “The use of misoprostol in preeclamptic women appears to be safe and is not associated with a higher risk of placental abruption when compared with other prostaglandins. Concerns about the use of misoprostol in the case of preeclampsia are not justified.”


MP vs DP. Induction for growth restricted term and near term fetuses. 

Conclusion: “Oral misoprostol is a safe method for labor induction in SGA near-term and term pregnancies and, concerning the neonatal outcome, comparable with other methods of labor induction or primary CS. Our study showed no adverse neonatal outcomes related to the use of oral misoprostol.”


MP vs DP. Randomized trial of IOL of patients “at high risk of fetal distress.” 140 patients. 

Conclusion: “Misoprostol and dinoprostone are equally safe for the induction of labor in pregnancies that are at high risk of fetal distress; however, misoprostol allowed the earlier induction of labor than did dinoprostone.”


Vag MP vs DP. RTC of IOL at term. 112 women. 

Conclusion: “Using vaginal misoprostol is an effective way of labor induction in term pregnant women with unfavorable cervices, since it is associated with a shorter duration of labor induction and higher rates of vaginal delivery within 12 h. Misoprostol and dinoprostone are equally safe, since misoprostol did not result in a rise in maternal and neonatal morbidity, namely, tachysystole, uterine hyperstimulation, cesarean section rates and admission to neonatal intensive care units as reported previously in literature.”


MP vs DP. IOL in women with preeclampsia. 98 patients. 

Conclusion: “This study suggests that misoprostol may have some advantages compared to dinoprostone, including improved efficacy and lower cost of the drug, even in cases of preeclampsia.”


MP vs DP. IOL in twin pregnancies. 186 women. 

Conclusion: “Study data indicate that oral misoprostol and vaginal dinoprostone are similarly effective and safe for the induction of labor in twin gestations.”


MP vs Foley. IOL in IUGR pregnancies. RTC. 100 women. 

Conclusion: “Few women had uterine tachysystole with cardiotocography abnormalities. Vaginal misoprostol at 25 μg was more effective than a Foley catheter for IOL in fetal growth restriction.”


Oral MP vs DP. IOL. 863 women. 

Conclusion: “The cesarean section rate was comparable between groups. Adverse events and neonatal outcomes were comparable between groups. Misoprostol shows a higher VD rate with fewer patients needing a second type of induction and a shorter time to the onset of active labor and to VD.”


Vaginal MP vs DP. RTC. 681 women. 

Conclusion: “Misoprostol in this dosing regimen is a safe method of labour induction. NICU admission rates were lower in the misoprostol group. No difference could be detected in patient satisfaction between groups.”


Systematic review of oral MP for IOL. 75 trials, 13,793 women. 

Conclusions: “Oral misoprostol as an induction agent is effective at achieving vaginal birth. It is more effective than placebo, as effective as vaginal misoprostol and vaginal dinoprostone, and results in fewer caesarean sections than oxytocin alone.”

For the ten trials comparing oral MP to vaginal DP (3,240 women): “There was little difference in the frequency of: vaginal birth within 24 hours (RR 1.10, 95% CI 0.99 to 1.22; 5 trials; 2,128 women), uterine hyperstimulation with fetal heart rate changes (RR 0.95, 95% CI 0.59 to 1.53; 7 trials; 2,352 women), and caesarean birth (RR 0.92, 95% CI 0.81 to 1.04; 10 trials; 3240 women).”


Prostaglandins and CD for NRFHT for IUGR fetuses. 1097 patients. 74% of patients received MP. 21% received DP. 

Conclusion: “In propensity score analysis, there was no association between the use of prostaglandins for labor induction at term and cesarean for NRFS in pregnancies complicated by SGA.”

“The findings of our study add to the body of literature that suggests that prostaglandin use is not associated with cesarean for NRFS in patients delivering SGA neonates at term. The primary mechanism thought to lead from prostaglandins to cesarean for NRFS is tachysystole [6]. However, although prostaglandins may be associated with an increased rate of tachysystole, this may be resolved with conservave measures and not uniformly require cesarean delivery [6]. Indeed, inducon of labor with vaginal prostaglandins, compared to other methods, has the highest rate of vaginal delivery within 24 hours, even though the rates of tachysystole are also increased [26].”


RTC of MP, DP, and cervical balloon for term IOL. 588 women. 

Conclusion: “Induction of labour with a transcervical balloon catheter is effective and safe and can be recommended as the first choice. The two prostaglandins, dinoprostone and misoprostol, were shown to be equally effective and safe, while misoprostol costs significantly less and is easier to store.”

Single versus double-balloon catheters for the induction of labor of singleton pregnancies: a meta-analysis of randomized and quasi-randomized controlled trials

Risk-based antenatal type-and-screen blood testing safe and economical

To compare cost effectiveness for routine type and screen for patients undergoing cesarean section and vaginal delivery

The cost-effectiveness of routine type and screen admission testing for expected vaginal delivery

Traditional uterine tamponade and vacuum-induced uterine tamponade devices in obstetrical hemorrhage management

Sterilization: Postpartum tubal vs. interval laparoscopic tubal