DOI: 10.1111/tog.

12395 2017;19:219–26
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

An overview of the past, current and future trends for

cervical ripening in induction of labour
a, b c
Rohan Chodankar MBBS MD MRCOG, * Akanksha Sood MBBS MD DNB MRCOG, Janesh Gupta MSc MD FRCOG
a
Specialty Registrar in Obstetrics and Gynaecology, Royal Infirmary of Edinburgh, 51 Little France Drive, Edinburgh EH16 4SA, UK
b
Senior Clinical Fellow in Obstetrics and Gynaecology, Saint Mary’s Hospital, Oxford Road, Manchester M13 9WL, UK
c
Professor of Obstetrics and Gynaecology, Centre for Women’s and Newborn Health, Institute of Metabolism and Systems Research (IMSR),
University of Birmingham, Birmingham Women’s Hospital, Birmingham B15 2TG, UK
*Correspondence: Rohan Chodankar. Email: [email protected]

Accepted on 15 November 2016

Key content Learning objectives

 The advantages and disadvantages of pharmacological methods  To know the past, current and future trends in cervical ripening for
and mechanical methods (such as the osmotic cervical dilator labour induction.
Dilapan-S
and Foley catheter) for labour induction are discussed.  To understand that mechanical methods (e.g. Dilapan-S
and
 This article looks at the international and local (UK) experience Foley catheter) offer similar efficacy and better safety compared
with use of Dilapan-S
for cervical ripening. to PGE2.
 The Cochrane and Royal College of Gynaecologists and
Keywords: cervical ripening / Foley catheter / induction of labour /
Obstetricians (RCOG) statements with regards to use of
mechanical dilators / oxytocin / prostaglandins
mechanical dilators are referenced.

Please cite this paper as: Chodankar R, Sood A, Gupta J. An overview of the past, current and future trends for cervical ripening in induction of labour. The
Obstetrician & Gynaecologist 2017;19:219–26. DOI:10.1111/tog.12395

However, when used alone, it is only effective when the cervix

Historical background
is favourable. Other mechanical methods included the use of
“The spontaneous onset of labour is a robust and effective uterine Bougies, De Ribes’ bag, forced rapid dilation of the
mechanism which is preceded by the maturation of several fetal cervix and oral castor oil. The latter was abandoned in the
systems and should be given every opportunity to operate on its early 20th century because of the side effects of violent
own. We should only induce labour when we are sure that we diarrhoea, resulting in patient exhaustion.3
can do better”— Alec Turnbull, 1976. The first description of amniotic membrane sweeping for
A desire to control natural processes is an innate human inducing labour was first documented by James Hamilton, in
tendency, and throughout history there have been efforts to England in 1810.4
control the process of parturition by timed induction. The Amniotomy and mechanical methods remained the
history of induction of labour (IOL) dates back to commonest methods of labour induction until 1906, when
Hippocrates’ original description of mammary stimulation Sir Henry Dale observed that extracts of posterior pituitary
and mechanical dilation of cervical canal.1 gland caused uterine contractions.5 He gave samples to an
Historically, induction was only done in the event of life- obstetrician, William Blair Bell, who reported the first
threatening maternal disease. With the advent of safer and experience of its use in labour induction.6 Initially, the
improved methods, the threshold for intervention for IOL preparations were crude and of variable potency and purity.
has reduced. This article has been written by authors working The large doses, administered via intramuscular or
in the UK and, as such, several references and generalisations subcutaneous routes, were associated with fatal adverse
are based upon such practice. outcomes as a result of uterine hyperstimulation.
Artificial rupture of membranes, also called amniotomy In 1953, oxytocin, a synthetic octapeptide, was first
and popularly known as the ‘English Method’, was first produced;6 thereafter, a ‘physiological drip’ of a dilute
reported by Thomas Denman of London’s Middlesex intravenous concentration of oxytocin was used. The use of
Hospital in 1756.2 Early amniotomy was regarded as a safe buccal oxytocin ‘linguettes’, with one or more tablets placed
and efficacious method in nulliparous labour inductions. at once, was discarded at an early stage.3 It was not until the

ª 2017 Royal College of Obstetricians and Gynaecologists 219

 An overview of the trends for cervical ripening

late 1960s that Alec Turnbull and Anne Anderson advocated cervical os remains closed, the cervix may be massaged
the ‘oxytocin titration’ method. This entailed the use of around the vaginal fornices for a similar effect.
steadily increasing the rate of a low-dose infusion until According to the National Institute for Health and Care
adequate uterine contractility was achieved, at which point Excellence (NICE), prior to formal IOL, women should be
the dose rate was maintained.7 Since 1990, electronic offered a vaginal examination for membrane sweeping as an
intravenous infusion pumps have been used, allowing more adjunct to formal induction.13 Several studies have reported
accurate regulation of oxytocin infusion flow rate. that membrane sweeping is associated with higher rates of
The next phase of methods used for IOL began with the spontaneous vaginal delivery, shorter induction-to-delivery
introduction of prostaglandins (PGs) into clinical practice in interval, reduced likelihood of post-term pregnancy, and a
the 1970s. This changed obstetric practices, largely because decreased need for IOL.11,12,14,15 For formal IOL to be
PGs induce cervical ripening along with starting uterine avoided in one woman, eight must have their amniotic
activity, thus supposedly mimicking the natural labour membranes swept.
process. Several types of PG are used for IOL: PGF2a, Women who undergo membrane sweeping should be
PGE1 and PGE2. According to a recent Cochrane review, counselled about its undesirable effects, including discomfort
when used for IOL, PGs increase the incidence of uterine from the procedure, vaginal bleeding and irregular uterine
hyperstimulation with fetal heart rate (FHR) changes, but contractions in the 24 hours after the procedure.11,16 A
either have no effect on caesarean section rates, or may Cochrane review in 200511 confirmed that membrane
reduce them by up to 10%.8 sweeping does not increase the risk of maternal and
Based on our growing knowledge of the physiological neonatal infection. The ‘STRIP-G’ study revealed that
processes involved in spontaneous labour, the cervix usually membrane sweeping was a safe procedure in women who
undergoes a process of softening, effacement and then dilation were found to be carriers of Streptococcus agalactiae (Group
(‘cervical ripening’). Cervical ripening is a physiological B Streptococcus).17
process occurring throughout the latter weeks of pregnancy
and is completed with the onset of labour. There is a Amniotomy
continuum from ‘unripe’ to ‘ripe’, or ‘unfavourable’ to Amniotomy (artificial rupture of membranes) can be a
‘favourable’ cervix. The nature of the cervix is therefore simple and effective component of IOL when the membranes
crucial in determining whether labour and delivery is likely to are accessible and the cervix is favourable. The time interval
be successful. In 1964, Edward Bishop devised a five-point scale between an amniotomy and the onset of labour is
(with a maximum score of 13), which included an assessment unpredictable. When oxytocin is used to induce labour, an
of cervical dilation, effacement of the cervix (length), station of amniotomy is always performed first. However NICE does
the fetus, consistency of the cervix, and position of the cervix, not recommend the use of an amniotomy, with or without
to predict the likelihood of a woman entering labour naturally oxytocin, as a primary method of labour induction, unless
in the near future.9 The score was modified in 1974 to become there are specific contraindications to the use of PGs.13 Data
the ‘Calder score’, or modified Bishop score (with minor on the effectiveness and safety of amniotomy and intravenous
changes in emphasis), and is now the most commonly used oxytocin alone are lacking.18
scoring method.10 A cervix is viewed as ‘unfavourable’ if the The immediate versus delayed use of an oxytocin infusion
modified Bishop score is less than six. after amniotomy for the purpose of IOL was compared in a
small randomised controlled trial (RCT) in 2009. The
likelihood of being in established labour 4 hours after
Common methods for induction of labour
amniotomy, and having a shorter amniotomy-to-delivery
The most common methods for IOL are membrane sweeping, interval, was higher in the immediate infusion group.19 A
amniotomy, oxytocin infusion and PGs. Common mechanical more recent RCT compared immediate and delayed
methods include balloon catheters and osmotic dilators. Extra- (4 hours) oxytocin use in parous women and found that
amniotic saline infusion is less commonly used in the context both options were reasonable, thus the decision should be
of labour induction. based on local resources and maternal choice.20
Cord prolapse is the major risk with amniotomy, especially
Membrane sweeping when performed with an unengaged presenting part of
Membrane sweeping involves a vaginal examination during the fetus.
which a finger is passed through an open cervical os and
circumferentially rotated to separate the chorioamniotic Oxytocin
membrane from the decidua of the lower uterine Titrated intravenous oxytocin is now the commonest adjunct
segment.11 The associated increase in local prostaglandin used for IOL and maintaining uterine contractions. Oxytocin
concentration is thought to induce labour.12 When the is a naturally occurring peptide from the posterior

220 ª 2017 Royal College of Obstetricians and Gynaecologists

 Chodankar et al.

hypothalamus, which acts on oxytocin receptors in the uterus Therefore, 50 microgram vaginal misoprostol tablets may
with no direct effects on the cervix.21 Oxytocin induction be a reasonable treatment of choice where a quicker delivery
may increase the rate of surgical interventions in labour, needs to be achieved and facilities for intensive monitoring
especially when the cervix is unfavourable.22 Overall, are available. Further studies are needed to support dosing
oxytocin should be used judiciously as its uncontrolled use and intervals (2, 4 or 6 hourly) for misoprostol use.
can be associated with a risk of hyperstimulation and
FHR abnormalities.23
Mechanical methods of induction of labour
Extra-amniotic saline infusion Mechanical methods of induction include the use balloon
Extra-amniotic saline infusion (EASI) has historically been used catheters and hygroscopic dilators.
in the context of pregnancy termination in advanced gestations.
For the purpose of IOL in the third trimester, extra-amniotic Balloon catheters
saline is infused through a transcervical catheter. Infusion rates
can vary between 30 and 60 ml/hour.24–26 This results in Mechanism of action of transcervical balloon catheters
stripping of the membranes with an increase in local PGs and Placement of a cervical balloon catheter (such as a Foley
other inflammatory mediators to induce labour.27 catheter) is thought to cause cervical ripening by the physical,
Although chorioamnionitis and/or endometritis appear to mechanical stretching of the cervix, which in turn stimulates
be theoretical risks, neither a Cochrane review28 nor a recent release of endogenous PGs. A recent study using immunoassay
systematic review29 supported these concerns. and immunohistochemistry showed that, when used for pre-
The evidence with regard to effectiveness is contradictory. induction cervical ripening, Foley catheters affect cervical
A Cochrane review concluded that there was insufficient ripening through changes in biochemical mediators.37 Levels of
evidence to support the use of EASI alone for IOL.28 EASI interleukins (IL-6, IL-8), matrix metalloproteinase (MMP)-8,
was found to reduce the induction delivery interval when nitric oxide synthetase (NOS) and hyaluronic acid synthetase
used in association with the Foley catheter versus the Foley (HAS-1) were significantly higher in women who have received
catheter itself;25 however, other studies found no benefit to a Foley catheter.
using EASI in combination with Foley catheters.26,30
The evidence for using EASI in association with PGs is Double balloon catheter
similarly conflicting. With regard to induction delivery time, Atad et al.38 first described the double balloon catheter in
some studies31,32 have shown a benefit (3–5 hour reduction), 1991. In 2005, the US Food and Drug Administration (FDA)
while others have shown no effect.24,33–35 However, when used approved the ‘Atad Ripener Device’, an 18 French natural
with PGs, EASI has been shown to improve cervical ripening latex, 3-lumen catheter with double balloons, each with a
scores in most studies.24,33–35 This does not, however, translate to capacity of 80 ml, placed 2 cm apart at the distal end. The
reduction in induction-to-delivery intervals. double balloon is thought to be superior to a Foley catheter
because the forces of dilation occur from both sides of the
Prostaglandins cervical os, whereas the Foley catheter only exerts force on the
There are two main types of PGs used for IOL: PGE1 (oral or internal os, particularly when placed on traction.38,39
vaginal misoprostol) and PGE2 (tablets and gels, and a The FDA approved the Cook cervical ripening balloon in
controlled-release preparation called dinoprostone). A 2015 2013.40 This is an 18 French silicone double balloon catheter
systematic review and network meta-analysis of 280 RCTs (balloon capacity 80 ml each), which comes with an optional
including 48 068 women compared the different PGs for the stylet to aid insertion.
purpose of cervical ripening or IOL.36 Robust data on
hyperstimulation as an outcome measure were not readily Single balloon Foley catheter versus double balloon
available from the study because of unresolved inconsistency catheter
for this event. The network meta-analysis showed that, Recent evidence shows no significant difference in delivery
compared to dinoprostone, misoprostol is likely to be intervals or modes of birth between use of the single balloon
superior for the purpose of IOL. The lowest caesarean Foley catheter over the double balloon catheter.41–44 The
section risk was associated with the use of a titrated low-dose Foley catheter is not currently licensed for pre-induction
oral solution (<50 micrograms) of misoprostol. Vaginal cervical ripening unlike the double balloon catheters.
delivery within 24 hours of induction was most likely to be
achieved when vaginal misoprostol tablet (≥50 micrograms) Balloon volumes
was used; however, this effectiveness was associated with A 2014 systematic review and meta-analysis45 compared the
undesirable effects including an increased risk of adverse fetal use of low volume (30 ml) and high volume (60 ml, 80 ml)
heart changes and uterine hyperstimulation. Foley bulbs. Attainment of a favourable cervix was more

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 An overview of the trends for cervical ripening

likely with the use of high volume catheters. High volume chorioamnionitis (7.6 versus 3.7%, pooled OR 2.05, 95%
Foley catheters resulted in a significantly reduced likelihood CI 1.22–3.44) was found, but the rates of endomyometritis
of failure to deliver within 24 hours (relative risk [RR] 0.70; were not raised (5.1 versus 3.2%, pooled OR 1.42, 95% CI
95% confidence interval [CI] 0.54–0.90), and the reduction 0.74–2.97).
was greater with use of 80 ml Foley catheters than with 30 ml
Foley catheters (RR 0.57; 95% CI 0.40–0.81). The rate of Mechanical methods in the context of prelabour
caesarean section with use of 80 ml Foley catheters was not rupture of membranes
significantly different to that observed with the 30 ml Foley Most of the current evidence relates to the use of mechanical
catheters (RR 0.82; 95% CI 0.48–1.41), but the overall risk methods on women with intact membranes. More recently, a
ratio slightly favoured the high volume Foley catheters. A retrospective cohort study48 demonstrated no significant
large RCT is required, using caesarean section as a primary increase in the risk of chorioamnionitis when using
outcome for low versus high volume catheters. intracervical balloons in women with prelabour rupture of
membranes. The risk of chorioamnionitis was correlated with
Balloon traction nulliparity (adjusted OR 12.5 [1.36, 114.6], P = 0.03) and
A 2013 RCT46 compared the use of inner thigh taping with intrauterine pressure catheter use (adjusted OR 4.39 [1.04,
using traction with a 500 ml weighted bag of fluid in women 18.5], P = 0.04).
with an intracervical 30 ml Foley catheter for pre-induction A randomised clinical trial comparing oxytocin versus
cervical ripening. No differences were identified in the time oxytocin and Foley catheter for IOL in women presenting
to delivery, delivery within a 24-hour period, rate of with prelabour rupture of membranes (and not in labour) is
caesarean sections, pain scores or the use of epidural likely to address this issue further.49
analgesia. These results were similar for nulliparous and
multiparous women. A statistically significant shorter Prostaglandins versus Foley catheters
catheter expulsion interval was identified in the traction A 2016 systematic review and network meta-analysis of
group, with no improvement in outcomes. 96 RCTs involving 17 387 women compared PGs and Foley
catheters.50 Only women with intact membranes were
Infection risk with balloon catheters analysed. No method of IOL (misoprostol – oral or
There is a reported theoretical risk of infection with the use vaginal; dinoprostone – vaginal or intracervical or Foley
of mechanical methods, but the evidence to support or refute catheter) was found to be superior overall. The outcomes
this claim is sparse. studied were vaginal birth within 24 hours, caesarean section
According to a 2012 Cochrane review,28 there is no evidence rate and risk of hyperstimulation with adverse FHR changes.
of an increased risk of infection with mechanical methods; The network meta-analysis shows that vaginal misoprostol
however, the authors advised caution in interpreting this followed by vaginal dinoprostone is the most effective IOL
finding in view of the limited available evidence. method in terms of achieving delivery with 24 hours.
In the Prostaglandin or Balloon Catheter for Induction of Prostaglandin methods are, however, associated with higher
Labour (PROBAAT) trial (n = 824), which compared the use rates of uterine hyperstimulation and adverse FHR changes.
of Foley catheters to vaginal PGE2 gel,47 suspected Use of the Foley catheter was associated with the lowest risk of
intrapartum infection was less common (1%) in the Foley hyperstimulation and adverse FHR changes. Oral misoprostol
catheter group than in the vaginal PGE2 gel (3%) group. The demonstrated the lowest caesarean section rate.50
criteria for suspected intrapartum infection included a body The Cochrane Database51,52 also supports the use of oral
temperature ≥38°C and commencement of broad-spectrum over vaginal misoprostol for IOL in women with intact
antibiotics. This association was statistically significant. The membranes and an unfavourable cervix. Oral misoprostol is
rate of neonatal admission for suspected infection was also more effective than placebo and results in fewer caesarean
significantly higher following PGE2 (20 versus 12%). The sections than vaginal dinoprostone or oxytocin. Evidence
authors were unable to clearly attribute prostaglandin-related suggests that a 20–25 microgram oral solution is ideal.
versus pathogen-induced pyrexia. The PROBAAT-II trial53 compared the use of oral
A meta-analysis29 of 30 RCTs demonstrated an increased misoprostol (n = 924) and Foley catheters (n = 921) in
risk of infectious morbidity with the use of mechanical 1859 women. The primary outcome measures were asphyxia
methods. However, this was limited to the use of Foley (i.e. pH ≤7.05 or 5-min Apgar score <7) and postpartum
catheters. The absence of significant increases in maternal haemorrhage ≥1000 ml. These events occurred in 12.2% of
infection in those patients whose pregnancy was induced women in the misoprostol group and 11.5% of women in the
specifically with EASI, Laminaria or hygroscopic dilators Foley catheter group. There was no significant difference in
may reflect the smaller number of studies assessing the neonatal ward and intensive care admissions in
these modalities. A significantly increased risk of both groups.

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 Chodankar et al.

Delivery after 24 hours was more common after IOL with RCT56 comparing the use of Dilapan-S
and Laminaria
misoprostol than with a Foley catheter; however, the effect japonica for this purpose concluded that use of Dilapan-S

was reversed at 36 hours. Results were similar when assessing was preferable as it was associated with a shorter induction–
time from randomisation (rather than time from induction) delivery interval and fewer dilators were necessary to obtain
to active phase of labour or delivery. The caesarean section significant cervical ripening. Another RCT57 comparing the
rate was 16.8% for the misoprostol group and 20.1% for the use of Dilapan-S
and intracervical prostaglandin E2 gel
Foley catheter group; this difference was not statistically found a statistically significant increase in the rate of uterine
significant. No significant differences in hyperstimulation or contractions with the use of PGs. In an RCT58 comparing the
FHR changes were observed in either group. The study use of intracervical PGE2 and Dilapan-S
, there was a
concluded that the use oral misoprostol and the Foley significantly higher rate of uterine hyperstimulation with the
catheter have similar levels of safety and effectiveness. use of PGs.
However, this finding should be interpreted with caution as An observational international Dilapan-S E-registry study
rare, but serious, complications are often difficult to measure has recently been completed and assesses the efficacy and
– even in such study settings. safety of osmotic dilators in pre-induction cervical ripening
The PROBAAT-P trial54 compared the use of Foley for IOL, including in women who have had previous
catheters and prostaglandin E2 vaginal inserts (10 mg slow caesarean sections.59 The evidence so far has shown no
release) for IOL. Both groups demonstrated comparable increased risk of hyperstimulation or associated FHR
effectiveness and safety. Meta-analysis of the data revealed abnormalities with Dilapan-S
use. It has been proposed
that using a Foley catheter was associated with fewer cases of that Dilapan-S
may be used as an outpatient agent for IOL.
hyperstimulation; however, the caesarean section rate was
comparable in both groups. Admissions to the neonatal
Discussion
intensive care unit did not differ statistically, and there were
The use of misoprostol for IOL has not been widely
no differences in umbilical cord pH between the two groups.
explored by maternity units in the UK.60 Current evidence
The PROBAAT trial compared the use of PGE2 gel (1 mg)
supports the use of low-dose titrated oral misoprostol
and a Foley catheter for labour induction.47 This RCT did not
solution and/or the Foley catheter (single balloon catheter)
identify a lower caesarean section rate with the use of the
for cervical ripening rather than other prostaglandin
Foley catheter, which was the primary outcome. With regard
methods. Neither of these treatments are currently
to secondary outcomes (hyperstimulation, postpartum
licensed for use in the UK.
haemorrhage and umbilical cord pH), there was no
The PROBAAT-II trial53 makes an important point with
statistically significant benefit of the use of the Foley catheter.
regard to assessing induction–delivery intervals. Most studies
Overall, there have been several studies comparing the use
use the criterion of delivery within 24 hours to assess the
of Foley catheters, misoprostol and dinoprostone for IOL
effectiveness of an intervention;61 and in the PROBAAT-II
showing comparable effectiveness and safety profiles.
trial, this criterion suggested that misoprostol was more
effective. However, when this interval was increased to 36
Osmotic dilators hours, the Foley catheter was found to be more effective.
Until recently, osmotic (or hygroscopic) dilators have been
Achieving a safe vaginal birth is more important than
used in the context of cervical ripening prior to surgical
timescales alone, as was highlighted by the authors of the
termination of pregnancy at advanced gestations. Osmotic
PROBAAT-II study.
dilators predominantly act by absorbing water from the cervix,
Advantages of the Foley catheter during labour
thereby dehydrating the cervix and making it ‘soft’ and ‘ripe’. As
induction include:
the dilator expands, it has a mechanical expanding dilation effect,
which stimulates endogenous prostaglandin release, thereby  lowest risk of uterine hyperstimulation and adverse
actively aiding the ripening process.55 FHR changes
Laminaria are hygroscopic rods made from sterile seaweed  lower in cost than dinoprostone or the double
(Laminaria japonica or Laminaria digitata). Dilapan-S
balloon catheter
[MEDICEM, the Netherlands] is a hydrophilic polymer rod  easier to store than dinoprostone
made of Aquacryl, a proprietary hydrogel, which is  less stringent monitoring of uterine contractions
hygroscopic in action. Both need insertion into the cervical  no further clinical intervention required until expulsion of
canal under direct visualisation, using a sterile speculum after the catheter
local cleansing. In general, up to five dilators can be  more suitable for induction in women at risk of placental
used simultaneously.55 insufficiency and fetal compromise such as pre-eclampsia
There is limited evidence with regard to the use of osmotic and intrauterine growth restriction
dilators in the context of pre-induction cervical ripening. An  no clear evidence of an increased risk of chorioamnionitis

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 An overview of the trends for cervical ripening

 possible alternative for IOL in women who want a Conclusions

‘home induction’.
One in five pregnant women in high-income countries have
The advantages of low-dose oral misoprostol solution are induced labours. Despite the variety of methods available, no
that it is: method is optimum. In the UK, PGE2 inserts (10 mg) and
 associated with the lowest caesarean section rate PGE2 gel (1–2 mg) are licensed and commonly used for pre-
 cost-effective (although an RCT in low-resource settings is induction cervical ripening. Comparing the use of Foley
required to prove this) catheters to PGs, the PROBAAT, PROBAAT-P and
 easier to store than dinoprostone PROBAAT-II trials suggested equivalent efficacy, equal
 more acceptable to women as it is orally administered caesarean section rates, lower risk of hyperstimulation, and
 easier to administer. no clear evidence of increased infection risk. The PROBAAT-II
trial also demonstrated >99% acceptability for Foley catheter
use in eligible women. In light of the current available evidence,
Current guidelines on methods for there is a need to revisit current guidance with regards to
induction of labour mechanical methods, such as Foley catheters, for IOL in the
UK. The use of potential alternatives, such as hygroscopic
The current NICE guidance13 on IOL states that vaginal agents like Dilapan-S
, are currently being evaluated.
PGE2 (as a tablet, gel or controlled-release pessary) should be
used as the first-line agent. Misoprostol should be offered as a Disclosure of interests
method of IOL only to women who have intrauterine fetal There are no conflicts of interest.
death, or in the context of a clinical trial. It also suggests that
mechanical methods (balloon catheters, Laminaria tents) Contribution to authorship
should not be routinely used for IOL. The RCOG’s guidance All authors contributed equally towards completion of
on vaginal birth after a caesarean (VBAC) indicates that PGs the project.
should be used with caution, as prostaglandin use is
associated with an increase risk of uterine rupture. Further
research into mechanical methods for IOL in VBAC patients
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