Because vaginal PGE2 is widely recognized and accepted as a standard method of labour induction, alternative methods which are less well established will be compared with PGE2 as the 'gold standard'. Particular attention will be paid to misoprostol because of the controversy surrounding its use and the volume of recent research.
Comparisons of alternative methods are most reliably based on the results of randomized clinical trials. To manage the complexity of several hundred reported randomized trials comparing multiple combinations of 25 methods of labour induction, the Pregnancy and Childbirth Group of the Cochrane Collaboration, in collaboration with the Clinical Effectiveness Support Unit, Royal College of Obstetricians and Gynaecologists, developed a strategy to review well-defined clusters of comparisons in a series of systematic reviews using standardized outcomes and clinical subgroups . For the purposes of this chapter, data comparing PGE2 administered vaginally (as the 'gold standard') with any other method have been extracted from these reviews (Table 23.2).
A problem fundamental to these comparisons is that one method may appear to be more effective than another simply because a large dosage has been used. What is most relevant is the relationship between effectiveness and the incidence of uterine hyperstimulation (with the attendant risks of fetal compromise and uterine rupture), for each method. In the last column of Table 23.2, the relative risk of failed delivery within 24 h is multiplied by the relative risk of uterine hyperstimulation with fetal heart rate changes. The result serves as a rough indication of efficiency (relationship between effectiveness and hyperstimulation) for each method, relative to PGE2 as the 'gold standard'. On the basis of this method, the efficiency of mechanical methods appears better, vaginal misoprostol worse and oral misoprostol and oxytocin with amniotomy similar to that of PGE2. There were too few data on vaginal PGF2-alpha for comment.
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