Elective Induction of Nulliparous Labor

February 7, 2025 updated by: Sandra Smith, Madigan Army Medical Center

Elective Induction of Nulliparous Labor: A Randomized Clinical Trial

Primary outcome: to evaluate the effect of elective induction of labor (IOL), at 39 weeks gestation, on cesarean delivery rates in nulliparous women compared to expectant management (EM).

Secondary outcomes: to evaluate differences in the mean number of clinic visits/antepartum tests avoided with IOL, to compare the differences in utilization of inpatient resources (mean duration of inpatient stay, mean duration of labor), and to evaluate the effect of IOL on the risk of urinary/anal incontinence and sexual dysfunction as analyzed using previously validated measurements. We will evaluate differences in the rate of cervical change once active labor is diagnosed, and the time from completion of active labor, defined as complete dilation and complete effacement, to the delivery of fetus (definition of second stage of active labor). Furthermore, other secondary outcomes to be evaluated include comparisons between IOL and EM in regards to the occurence of chorioamnionitis, stillbirth, operative vaginal delivery, and meconium stained amniotic fluid. An evaluation of the predictive value of cervical length and Bishop score for vaginal delivery will also be examined.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

A research nurse will screen patients at the 38 week visit through chart review and potential candidates will be identified. One of the study investigators or research nurse will interface with the patient at the 38 week visit and written informed consent will be obtained after the study protocol is explained and eligibility determined. Since eligibility determination cannot be made without performing a digital cervical examination, the patient will be offered a cervix exam with Bishop score determination. If the Bishop score meets inclusion criteria, the patient will be offered participation in the study. Women who consent to the study will be randomized using a computer-generated list by means of sequentially numbered, opaque, sealed envelopes which reveal the allocation of the subject to either induction or expectant management. All subjects will then receive the following evaluation: transvaginal cervical length measurement, and completion of a standard urinary/rectal incontinence/sexual function questionnaire. Patients randomized to induction will be scheduled not earlier than 39 weeks gestation and in coordination with the labor and delivery physician and nursing leadership. The method of induction will be dependant on whether or not a cervical foley bulb can be placed at the time of admission for induction of labor. If cervical foley bulb placement is possible, the foley bulb will remain in place until either spontaneously removed or after 12 hours, whichever is earlier. If placement is not possible, cervical ripening with misoprostol 25 mcg per vagina every 4 hours (maximum of 4 total doses) will be initiated. Cervical examination will occur every 4 hours (coincident with vaginal misoprostol placement). Repeat doses of misoprostol will be given only if foley bulb placement is not possible and/or if palpably firm uterine contractions are less than 6 in 10 minutes in consecutive 10 minute intervals. Once placement of a cervical foley bulb can be performed this will be accomplished and initiation of oxytocin administration will begin at 2 mIU/minute and increasing by 2 mIU/minute every 20 minutes to ensure adequate contractions (maximum oxytocin infusion rate 36 mIU/minute). Adequate contractions will be defined as 7 contractions in 15 minutes in consecutive 15 minute intervals that palpate moderate to firm. Oxytocin infusion will begin not earlier than 4 hours after the last misoprostol dose (if given). Subjects expectantly managed (EM) will be scheduled for routine follow-up appointments and delivered for obstetric indications but not later than 42 weeks gestation.

A routine 6-8 week immediate postpartum and 1 year follow-up examinations will be scheduled for all subjects following delivery. In addition to the routine examinations, all subject evaluations during these visits will include completion of a standard urinary/rectal incontinence/sexual function.

Study data will be entered into a password protected Excel file on a DoD government computer accessible only to study investigators and a clinical research nurse. Withdrawal from the study will be voluntary and results will be analyzed on an intent-to-treat basis.

Data analysis will focus on the primary outcome: to evaluate the effect of elective induction of labor, at 39 weeks gestation, on cesarean delivery rates in nulliparous women compared to expectant (typical) management. Also evaluation of secondary outcomes will include determination of the predictive value of cervical length and Bishop score for successful vaginal delivery; the risk of urinary/anal incontinence and sexual dysfunction with labor induction compared to spontaneous labor; number of clinic visits/antepartum tests avoided with elective induction compared with potential increased utilization of inpatient resources; evaluation of the labor curve with induction compared to spontaneous labor. Other secondary outcomes to be evaluated include comparisons between IOL and EM in regards to the rate of chorioamnionitis, rate of stillbirth, rate of operative vaginal delivery, and rate of meconium stained amniotic fluid. Students t-test will be used to compare continuous variables and the Chi-square test will be used to compare proportions between the groups. Analysis is by intent-to-treat with a p-value of less than 0.05 considered significant.

Study Type

Interventional

Enrollment (Actual)

162

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Washington
      • Tacoma, Washington, United States, 98431
        • Madigan Army Medical Center

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 40 years (Adult)

Accepts Healthy Volunteers

Yes

Description

Inclusion Criteria:

  • Nulliparous patients evaluated at 38 weeks gestation without contraindication for induction of labor, and
  • Patients who meet dating criteria as outlined above, and
  • Patients who have a Bishop score of ≤ 5.

Exclusion Criteria:

  • Contraindication to induction of labor,
  • Scheduled induction of labor for medical indications, and/or
  • Failure to meet dating criteria above, Bishop score of > 5.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
No Intervention: Expectant management (EM) arm
Standard of care: routine clinic appointments until they deliver, fetal heart rate and contraction monitoring during their 41st week if not delivered. Also if they have not gone into labor the subjects will be scheduled for an induction by 42 weeks.
Experimental: Induction of Labor (IOL) arm
Elective induction of labor at 39 weeks.
Procedure: Induction of Labor
If cervical foley bulb placement is possible, the foley bulb will remain in place until either spontaneously removed or after 12 hrs, whichever is earlier. If placement is not possible, cervical ripening with misoprostol 25 micrograms (mcg) per vagina every 4 hrs (max of 4 total doses) will be initiated. Cervical examination will occur every 4 hr. Repeat doses of misoprostol will be given only if foley bulb placement is not possible and/or if palpably firm uterine contractions are less than 6 in 10 min in consecutive 10 min intervals. Once placement of a cervical foley bulb can be performed, oxytocin administration will begin at 2 mIU/min and increasing by 2 mIU/min every 20 min to ensure adequate contractions (maximum oxytocin infusion rate 36 mIU/min). Adequate contractions will be defined as 7 contractions in 15 min in consecutive 15 min intervals that palpate moderate to firm. Oxytocin infusion will begin not earlier than 4 hrs after the last misoprostol dose (if given).
Other Names:
  • oxytocin
  • misoprostol

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Time Frame
Cesarean Birth Rate
Time Frame: 39 weeks gestation
39 weeks gestation

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Madigan Army Medical Center

Investigators

  • Principal Investigator: Nathaniel R Miller, MD, Madigan Army Medical Center
  • Study Director: Peter Nielsen, MD, Madigan Army Medical Center

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

October 27, 2009

Primary Completion (Actual)

April 24, 2017

Study Completion (Actual)

April 24, 2017

Study Registration Dates

First Submitted

February 24, 2010

First Submitted That Met QC Criteria

February 24, 2010

First Posted (Estimated)

February 25, 2010

Study Record Updates

Last Update Posted (Actual)

March 25, 2025

Last Update Submitted That Met QC Criteria

February 7, 2025

Last Verified

February 1, 2025

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 210013

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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