N. Al-Ibraheem, M. Al-Khateeb, T. Athamneh, Z. Shraideh

A Comparison of Intracervical Foley’s Catheter Versus
Posterior Fornix Prostaglandin E2 for Cervical Ripening
in Post-Date Pregnancy
Nedal Al-Ibraheem MD*, Mahmood Al-Khateeb MD*, Tareq Athamneh MD*,
Ziad Shraideh MD*
ABSTRACT
Objective: To compare the efficiency, safety and side effects of intracervical Foley’s catheter versus
posterior Fornix Prostaglandin E2 for cervical ripening in post-date pregnancy.
Methods: This study was conducted on 200 women at Prince Rashed military hospital in the north of Jordan
between October 2004 and October 2005. A total of 200 women were studied. All were post-date of at least
one week and in need for induction of labour. They were divided into two groups: the first group consisted of
100 women who underwent pre-induction cervical ripening by intra – cervical Foley’s catheter, while the
second group consisted of 100 women who were induced by posterior Fornix Prostaglandin E2 at six hour
interval.
Results: The efficacy of both methods for pre-induction cervical ripening of labor in post-date pregnancy
were almost the same. Foley’s catheter success rate was slightly higher in primigravidae and it was
inexpensive while PGE2 success rate was almost the same with shorter time for cervical ripening. Both
methods were the same regarding safety and frequency of side effects.
Conclusion: The use of intracervical Foley’s catheter for cervical ripening of labour in post date
pregnancy is safe, effective, and the success rate is comparable with posterior fornix prostaglandin E2.
Key words: Foley’s catheter, Prostaglandin E2, Post-date pregnancy, Cervical ripening
JRMS July 2010; 17(Supp 2): 21-24
Introduction
Post-date pregnancy is defined as pregnancy
extended beyond 40 weeks gestational age. It
accounts for 10% of all pregnancies (1) and is
considered to be a risk factor for both mother and
fetus with increased perinatal mortality, (2) therefore
intervening at the appropriate time is the best
solution. This can be performed by various methods
including the oldest methods (nipple stimulation,
sexual activity, castor oil, enemas, stripping the
membranes, amniotomy, mechanical dilatation by
intracervical Foley’s catheter, posterior fornix
prostaglandin E2 and oral or vaginal PGE1). (3)
Insertion of intracervical Foley’s catheter is at
least as effective as PGE2 in the ripening process,
perhaps even more effective. (4) This process is
critical for successful induction of labor (5) in postdate
pregnancy. The cervix undergoes significant
biochemical changes which are controlled by certain
hormones (in particular PGE2) that play a role in
triggering uterine contractile activity. (6) The ripening
process usually begins prior to onset of labor
contraction and is necessary for cervical dilatation. (6)
*From the Department of Gynecology and Obstetrics, Prince Rashid Ben Al-Hassan Hospital (PRHH), Irbid-Jordan
Correspondence should be addressed to Dr. N. Al-Ibraheem (PRHH), Irbid-Jordan.
Manuscript Received March 13, 2006. Accepted September 30, 2006.
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Table I. Demographic characteristics of the study groups
Characteristics Group I Group II Significance
Mean Maternal Age (years) 25.3±5.2 27.2±4.5 NS
Mean Gestational Age (weeks) 41.5±0.3 41.2±0.2 NS
Primigravida 50 50 NS
Multigravida 50 50 NS
NS: not significant
Table II. Induction outcomes of the study groups
Outcome Group I Group II Significance
Mean cervical ripening time (hours) 16.2±4.3 14.1±3.5 NS
Number of pregnant women with Bishop Score >7 88 92 NS
Number of primigravida with Bishop Score >7(%) 46(92) 47(94) NS
Number of multigravida with Bishop Score >7(%) 42(84) 45(90) NS
Since post-date pregnancy is one of the commonest
indication for induction of labor (6,7) this process
should be considered when it is felt that the benefits
of vaginal delivery outweigh the potential maternal
and fetal risks of induction. There is clinical
evidence which shows that the appropriate
utilization of mechanical methods for pre-induction
cervical ripening is safe, not expensive, and with a
similar success rate to that of intravaginal PGE2.
The most commonly used mechanical method is the
intracervical Foley’s catheter. (7)
In this study, we compare the efficiency, safety
and side effects of intracervical Foley’s catheter
versus PGE2 suppositories for cervical ripening in
post-date pregnancy.
Methods
This study was conducted on 200 women at Prince
Rashed Military Hospital in the North of Jordan
between October 2004 and October 2005. All were
post-date of at least one week. This was chosen
since perinatal morbidity and mortality did not
increase appreciably between 40-41 weeks of
gestation, however several complications were
associated with longer gestation. (8)
Women whose fetuses were 41 weeks of
gestational age or above measured according to
accurate last menstrual period and had closed or
nearly closed cervix, excluding those who were
lactating or had contraindications to either Foley’s
catheter (spontaneous rupture of membranes,
antepartum bleeding) and PGE2 (bronchial asthma,
PGE2 allergy) were included in the study. The
pregnant women were divided in two groups.
Group I (n=100) had an intracervical Foley’s
catheter inserted. Group II (n=100) had posterior
fornix PGE2 suppositories inserted six hours apart.
In this study, patients in Group I had an 18 F
balloon – tipped Foley’s catheter inserted through
the cervical canal beyond the internal os under direct
vision using sterile technique (bivalve speculum,
two sponge forceps, Foley’s catheter) after washing
the vagina and vulva with Betadine solution. An
intravenous prophylactic antibiotic was given
(Cephalothin one gram single dose). A Foley’s
catheter was inflated with 50cc of normal saline
solution and placed under traction by fixation to the
patients’ thigh using a cord clamp and adhesive
tape. This would increase the release of
prostaglandin from the cervix. (9) The Foley’s
catheter remained for 24 hours and was deflated
after that if it was not spontaneously expelled. The
pregnant women underwent external fetal heart rate
monitoring for one hour, then were allowed to
ambulate and were monitored regularly.
Women who were subjected to the posterior
fornix PGE2 were given 3mg suppositories six
hours apart over 24 hours for three doses under
aseptic technique and were advised to remain in bed
for at least two hours after each dose with
continuous fetal heart monitoring. Before the next
dose, patients were evaluated for cervical dilatation
and 100mg Pethidine intramuscularly was given
according to the strength of contraction. Pregnant
women who did not have favorable cervix (Bishop
score 7 within 24 hours (10) after which
artificial rupture of membranes was performed and
labor was induced by intravenous Syntocinone
infusion. After a successful trial, pregnant women
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Table III. Modified Bishop scores in the study groups
Score Dilatation (cm) Effacement (%) Station ³ Position of cervix
0 Closed 0- 30 -3 Posterior
1 1-2 40- 50 -2 Midposition
2 3-4 60-70 -1-0 Anterior
3 ≥5 ≥ 80 +1-+2 ------
Table IV. Side effects in the study groups
Symptoms Group I Group II Significance
Nausea 1 4 NS
Vomiting 2 3 NS
Diarrhea 1 2 NS
Fever 3 2 NS
Discomfort 3 1 NS
NS: Not significant
were examined for any side effects including
maternal fever, vaginal bleeding, hypertonic uterine
contraction, and nausea and vomiting. P0.5). The number of patients with ripened cervix
was almost similar in both groups (88% versus 92%
respectively) as shown in Table II, ripened cervix
was considered as Bishop score >7, the remaining
patients were given trial of cervical sweeping and
others underwent CS for failed induction.
Side effects like nausea, vomiting, diarrhea and
fever were similar and minimal in both groups
(Table IV). The most common side effect was mild
discomfort during the procedure in the first group
and nausea in the second group, no case of uterine
rupture was recorded, although three cases of
previous scar were included in first group, patients
who were in need for analgesia in form of
intramuscular Pethidine were higher in the second
group. We also found that Foley’s catheters were
cost effective when used for same purpose which is
an important issue in medical therapy for the
patients and medical staff. In our study, the Foley’s
catheter is relatively inexpensive (about 2,5 JD or
3.6 US dollars compared to 20 JD or 28.4 US dollars
for PGE2 suppositories).
The success rate of intracervical Foley’s catheter
was higher in primigravidae in comparison with
multigravidae (92% versus 84%) while it was
almost the same regarding prostaglandin E2 (90%,
94%) respectively as shown in Table II. Most
patients in group II needed at least two PGE2
suppositories.
Discussion
Few previous studies recommended use of Foley’s
catheter with extra-amniotic corticosteroids infusion
to increase its efficacy and shorten inductiondelivery
time. (11) It is generally accepted that
antepartum interventions are indicated in the
management of prolonged pregnancy. (12) This can be
performed by various methods, the most popular are
to use either intracervical Foley’s catheter or PGE2
suppositories, there have been theoretic concern
regarding the introduction of infection with the use
of Foley’s catheter, but this can be ignored by using
aseptic technique as noted by a previous study. (12)
The other concern is uterine hyperstimulation with
the use of PGE2 suppositories which can be
minimized by using continuous fetal heart and
uterine contraction monitoring for at least two hours
after each PGE2 insertion as mentioned previously.
Numerous studies compared these two methods
and proved to be effective. St Onge and Connors
reported that for preinduction cervical ripening there
is no difference in the efficacy between an
intracervical Foley’s catheter and vaginal PGE2
suppositories. (12) Al Taani’s study concluded that for
grandmultiparas, PGE2 vaginal tablets may be
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preferable for cervical ripening as well as for labour
induction. (6) In this study, we compared two
methods (intracervical Foley’s catheter versus
posterior fornix PGE2) and found that both methods
were effective, safe, and with less side effects when
used for cervical ripening in post-date pregnancy, a
finding which was supported by other previous and
similar studies. (10,11,12)
The risk of uterine rupture with PGE2 use versus
spontaneous trial was 6.41 (13) and for this reason
women with previous scar were excluded from the
second group while Foley’s catheter can be used
safely in patients with previous scar without risk of
uterine rupture, (14) Some hospitals have discontinued
PGE2 use for all women with previous scar, PGE2
suppositories induce cervical ripening by collagen
breakdown and altering tissue hydration and
collagen binding.
Various studies have shown considerable variation
in induction delivery time ranging from 9-17.9 hours
and the incidence of CS was 16.67%. (14) These were
consistent with our study findings (cervical ripening
time 16.2 hours for group I, 14.1 hours for group II,
incidence of CS 12%, 8% respectively). In our
study, we observed that pregnant women with
Bishop Score 3-4 at beginning of the study respond
better to induction than those with closed thick
cervix and the induction delivery time was shorter.
The complications in our study were minimal and
treated successfully. No uterine rupture or cervical
laceration occurred. Since patients with previous
scar were excluded from the start, both methods of
labor induction in post-date pregnancy were
effective and successful with minimal adverse
effects which were comparable to other
studies. (12,13,14)
We conclude that intracervical Foley’s catheter
for labor induction in post-date pregnancy,
particularly in primigravida and patients with
previous scar, is a reasonable alternative to PGE2
suppositories, is reversible, easy to use, costeffective
and has minimal adverse effects.
References
1. Harman JH, Kim A. Current Trends in cervical
ripening and labor induction. Am Academy of
family physician 1999; 60: 477- 484.
2. Cunninham FG, MacDonald PC, Gant NF,
Leveno KJ, et al. Williams obstetrics textbook,
20 th edition, 1997; P. 430,827-837.
3. Crane J, St. Johns NF. SOGC clinical practice
guidelines, Induction of labour at term. J obstet .
gynaecol Can 2001; 23(8): 717-728.
4. Chamberlain G, Zonder L. Major indication for
induction of labour. BMJ 1999; 318(7): 995-998.
5. Khadem N, Khadivzadeh N. Comparison of the
efficacy of PGE2 suppositories and cervical Foley
catheter with pre-induction ripening of the cervix.
Iran J Med Sci 2003; 28(3): 119-122.
6. Al-Taani MI. Comparison of PGE2 tablets or
Foley catheter for labor induction in grand
multiparas. Eastern Mediterranean Health J 2004;
10(4): 547-553.
7. Ghezzi F, Massimo F, Raio L, et al. Extraamniotic
Foley catheter and PGE2 gel for cervical
ripening at term gestation. Eur J of Obst & Gyn
and Repord Boil 2001; 97(2): 183-187.
8. Wilkes PT, Galan H, Cowan BD. Postdate
Pregnancy, e-medicine, last updated: August 8,
2002.
9. Sciscione AC, McCullough H, Manley JS, et al.
A prospective randomized comparison of Foley
catheter insertion versus intracervical prostaglandin
E2 gel for preinduction cervical ripening. Am J of
Obstetric and gynecology 1999; 180(1): 55–60.
10. Mazhar SB, Sarwar S, Mahmud G. Induction of
labour, A randomized trial comparing PGE2
pessary, intra cervical Foley catheter and extraamniotic
saline infusion. J Surg 2000; 19(20): 12-
18.
11. Zafarghandi AS, Zafarghandi N, Baghaii N.
Foley catheter cervical ripening with extraamniotic
infusion of saline or corticosteroid: A
double-blind, Randomized controlled study. Acta
Medica Iranica 2004; 42(5): 338-342.
12. St Onge RD, Connors GT. Preinduction cervical
ripening: A comparison of intracervical
prostaglandin E2 gel versus the Foley catheter. Am
J Obstetric and Gynecology 1995; 172(2): 687–
690.
13. Ravasiax D, Woodx S, Pollard J. Uterine rupture
during induced trials of labour in women with a
previous C/S. Am J of Obstetrics and Gynecology.
2000; 2(182): 36-43.
14. Bujold E, Blackwell SC, Gauthier RJ. Cervical
ripening with Trans cervical Foley catheter and the
risk of uterine rupture. Obstetric& Gynecology
2004; 103: 18-23.
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