Nitric oxide donors for cervical ripening and induction of labour

Kelly AJ, Munson C, Minden L

Published Online:

June 15, 2011

Sometimes it is necessary to bring on labour artificially in the third trimester because of safety concerns for the mother or her baby. Most commonly used cervical ripening or induction agents also cause uterine activity or contraction, which requires close monitoring of mother and baby within a hospital environment. Nitric oxide (NO) donor agents such as isosorbide mononitrate, nitroglycerin and sodium nitroprusside are thought to bring on ripening of the cervix (neck of the womb) without producing contractions and could be used in an outpatient setting. However, there are still very limited data to support their use. There was no evidence from four trials to suggest that NO donors were superior to placebo. The rate of caesarean section was similar if NO donors were used or placebo. Nor were NO donors more effective in bringing on labour than other more traditional agents such as vaginal prostaglandins (three trials). Vaginal misoprostol appeared to be more effective than NO donors for induction of labour (three trials). NO donors were associated with an increase in the rates of headache and nausea. This review included 10 studies involving 1891 women.

Abstract (click to read)

Background:

Sometimes it is necessary to bring on labour artificially because of safety concerns for the mother or baby. This review is one of a series of reviews of methods of labour induction using a standardised protocol.

Induction of labour occurs in approximately 20% of pregnancies in the UK. The ideal agent for induction of labour would induce cervical ripening without causing uterine contractions. Currently most commonly used cervical ripening or induction agents result in uterine activity or contractions, or both. Cervical ripening without uterine contractility could occur safely in an outpatient setting and it may be expected that this would result in greater maternal satisfaction and lower costs.

Objectives:

To determine the effects of nitric oxide (NO) donors for third trimester cervical ripening or induction of labour, in comparison with placebo or no treatment or other treatments from a predefined hierarchy.

Search strategy:

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2010) and the reference lists of trial reports and reviews.

Selection criteria:

Clinical trials comparing NO donors for cervical ripening or labour induction to other methods listed above it on a predefined list of methods of labour induction. The trials include some form of random allocation to either group; and report one or more of the prestated outcomes. NO donors (isosorbide mononitrate, nitroglycerin and sodium nitroprusside) are compared to other methods listed above it on a predefined list of methods of labour induction.

Data collection and analysis:

This review is part of a series of reviews focusing on methods of induction of labour. Three review authors independently assessed trials for inclusion, assessed risk of bias and extracted data.

Main results:

We considered 19 trials; we included 10 (including a total of 1889 women) trials, excluded eight trials and one trial report is awaiting classification. Included studies compared NO donors to placebo, vaginal prostaglandin E2, intracervical PGE2 and vaginal misoprostol. All included studies were of a generally high standard with a low risk of bias.

There are very limited data available to compare nitric oxide donors to any other induction agent. There is no evidence of any difference between any of the prespecified outcomes when comparing NO donors to other induction agents, with the exception of an increase in maternal side effects.

Authors' conclusions:

NO donors do not appear currently to be a useful tool in the process of induction of labour. More studies are required to examine how NO donors may work alongside established induction of labour protocols, especially those based in outpatient settings.

This record should be cited as:

Kelly AJ, Munson C, Minden L. Nitric oxide donors for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD006901. DOI: 10.1002/14651858.CD006901.pub2

Assessed as up to date:

May 4, 2011

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Primary Review Group:

Pregnancy and Childbirth Group

Health topics:

Pregnancy & childbirth > Induction of labour > Techniques

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Nitric oxide donors for cervical ripening and induction of labour

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