Labor is induced to stimulate contractions of the uterus in an effort to have a vaginal birth. Labor induction may be recommended if the health of the mother or fetus is at risk. In special situations, labor is induced for nonmedical reasons, such as living far away from the hospital. This is called elective induction. Elective induction should not occur before 39 weeks of pregnancy. To prepare for labor and delivery, the cervix begins to soften ripen , thin out, and open.
These changes usually start a few weeks before labor begins. Health care professionals use the Bishop score to rate the readiness of the cervix for labor. With this scoring system, a number ranging from 0—13 is given to rate the condition of the cervix. A Bishop score of less than 6 means that your cervix may not be ready for labor. Ripening the cervix is a process that helps the cervix soften and thin out in preparation for labor. Medications or devices may be used to soften the cervix so it will stretch dilate for labor.
Ripening of the cervix can be done with prostaglandins or with special devices. Prostaglandins are drugs that can be used to ripen the cervix. They are forms of chemicals produced naturally by the body. These drugs can be inserted into the vagina or taken by mouth. Some of these drugs are not used in women who have had a previous cesarean delivery or other uterine surgery to avoid increasing the possible risk of uterine rupture tearing.
Laminaria a substance that absorbs water can be inserted to expand the cervix. A catheter small tube with an inflatable balloon on the end also can be inserted to widen the cervix. Stripping the membranes is a way to induce labor. The health care professional sweeps a gloved finger over the thin membranes that connect the amniotic sac to the wall of your uterus. The criteria for inclusion and exclusion of studies for the systematic review will be based on the Key Questions and on the specific criteria listed in Table 1.
Outcomes prioritized as primary outcomes for this systematic review are footnoted and listed in bold below. If evidence on benefits from RCTs is inconclusive for a key question or subquestion, comparative observational studies may be considered with preference given to those which control for confounding. We will make this determination based on strength of evidence ratings of insufficient, where there is typically only one study, possibly two small studies for a prioritized primary outcome.
In this case we will conduct separate searches to identify cohort studies for that specific question and outcome. In the case where a systematic review is recent enough to cover the majority of the available evidence for a given question or subquestion, and evaluates a cohesive group of interventions, outcomes and time frames within the scope for this review, we will include the review as the primary evidence. If there are more than two studies published since the review, our preference will be to use the review only to identify eligible studies for this review.
Non-English Language Studies : We will restrict to English-language articles, but will review English language abstracts of non-English language articles to identify studies that would otherwise meet inclusion criteria, in order to assess for the likelihood of language bias.
Publication Date Range : Searches will be conducted across all key questions, with study dates reaching back to the inception of each database. Searches will be deduplicated and screened for inclusion. Searches will be updated while the draft report is open to public comment, to capture any new publications. Literature identified during the updated search will be assessed by following the same process of dual review as all other studies considered for inclusion in the report. If any pertinent new literature is identified for inclusion in the report, it will be incorporated before the final submission of the report.
Supplemental Evidence and Data for Systematic review SEADS : Manufacturers and other stakeholders of included drugs and devices will be informed about submitting information relevant to this review using a Federal Register notification.
A portal about the opportunity to submit information will be made available on the EHC website. Hand Searching : Reference lists of included articles will also be reviewed for includable studies.
In accordance with the Methods Guide for Effectiveness and Comparative Effectiveness Review , 18 we will use the pre-established criteria above to screen citations titles and abstracts identified through our searches or SEAD submissions to determine eligibility for full-text review. We will begin by screening randomized controlled trials and noting any potential observational studies for include. Observational studies will be screened if evidence from RCTs alone is insufficient to draw conclusions.
To ensure accuracy, any citation deemed not relevant for full-text review will be reviewed by a second researcher. All citations deemed potentially eligible for inclusion by at least one of the reviewers will be retrieved for full-text screening. Each full-text article will be independently reviewed for eligibility by two team members.
Any disagreements will be resolved by consensus. A record of studies excluded at the full-text level with reasons for exclusion will be maintained. After studies are selected for inclusion, data will be abstracted into categories that include but are not limited to: study design, year, setting, country, sample size, eligibility criteria, population and clinical characteristics, intervention characteristics, funding, and results relevant to each Key Question as outlined in the previous PICOTS section.
Information that will be abstracted that is relevant for assessing applicability will include the description of the source of potential study participants, number of patients randomized relative to the number of patients enrolled, and characteristics of the population, intervention including process details such as monitoring prior to discharge to the outpatient setting, timing or factors determining re-admission, etc.
All study data will be verified for accuracy and completeness by a second team member. Preventive Services Task Force. Any systematic review with multiple flaws, rated poor quality will not be included as primary evidence. Good-quality studies include clear descriptions of the population, setting, interventions, and comparison groups; a valid method for allocation of patients to treatment; low dropout rates and clear reporting of dropouts; appropriate means for preventing bias; and appropriate measurement of outcomes.
These studies may not meet all the criteria for a rating of good quality, but no flaw is likely to cause major bias. The study may be missing information, making it difficult to assess limitations and potential problems. The fair-quality category is broad, and studies with this rating will vary in their strengths and weaknesses. The results of some fair-quality studies are likely to be valid, while others may be only possibly valid.
The results of these studies will be least as likely to reflect flaws in the study design as the true difference between the compared interventions.
We will construct evidence tables identifying the study characteristics as discussed above , results of interest, and quality ratings for all included studies, and summary tables to highlight the main findings. We will review and highlight studies by using a hierarchy-of-evidence approach, where the best evidence is the focus of our synthesis for each key question. Data will be qualitatively summarized in tables, using ranges and descriptive analysis and interpretation of the results.
Meta-analyses, using random effects models, will be conducted to summarize data and obtain more precise estimates where there are at least three studies reporting outcomes that are homogeneous enough to provide a meaningful combined estimate. Study designs will be pooled separately RCTs vs.
Data from any included high-quality systematic reviews will be handled individually and not pooled. Meta-analysis results for similar outcomes across study types will be compared and discussed where applicable, see section below for evaluation of bodies of evidence with mixed study designs. The feasibility of a quantitative synthesis will depend on the number and completeness of reported outcomes and a lack of heterogeneity among the reported results. To determine whether meta-analysis could be meaningfully performed, we will consider the quality of the studies and the heterogeneity among studies in design, patient population, interventions, and outcomes, and may conduct sensitivity analyses.
The Key Questions are designed to assess the comparative effectiveness and harms by patient demographics, patient characteristics such as gestational age, parity, uncomplicated pregnancy, prior cesarean delivery, etc. We will not exclude studies rated as being poor in quality a priori, but poor-quality studies will be considered to be less reliable than higher quality studies when synthesizing the evidence, particularly if discrepancies between studies are present. Sensitivity analyses will be conducted with and without poor quality studies where possible.
Meta-regression may be conducted to explore statistical heterogeneity using additional variables for methodological or other characteristics e. Publication bias will be assessed using funnel plots and statistical methods when there are at least 10 studies that can be combined in meta-analysis.
Results will be presented as structured by the Key Questions, and any prioritized outcomes will be presented first.
Outcomes to be assessed for strength of evidence were prioritized based on input from the Technical Expert Panel, these are footnoted and listed in bold in the PICOTS table above.
Based on this prioritized list, the strength of evidence for comparison-outcome pairs within each Key Question will be initially assessed by one researcher for each clinical outcome see PICOTS by using the approach described in the Methods Guide for Effectiveness and Comparative Effectiveness Review.
The strength of evidence will be assigned an overall grade of high, moderate, low, or insufficient according to a four-level scale by evaluating and weighing the combined results of the above domains:.
For observational study evidence, the strength starts at moderate for harms outcomes, and low for benefit outcomes. In cases where both RCTs and observational studies are included for a given intervention-outcome pair, we follow the additional guidance on how to weight RCTs over observational studies, how to assess consistency across the two bodies of evidence, and how to come to a final rating.
Applicability addresses the extent to which outcomes associated with an intervention are likely to be similar across the individual studies, bodies of evidence, and individual patients in clinical practice based on different populations, interventions, comparisons, and outcome measures in various settings. Inclusion of only very low-risk pregnancies also reduces applicability to women with moderate risk, who may be candidates for CR depending on the specific risk, method of CR, and monitoring available.
Factors that may affect applicability which we have identified a priori include narrowly defined eligibility criteria and resulting characteristics of included patients, such as demographics including maternal age, gestational age, race and ethnicity , pregnancy risk factors such as diabetes, high blood pressure, pre-eclampsia , obstetric factors e.
Intervention-related factors that may limit applicability include dose and re-administration schedule variation with medications, and balloon-fill volume variation with catheters. In this review, the setting is the key comparison — inpatient versus outpatient — but other features of setting are expected to affect applicability of the findings.
These include provider type e. We will use this information to assess the situations in which the evidence is most relevant and to evaluate applicability to real-world clinical practice in typical U. The team will also identify any information relevant to this question opportunistically, while reviewing comprehensive literature searches for key questions. The information on the contextual questions will be summarized in the introduction of the report, and discussed in relation to the systematic review evidence on the Key Questions in the Discussion sections.
This input is intended to ensure that the key questions are specific and relevant. Key Informants are the end-users of research; they can include patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions.
Within the EPC program, the Key Informant role is to provide input into the decisional dilemmas and help keep the focus on Key Questions that will inform health care decisions.
The EPC solicits input from Key Informants when developing questions for the systematic review or when identifying high priority research gaps and needed new research. Key Informants are not involved in analyzing the evidence or writing the report. They do not review the report, except as given the opportunity to do so through the peer or public review mechanism. Because of their role as end-users, individuals are invited to serve as Key Informants and those who present with potential conflicts may be retained.
Technical Experts constitute a multi-disciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes and identify particular studies or databases to search.
The Technical Expert Panel is selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicting opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, study questions, design, and methodological approaches do not necessarily represent the views of individual technical and content experts.
More Related News. Follow Medindia. By using our site, you acknowledge that you have read and understand our Cookie Policy , Privacy Policy , and our Terms of Use. What is Cervical Ripening? Written by Dr. Medically Reviewed by Dr. Last Updated on Jul 06, Noscaphene Noscapine. Iron Intake Calculator. Blood - Sugar Chart. Breech Presentation and Delivery. Breech birth or presentation is delivery of the fetus in a bottom or foot-first position.
Causes of breech presentation include premature labor, uterine malformations and fetal abnormalities. Cervical Cancer - Incidence. Cervical cancer is the second most common cancer among women and is the primary cause of cancer-related deaths in developing countries.
The cervix is the lower most part of the uterus and is made up of strong muscles. It also provides support to the uterus due to attachment of muscles from the pelvic bone.
Female Reproductive System - Animation. Interactive section of Medindia gives details regarding Female reproductive system showing how the sperm fetilize the eggs. Abortion is one of the most controversial topics in medicine. Legalization of abortion in several countries was necessary to prevent complications and deaths of women due to illegal abortions.
Childbirth is one of the most marvelous and memorable segment in a woman's life that calls for celebration. Knowledge about labor and delivery can ease unnecessary fear, ensuring a unique experience.
Dilatation and Curettage - Animation. Dilatation 'D' is a widening of the cervix and Curettage 'C' is the scraping of the contents of the uterus. Researchers at UT Southwestern Medical Center have found that cervical ripening that instigates preterm labor is distinct from what happens at the onset of normal term labor. Inducing labor for women after 37 weeks of pregnancy can help reduce the perinatal mortality without increasing caesarean section rates. View all.
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