High Volume Foleys Increasing Vaginal Birth Pilot Trial

It is currently unknown if there is a way to decrease the risk of cesarean delivery when undergoing cervical ripening and induction of labour. Some research suggests a Foley catheter placed through the cervix and filled to 80cc may decrease this risk. We wish to run a large scale trial to see if Foleys filled to 80cc decrease the risk of Cesarean section compared to the commonly used medication for cervical ripening, prostaglandins. Before we can undertake a large trial, we need to do a pilot to see if women will agree to participate in this type of study. As well, a pilot will help with trouble shooting prior to a large trail, to improve the chances of successfully answering this clinically important question.

Background:

Approximately 1/3 of first-time mothers (nulliparous women) undergoing induction of labour deliver by cesarean. Cesarean delivery can have negative consequences to the initial and subsequent pregnancies. Women who have a cesarean in their first pregnancy are more likely to have a cesarean in their following pregnancies and this group is the largest contributor to the overall cesarean delivery rate. Therefore, targeting interventions that prevent cesareans in nulliparous women undergoing induction of labour will have a substantial impact on the overall cesarean delivery rate.

Adequate ripening or preparing the cervix before induction has been found to decrease the risk of cesarean. This can be done by a variety of methods, such as prostaglandins (a chemical messenger) or a Foley filled to a moderate volume of fluid. These methods have been found to be equal regarding the risk of cesarean delivery. However, a meta-analysis by our team discovered a trend towards a decreased risk of cesarean when cervical ripening is undertaken with Foleys filled to a high volume of fluid (80cc) compared to those filled to a low volume (30cc).Most Canadian Obstetricians use prostaglandins for cervical ripening. To assess if 80cc Foleys result in a lower risk of cesarean, they need to be compared to the Canadian standard of prostaglandins. Therefore a randomized controlled trial is required.

The Greater-Toronto-Area Obstetric (GTA-OB) Network is a group of hospitals committed to facilitating research and will be the setting for the planned large scale trial. The large scale trial will aim to demonstrate a difference in the rate of cesarean from 38% to 31%, which will require the enrollment of 1442 women. It has been estimated that there are 5,437 women who will meet entry criteria in the GTA-OB network each year, if ½ are approached, 20% will need to consent to complete the trial in 3 years. Therefore, this pilot study will determine if this recruitment rate is potentially achievable and will inform design strategies to ensure its success.

The discovery of a simple, non- pharmacological, cost effective manner of cervical ripening that decreases the risk of cesarean would change clinical practice and significantly improve safety for the 33,000 Canadian women and their babies who undergo cervical ripening each year. This pilot trial is a crucial step towards this discovery.

Objectives:

The primary objective for this pilot trial is to determine the probability that an eligible woman will agree to be randomized into the trial comparing 80cc Foleys to prostaglandins for cervical ripening. This study aims to assess if it is possible to obtain a recruitment rate of 20%.

The secondary objective will be a systematic evaluation of the pilot trial process to guide full-scale study design.

Eligibility Criteria:
Inclusion Criteria:

* Nulliparous women 37 weeks and 0 days to 41 weeks and 6 days gestational age (term) requiring cervical ripening
* Health care provider feels it is possible to administer either method of cervical ripening.
* Bishop score of 6 or less
* Live, singleton, cephalic fetus
* Availability of personnel to consent and randomize participants

Exclusion Criteria:

* Non-viable fetus
* Contraindication to cervical ripening, labour induction or labour
* Prior attempt at induction of labour in this pregnancy
* Spontaneous rupture of fetal membranes
* Evidence of labour or regular uterine contractions
* Lack of consent