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McDonagh M, Skelly AC, Hermesch A, et al. Cervical Ripening in the Outpatient Setting [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Mar. (Comparative Effectiveness Review, No. 238.)

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Cervical Ripening in the Outpatient Setting [Internet].

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Figure 1 is the analytical framework for cervical ripening in the outpatient setting. The population of interest is term pregnant women undergoing cervical ripening as the first step in induction of labor, either medically indicated or elective. The interventions include Key Question 1: pharmacologic agents in outpatient versus inpatient settings; Key Question 2: mechanical methods in outpatient versus inpatient settings; Key Question 3: outpatient settings with pharmacologic agents versus mechanical methods; and Key Question 4: methods of fetal surveillance. Fetal harms include perinatal mortality, hypoxic-ischemic encephalopathy, seizure, infection, meconium aspiration syndrome, birth trauma, intracranial or subgaleal hemorrhage, need for respiratory support within 72 hours after birth, Apgar score ≤3 at 5 minutes, hypotension requiring vasopressor support, and umbilical cord gas < pH 7.0 or 7.10. Maternal harms include hemorrhage requiring transfusion, postpartum hemorrhage by mode (i.e., vaginal or cesarean delivery), uterine infection, placental abruption, uterine rupture, umbilical cord prolapse, and insufficient duration of time from admission to birth for GBS prophylaxis antibiotics administration. Effectiveness includes total time admission to vaginal delivery; total labor and delivery length of stay; cesarean delivery rate overall; vaginal delivery within 24 hours; failed induction rate defined as cesarean delivery in patient at <6 cm dilation excluding fetal distress (labor dystocia, failure to progress, etc.) or cesarean delivery in patient at <6 cm dilation for fetal distress; cervical assessment at time of admission (e.g., latent versus active phase, Bishop score, cervical dilation); and time from ROM to delivery. Key Question 3 includes breastfeeding, maternal mood, and mother-baby attachment.

Figure 1Analytic framework

GBS = Group B Streptococcus; KQ = Key Question; ROM = rupture of membrane

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