Labor induction is a common obstetrical intervention that has significantly increased in recent decades [1]. Induction of labor (IOL) is suggested when the benefits of delivery outweigh those of continuing the pregnancy for the mother or fetus [2,3]. These conditions include premature rupture of amniotic membranes, maternal medical complications, chorioamnionitis, gestational age of 41 completed weeks or more, vaginal bleeding, fetal growth restriction, fetal death, and other complications [4,5]. The success of labor induction relies on the favorability of the cervix [6]. Prior to induction, the Bishop score (cervical position, consistency, effacement, length, and station of the presenting part) is evaluated. Bishop score of ≤6 is classified as an unfavorable cervix [7,8].

The available methods used for cervical ripening include synthetic prostaglandins (oral or vaginal) and balloon catheter [9]. These two options appear to have similar efficacy [10]. However, the balloon catheter is associated with lower rates of uterine hyperstimulation syndrome and fetal heart rate changes [11]. The mechanisms of action of the balloon catheter for cervical ripening include increased secretion of prostaglandins and oxytocin, as well as direct dilatation of the cervical canal [12]. Two types of balloon catheters are commonly used: Foley catheter (single balloon) and double-balloon catheter [13]. A recent meta-analysis revealed that the efficacy and safety between double balloon and Foley catheters were similar [14].

The Foley catheter is most commonly placed under direct cervical visualization during a sterile speculum examination [15]. Alternatively, the catheter can be placed during a digital cervical examination, which is an option for cases where speculum examination is not feasible [16]. Research comparing the two methods of Foley catheter insertion for labor induction has shown mixed results. A notable randomized controlled trial indicated that inserting the Foley catheter digitally during labor induction was significantly faster and less painful, resulting in greater satisfaction with the delivery process than when inserted with a speculum [17]. Conversely, another study found no significant differences in pain levels, duration of catheter insertion, or maternal satisfaction between the two methods [18].

Given these varying outcomes, we plan to carry out a systematic review and meta-analysis. This study will compare digital and speculum-guided Foley catheter placement for inducing labor in women with an unripe cervix, focusing on aspects such as pain levels, duration of insertion, effectiveness in cervical ripening, and maternal satisfaction. This information will be valuable for healthcare providers in determining the best approach to ensure a positive labor experience for their patients.