Pain and satisfaction in women induced by vaginal dinoprostone, double balloon catheter and oral misoprostol

In France, the term of a pregnancy arbitrarily corresponds to the period from 37+0 to 41+6 weeks of gestation (WG) [1]. Although the majority of women go into labor spontaneously, some need to be induced during this period or before term. Labor induction concerns 22% of deliveries in France [2], which is comparable to the figures found in the United States and England [3]. In 2020 the indications for labor induction are justified by a risk-benefit balance at maternal or fetal level. The main maternal indications are preeclampsia, therapeutic windows for anticoagulants, severe medical conditions aggravated by pregnancy, diabetes.... The main fetal indications are over term, premature rupture of membranes, gestational cholestasis, and intrauterine growth retardation [4].

To date, several methods of induction exist. The choice is based on the evaluation of the Bishop score calculates with dilatation, consistency, position, effacement of the cervix and height of presentation. A cervix is said to be unfavorable if the score is less than or equal to 6–7 and requires a stage of cervical ripening [4]. Cervical ripening is based on mechanical (balloon or Foley) or pharmacological (prostaglandins delivered by gel or intra-vaginal pad (Dinoprostone) or orally (Misoprostol)) methods, each of which has its own contraindications. Common to both methods are the general contraindications to vaginal delivery such as overlying placenta previa, transverse presentation, active genital herpes infections and others [5]. The use of prostaglandins is widely preferred in France (92% of cervical ripening methods) [2]. However, when faced with a scarred uterus, the mechanical balloon method remains the only one that can be used in these conditions of contraindications to prostaglandins. The contraindications to balloons are essentially the contraindications to vaginal delivery [6].

Although the experience of a first birth has been known to have an impact on the occurrence of a future pregnancy [7] and one of the main fears of childbirth is pain [8], there are only a few recent studies in the literature on the experience of pain or the overall satisfaction of women who have undergone labor induction.

The experience of childbirth in the case of labor induction is considered to be less satisfying than spontaneous labor [3,9]. Few studies have investigated the women overall satisfaction induced by double balloon catheter versus oral or vaginal prostaglandins [10,11] which appears to be identical between the methods. However, one of these two studies noted discomfort with the sensation of balloon pressure [5]. Women induced by balloon were more likely to choose a different method of induction for future pregnancies [11,12]. In our experience, intracervical balloon induction is generally well tolerated but is frequently associated with pain and acute anxiety during insertion. Few studies in the literature have looked at pain during cervical ripening device insertion. Of these, the study by Pennel et al. found significantly more pain, as quantified by a visual analogue scale, during insertion of a double balloon catheter compared to prostaglandin gel [12]. This explains why this method, which is known to be painful, is mainly used when there is a contraindication to prostaglandins. We did not find any study that compared the three methods of induction.

The primary objective of our study was to evaluate the pain experience of women induced by intravaginal dinoprostone device (Propess®), oral misoprostol (Angusta®) or double balloon catheter (Cook®). The secondary objectives were [1] to evaluate the pain experience at the time of device insertion and in the two hours preceding removal or passage to the delivery room; [2] to compare overall satisfaction according to the modes of induction; and [3] to evaluate the impact on the choice of a technique at a later date and on a new pregnancy.

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