The goal of this randomized controlled trial is to examine the efficacy of combining castor oil ingestion with extra-amniotic single balloon catheter for cervical ripening on time from induction to delivery in multiparous women. The main question it aims to answer are: Does the addition of the use of castor oil to extra-amniotic single balloon reduce the time until birth? Does the addition of the castor oil affect other perinatal outcomes during childbirth? Are the side effects of the castor tolerated by the mothers? Participants will be randomly divided into 2 groups: the study group will drink a mixture of 60 ml of castor oil mixed with 140 ml of orange juice. Thirty minutes later, extra-amniotic single balloon catheter will be inserted above the internal cervical os and filled with 60 mL of normal saline. In the control group, the catheter will be inserted into cervical canal without ingestion of castor oil.
The rate of labor induction has increased up to 25.7% in 2018 for several demographic and obstetric reasons. Various methods are used to induce labor worldwide, including natural, mechanical and pharmacological agents. of all methods balloon catheters were proven to cause fewer adverse perinatal events. Though induction is considered a safe and effective procedure, it may lead to a prolonged labor which is associated with complications such postpartum hemorrhage, infection, and operative delivery. Based on these data several studies have examined the combinations of balloon catheters with other pharmacological agents on labor durations. The results were inconsistent, and several reports showed that the combination reduced significantly the length of labor. Nevertheless, pharmacological agents may be associated with adverse events including uterine hyperstimulation, placental abruption, and postpartum hemorrhage, though the overall risk is small. Castor oil, extracted from the seeds of Ricinus communis plant, is a natural effective substance for induction of labor. it's considered a safe and inexpensive though the exact mechanism by which it induces labor is still unclear. Our hypothesis suggests that ingestion of castor oil combined with the balloon catheter will shorten the time to delivery. In order to show a reduction by 2 hours, a sample size of 98 in each group will be needed assuming 80% power and a two-tailed alpha of 5%. Since the success rate of vaginal delivery was nearly 95% according to the same report, the sample size was calculated to 103 women in each group. Additional 5% are planned to be recruited to account for trial drop out for any reason, yielding a total final sample size of 108 women in each group (216 in both groups).
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
SINGLE
Enrollment
216
In both groups the balloon catheter will be removed at nearly 12 hours after insertion. Following removal, artificial rupture of the membranes will be performed as long as it is safe with regards to fetal head position. Oxytocin infusion will be commenced at once if contraction has not begun spontaneously (2 to 3 regular uterine contractions per 10 minutes). Continuous electronic fetal monitoring will be used throughout labor. Labor will be managed by the attending obstetricians and midwives. Labor progress abnormalities will be diagnosed and managed according to the department protocol based on the recommendations of the American College of Obstetricians and Gynecologists.
Holy Family hospital, Nazareth
Nazareth, Israel
RECRUITINGtime to delivery
Time from catheter insertion to vaginal delivery
Time frame: 48 hours
balloon expulsion time
The time until balloon was spontaneously expelled
Time frame: 12 hours after insertion
Bishop score at catheter expulsion
Bishop score after removal of the catheter where a high score (above 7) indicates a better outcome
Time frame: 12 hours
Number of women that will have non-vertex presentation after removal of the catheter
The insertion of a balloon may lead to a change in the presenting part of the fetus. A change to a non-vertex presentation is carried as an undesired outcome.
Time frame: 48 hours
Duration of active phase
Duration of the time from 6 cm cervical dilatation to 10 cm cervical dilatation
Time frame: 4 hours
Duration of second stage
the time from 10 cm cervical dilatation until the delivery of the baby
Time frame: 4 hours
Mode of delivery
Whether the birth was a normal spontaneous birth, operative vaginal birth or a cesarean section
Time frame: 48 hours
Indications for cesarean or vacuum deliveries
Was the reason for operative vaginal delivery or cesarean delivery due to non progress labor, fetal status, or a combination of both?
Time frame: 48 hours
Number of patients that will have intrapartum fever ≥ 38 °C
Intrapartum fever ≥ 38 °C
Time frame: 48 hours
Number of patients that will require use of intrapartum use of antibiotic treatment
Number of patients that will require use of intrapartum use of antibiotic treatment due to intrapartum infection.
Time frame: 48 hours
Number of Participants with that will develop clinical signs of chorioamnionitis.
Clinical signs of chorioamnionitis includes abdominal tenderness, abnormal discharge, intrapartum fever, and tachycardia
Time frame: 48 hours
Number of Participants with that will develop 3rd and 4th degrees perineal lacerations.
Obstetric anal sphincter injury
Time frame: 48 hours
Number of Participants with develop postpartum hemorrhage.
early postpartum hemorrhage (PPH)
Time frame: 48 hours
Number of Participants with need blood transfusion.
PPH that will require blood transfusion.
Time frame: 72 hours
Number of women that will have side effects related to castor oil use
nausea, vomiting, uterine hyperstimulation\> the 5 contractions: 10 minutes
Time frame: 48 hours
Oxytocin dosage
A higher oxytocin dosage indicates lesser outcome.
Time frame: 48 hours
Number of participants with Umbilical Cord prolapse.
Umbilical cord prolapse is when the umbilical cord exits the cervical os before the fetal presenting part that may result in fetal hypoxia.
Time frame: 48 hours
Number of neonates that will have Apgar score (range 0 to 10) <7.
APGAR\< 7 after 1 and 5 minutes where lower scores mean a worse outcome.
Time frame: 48 hours
number of women with cord artery pH <7.1
pH taken from umbilical artery (lower pH means worse outcome)
Time frame: 48 hours
Neonatal birthweight
Neonatal birthweight
Time frame: 48 hours
Number of neonates with Neonatal fever ≥ 38 °C
Neonatal fever \> 38 °C
Time frame: 72 hours
The number of neonates that will develop neonatal sepsis.
Diagnosis of neonatal sepsis based on clinical signs of sepsis and positive cultures.
Time frame: 72 hours
The number of neonates that will require antibiotic treatment.
Need for antibiotic treatment
Time frame: 72 hours
number of neonates with any neonatal complications
respiratory distress syndrome, transient tachypnea of newborn, intracranial hemorrhage, intraventricular hemorrhage, seizures, Meconium aspiration syndrome ,Hypoxic ischemic encephalopathy
Time frame: 48 hours
The number of neonates that will Admit to neonatal intensive care unit (NICU)
Neonatal admission to NICU
Time frame: 30 days
Length of stay in NICU.
Neonatal length of stay in NICU
Time frame: 30 days
Number of neonatal death
neonatal death
Time frame: 30 days
Maternal hemoglobin level after delivery.
higher level of Hemoglobin indicates better outcome.
Time frame: 48 hours
Number of participants that will require postpartum hysterectomy.
Maternal hysterectomy
Time frame: 72 hours following delivery
Number of participants that will require postpartum laparotomy.
Number of participants that will require postpartum laparotomy after vaginal delivery or re-laparotomy after cesarean section.
Time frame: 72 hours following delivery.
Number of women that will develop postpartum complications
endometritis
Time frame: 72 hours following the delivery.
The length of stay from birth to discharge home.
The length of stay in days from birth to discharge home.
Time frame: up to 10 days
Maternal satisfaction
1 = Very dissatisfied, 10 = Very satisfied
Time frame: up to 10 days after delivery
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