DOI: 10.1111/j.1471-0528.2011.02905.

x
Systematic review
www.bjog.org

Intravaginal misoprostol versus Foley catheter

for labour induction: a meta-analysis
NS Fox,a,b DH Saltzman,b,c AS Roman,b CK Klauser,a,b E Moshier,d A Rebarbera,b
a
Maternal Fetal Medicine Associates, PLLC, b Department of Obstetrics, Gynecology, and Reproductive Science, c Carnegie Imaging for
Women, PLLC, and the d Department of Community and Preventative Medicine, Mount Sinai School of Medicine, New York, USA
Correspondence: NS Fox, Maternal Fetal Medicine Associates, PLLC, 70 East 90th Street, New York, NY 10128, USA. Email nfox@mfmnyc.com

Accepted 22 December 2010. Published Online 18 February 2011.

Background There are a number of agents used for cervical
ripening prior to the induction of labour. Two commonly used
agents are intravaginal misoprostol and a transcervical Foley
catheter.
Objective To review the evidence comparing misoprostol and
transcervical Foley catheter placement for induction of labour, and
perform a meta-analysis comparing these two induction agents.
Search strategy We conducted database searches of PubMed,
Embase, the Cochrane Library Database, and the ClinicalTrials.gov
website. Bibliographies of all relevant articles were reviewed.
Selection criteria Prospective, randomised trials comparing the
use of intravaginal misoprostol and transcervical Foley catheter for
the purpose of cervical ripening and induction of labour were
included. We excluded studies in which the patients in these two
intervention groups also received other induction agents
concurrently, such as oral misoprostol, oxytocin, or other
prostaglandins.
Data collection and analysis The primary outcomes selected were
time to delivery, and the rates of caesarean section, uterine
tachysystole, and chorioamnionitis. Random-effects generalised
linear models with a poisson distribution and log link function
were used to compare the two induction agents across the studies.
Main results Nine studies (1603 patients) were identified as
eligible to be included in this meta-analysis. There were no
significant differences in the mean time to delivery (mean
difference 1.08 2.19 hours shorter for misoprostol, P = 0.2348),
the rate of caesarean delivery (RR 0.991; 95% CI 0.768, 1.278), or
in the rate of chorioamnionitis (RR 1.130; 95% CI 0.611, 2.089)
between women who received misoprostol compared with
transcervical Foley catheter. Patients who received misoprostol had
significantly higher rates of tachysystole compared with women
who received a transcervical Foley catheter (RR 2.844; 95% CI
1.392, 5.812).
Conclusions Intravaginal misoprostol and transcervical Foley
catheter have similar effectiveness as induction agents.
Transcervical Foley catheter is associated with a lower incidence of
tachysystole.
Keywords Cervical ripening, Foley, induction, misoprostol.

Please cite this paper as: Fox N, Saltzman D, Roman A, Klauser C, Moshier E, Rebarber A. Intravaginal misoprostol versus Foley catheter for labour induc-
tion: a meta-analysis. BJOG 2011;118:647654.

staglandins. Regarding prostaglandin administration, pros-

Introduction
Between 1990 and 2006, the rate of labour induction in the
USA more than doubled from 9.5 to 22.5%.1 For the patient
with an unfavourable cervix, a number of cervical ripening
agents are available. These include mechanical dilation and
prostaglandin administration. Mechanical dilation was first
described with laminaria; more recently, the use of a trans-
cervical balloon catheter (Foley catheter) has also been used
successfully.2,3 The Foley catheter is inserted in order to act
primarily as a cervical ripening agent, with the capacity to
modify the cervical status, and may have limited effect on
uterine contractions, aside from the possible release of pro-
taglandin E2 given vaginally or intracervically has been
shown to be an effective ripening agent.4 Additionally, pros-
taglandin E1 (misoprostol) has been shown to be an effec-
tive cervical ripening agent.5 Misoprostol acts primarily as
an exogenous pharmacological agent with effects both on
cervical ripening as well on uterine contractions. A Cochra-
ne review in 2001 comparing all forms of mechanical dila-
tion with all prostaglandins concluded that there is
insufficient evidence to assess the effectiveness of mechani-
cal methods, compared with prostaglandins in women with
unripe cervices. The use of these methods, as compared
with the use of prostaglandins, was associated with fewer

2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG 647
 Fox et al.
episodes of excessive uterine contractions, without modifi-
cations of the risk of caesarean section.6
In our institution, two commonly used methods of cer-
vical ripening are vaginal misoprostol and a transcervical
Foley catheter. There are a number of randomised studies
comparing these two methods, most of which were pub-
lished subsequent to the 2001 Cochrane review. Given the
frequency of induction of labour, the knowledge of even
small differences between induction methods could be very
useful to individual obstetrical providers, as well as to lar-
ger hospital systems. The purpose of this study was to
review the evidence from randomised trials comparing the
effectiveness of vaginal misoprostol and transcervical Foley
catheter for the purpose of cervical ripening and induction
of labour.
Methods
Data sources
A literature search was conducted in Embase (January
1980November 2010) and PubMed (US National Library
of Medicine, January 1966November 2010) to identify
prospective, randomised trials with published data in Eng-
lish comparing the use of intravaginal misoprostol and
transcervical Foley catheter for the purpose of cervical
ripening and induction of labour. Keywords included
misoprostol, Foley, balloon, induction, and cervical ferences that exist among studies apart from those that
ripening. The AND operator was used to combine these
terms in varying combinations. No date restrictions were
used. Bibliographies of all relevant eligible articles were
reviewed for further potential references. In addition,
the Cochrane Library Database of Systematic Reviews and
the ClinicalTrials.gov website were searched to identify any
additional ongoing or completed trials.
Study selection and data extraction
Studies were included if patients undergoing induction of
labour were randomly assigned to intravaginal misoprostol
or transcervical Foley catheter placement. We excluded
observational and retrospective studies. Because of the nat-
ure of the interventions, we did not require the studies to
be blinded. We excluded studies in which the patients in
these two intervention groups also received other induction
agents concurrently with the vaginal misoprostol or trans-
cervical Foley catheter, such as oral misoprostol, oxytocin,
or other prostaglandins. As both misoprostol and transcer-
vical Foley catheter are typically followed by oxytocin
administration in labour, we did not exclude studies in
which oxytocin was given after the last dose of misoprostol,
or after the Foley catheter was removed. We also did not
exclude studies with more than two intervention groups, as
long as two of them received only vaginal misoprostol and
transcervical Foley catheter, respectively. For these studies,
648 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
we only extracted the data for the misoprostol and trans-
cervical Foley groups.
Studies deemed suitable were retrieved and reviewed by
two independent authors in duplicate (NF and AR) to
determine inclusion. Disagreements were resolved by con-
sensus.
Selection of outcomes
The primary outcomes selected were time to delivery and
the rates of cesarean section, uterine tachysystole, and
chorioamnionitis. As some of these clinical outcomes are
defined differently in various studies, we relied on the defi-
nitions of tachysystole and chorioamnionitis used by the
authors of the studies.
Quality assessment
Quality assessment was performed, and included the
following criteria: method of randomisation, intention to
treat, and loss to follow-up.7
Statistical analysis
Statistical analyses were performed using sas v9.2 (SPSS
Institute Inc., Cary, NC, USA). For the outcome of time to
delivery, which is a continuous outcome, the overall mean
difference and 95% confidence interval were estimated
using a random-effects linear model, which adjusts for dif-
could be directly controlled for, such as Bishop score, Foley
volume, misoprostol dose, and frequency of misoprostol
administration. For the outcomes of rates of caesarean
delivery and tachysystole, which are dichotomous out-
comes, the overall relative risks and 95% confidence inter-
vals were estimated using random-effects generalised linear
models with a Poisson distribution and log-link function.
For the dichotomous outcome of chorioamnionitis, the
overall relative risk and 95% confidence interval were esti-
mated using the fixed-effects method of Cochran Mantel
Haenszel. The homogeneity of the estimators of both rela-
tive risk and mean difference was tested using Cochrans Q
statistic. This is a chi-square test with the degrees of free-
dom equal to the number of studies minus one, and it tests
the null hypothesis that the within-study effect estimates
are homogeneous across studies. In addition, the I2 index
was estimated to measure the extent of true heterogeneity,8
and can be interpreted as the percentage of the total vari-
ability in a set of effect sizes that result from differences
between studies. Although significant heterogeneity was
only detected among the mean differences in time to deliv-
ery, the random-effects modelling approach was used to
obtain the combined effect estimates for all outcomes
except for chorioamnionitis.
Eggers linear regression method was used to detect
potential publication bias,9 whereas Duval and Tweeties
 Intravaginal misoprostol versus Foley catheter for labour induction

trim-and-fill procedure was used to compute corrected contractions in a 10-minute period and requiring intrave-
effect size estimates of augmented data sets.10 nous administration of terbutaline.16

Results
Nine studies (1603 patients) were identified as eligible to be
included in this meta-analysis.1119 The details of our search
can be found in Figure 1. The studies details are summar-
ised in Table 1, and their quality assessment is detailed in
Table 2. All of the studies reported time to delivery except
for one.14 For the one study that reported the median and
range time to delivery, the mean and standard deviation
were estimated using a standard formula.20 All studies
reported the caesarean rate. Only two studies reported the
rate of chorioamnionitis.11,16 All studies except one reported
the rate of uterine tachysystole.15 Seven studies defined
tachysystole as six or more contractions in 10 minutes
occurring over two consecutive 1-minute intervals.1114,1719
This definition is nearly identical to the current definition
suggested by the Eunice Kennedy Shriver National Institute
of Child Health and Human Development, the American
College of Obstetricians and Gynecologists (ACOG), and the
Society for MaternalFetal Medicine in 2008: more than five
contractions in 10 minutes, averaged over a 30-minute win-
dow.21 One study defined tachysystole as more than five
Time to delivery
Using the random-effects estimate, there was no significant
difference in the mean time to delivery between women
who received misoprostol compared with transcervical
Foley catheter (mean difference 1.08 2.19 hours shorter
for misoprostol, P = 0.2348). The heterogeneity between
studies was significant, with P < 0.0001. The estimate of I2
was 84%. The forest plot detailing these results can be
found in Figure 2.
Rate of caesarean delivery
Using the random-effects estimate, there was no significant
difference in the rate of caesarean delivery between women
who received misoprostol compared with transcervical
Foley catheter (RR 0.991; 95% CI 0.7683, 1.278). The het-
erogeneity between studies was not significant, with
P = 0.4840. The estimate of I2 was 0%. The forest plot
detailing these results can be found in Figure 3.
Rate of chorioamnionitis
Using the fixed-effects estimate, there was no significant
difference in the rate of chorioamnionitis between women

613 potentially relevant studies identified from searches

595 studies excluded after screening titles and/or abstracts

20 studies retrieved for more detailed evaluation

17 from electronic search

3 from bibliography review

11 excluded

4 administered misoprostol concurrent with the Foley

catheter placement
3 administered oxytocin concurrent with Foley catheter
placement
2 used misoprostol dose above 50 mcg
1 only reported outcome of change in Bishop score
1 manuscript was in Arabic

9 studies included in metaanalysis

Figure 1. Study search flowchart.

2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG 649
 Fox et al.

Table 1. Randomised trials included in the meta-analysis

Study and number Inclusion Patient characteristics Induction agent

of patients criteria (gestational age, (number of women, parity) characteristics (misoprostol dose
Bishop score) and frequency, Foley volume)

Chung 200311 28 weeks 103 patients 25 lg every 3 hours

n = 103*
Bishop <7 64.08% nulliparous 30 ml
12
Gelisen 2004 41 weeks 200 patients 50 lg every 6 hours
n = 200*
Bishop <5 46.5% nulliparous 50 ml
13
Owolabi 2005 GA not specified 120 patients 50 lg every 6 hours
n = 120
Bishop <5 20% nulliparous 30 ml
14
Adeniji 2005 37 weeks 96 patients 50 lg every 6 hours
n = 96
Bishop <6 47.92% nulliparous 30 ml

Kashanian 200615 28 weeks 200 patients 25 lg every 3 hours

n = 200*
Bishop <6 Parity not given Foley volume not given

Prager 200816 Full term 397 patients 25 lg every 4 hours

n = 397*
Bishop <7 64.23% nulliparous 50 ml
17
Sciscione 2001 28 weeks 111 Patients 50 lg every 4 hours
n = 111
Bishop <6 71.17% nulliparous 30 ml
18
Greybush 2001 GA not specified 136 patients 25 lg every 3 hours
n = 136*
Bishop <6 65.44% nulliparous 50 ml
19
Moraes Filho 2010 Full term 240 patients 25 lg every 6 hours
n = 240
Bishop <6 65.83% nulliparous 30 ml

*Studies had more than two groups. Number listed is the total in the misoprostol and transcervical Foley catheter groups only.

who received misoprostol compared with transcervical
Foley catheter (RR 1.130, 95% CI 0.611, 2.089). The heter-
ogeneity between studies was not significant, with
P = 0.3900. The estimate of I2 was 0%. The forest plot
detailing these results can be found in Figure 4.
Rate of tachysystole
Using the random-effects estimate, patients who received
misoprostol had significantly higher rates of tachysystole
compared with women who received a transcervical Foley
catheter (RR 2.844; 95% CI 1.392, 5.812). The heterogene-
ity between studies was not significant, with P = 0.5230.
The estimate of I2 was 0%. The forest plot detailing these
results can be found in Figure 5.
Publication bias
Employing Eggers linear regression test suggests that there
is no publication bias present. Moreover, employing
Duval and Tweeties trim-and-fill procedure leads to the
conclusion that three studies seem to be missing in the ori-
ginal data set of eight studies that reported rates of tachy-
systole. The adjusted weighted mean relative risk of
tachysystole for the augmented data set is 2.31 (1.54, 3.48)
using a random-effects model, which is not clinically mean-
ingfully different from the relative risk using the original
eight studies: 2.84 (1.39, 5.81).
Discussion
In this meta-analysis of prospective, randomised studies
with 1603 patients undergoing induction of labour, the
administration of vaginal misoprostol and the use of a
transcervical Foley catheter had similar effectiveness in
achieving vaginal delivery, and in a similar time frame.
There was also no difference in the rate of chorioamnioni-
tis, although there were only two studies that reported this
outcome. However, there was a 2.8-fold increase in the
rate of uterine tachysystole with the use of misoprostol,

650 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
 Intravaginal misoprostol versus Foley catheter for labour induction

Table 2. Results for the quality of the nine studies included in the
Misoprostol and transcervical Foley catheter are both
meta-analysis considered appropriate induction agents by ACOG.22
However, despite the data supporting its use there is still
Study Randomisation Intention Lost to controversy regarding misoprostol as an induction agent.
method to treat follow-up
On 23 August 2000, the manufacturer of misoprostol
(Cytotec, Searle) distributed a letter to clinicians in the USA
Chung 200311 Epistat Yes 0 (0%)
warning them against the use of misoprostol in pregnant
Gelisen 200412 Sealed envelope Yes 0 (0%) women, as it can cause abortion, and possibly even uterine
rupture, and maternal and fetal deaths, when used to induce
Owolabi 200513 Computer-generated Yes 0 (0%)
sealed envelope labour.23 That letter generated a widespread reaction and
significant controversy, causing many hospitals to remove
Adeniji 200514 Computer-generated Yes 0 (0%)
misoprostol from their formularies. In a response from
sealed envelope
ACOG in the December of 2000, ACOG reaffirmed their
Kashanian 200615 Unknown Yes 0 (0%) previous position from 1999 that substantial evidence sup-
Prager 2008 16
Computer-generated Yes 3 (0.5%) ports the use of misoprostol for the induction of labour.24
sealed envelope However, unfortunately, the use of misoprostol remains a
tool for trial lawyers when prosecuting obstetrical cases, and
Sciscione 200117 Computer-generated No 0 (0%)
many providers may remain fearful. Although in our opin-
sealed envelope
ion misoprostol, when used correctly, remains an appropri-
Greybush 200118 Computer-generated Yes 0 (0%) ate agent for the induction of labour, for those who may
sealed envelope
not want to use misoprostol, the results from this meta-
Moraes Filho19 Computer-generated Yes 0 (0%) analysis should be reassuring that the use of a transcervical
sealed envelope Foley catheter is as effective as misoprostol.
The finding that the transcervical Foley catheter is associ-
ated with a lower risk of tachysystole may be particularly
compared with the use of a transcervical Foley catheter. useful when inducing labour in patients at increased risk of
Although these studies did not report any adverse mater- fetal hypoxaemia, such as those with intrauterine growth
nal or neonatal outcomes in association with the tachysys- restriction, oligohydramnios, post-term pregnancy, chronic
tole, this should prompt caution when using misoprostol disease, thrombophilia, sickle cell disease, or pre-eclampsia.
compared with transcervical Foley for the induction of In these patients with the possibility of varying degrees of
labour. placental insufficiency, the reduction in risk of tachysystole

Figure 2. Impact of the use of misoprostol versus Foley catheter for the induction of labour on mean time to delivery.

2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG 651
 Fox et al.

Figure 3. Impact of the use of misoprostol versus Foley catheter for the induction of labour on the likelihood of caesarean delivery.

Figure 4. Impact of the use of misoprostol versus Foley catheter for the induction of labour on the likelihood of chorioamnionitis.

may lead to a reduced rate of caesarean delivery for nonre-
assuring fetal status, or a reduction in fetal academia, and
more studies are warranted in these high-risk populations.
Five of the studies used a Foley volume of 30 ml, three
used 50 ml, and one study did not specify the volume
used. There is evidence that a higher volume Foley (60 or
80 ml) is more effective than one of 30 ml.25,26 Addition-
ally, four studies used a 50 lg dose of misoprostol, which
is considered a second-choice dose, as it is associated with
an increased risk of tachysystole.22 Because of this, we con-
trolled for the Foley balloon volume, misoprostol dose and
misoprostol frequency in our analysis. Although the studies
reported the number of nulliparous patients in their popu-
lation, the studies did not stratify their results based on
parity, which could influence the relative effectiveness of
each induction method. More studies are warranted
to compare the effectiveness of these induction methods in
nulliparous patients only, as they are at the highest risk of
failed induction and caesarean delivery after the induction
of labour.
Like all meta-analyses, there are limitations to our study.
We could not assess the adherence to protocol in the stud-
ies, aside from that reported. Also, these studies represent
varying populations at different times. It is also possible
that there are other studies that we failed to locate in our
search. Additionally, this study could not address other
clinical circumstances when one induction method would
be preferable for other reasons, such as scarred uteri, a
tightly closed cervix, or morbid obesity, which could make
Foley placement difficult.

652 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
 Intravaginal misoprostol versus Foley catheter for labour induction
Figure 5. Impact of the use of misoprostol versus Foley catheter for the induction of labour on the likelihood of tachysystole.
We did not find evidence of publication bias, and employ-
ing Duval and Tweeties trim-and-fill procedure, there
appeared to be three unpublished studies, but this did not
appear to affect our significant findings. Our study repre-
sents the largest pooling of patients in estimating the relative
effectiveness and risk of intravaginal misoprostol and trans-
cervical Foley catheter as induction agents. Our data support
the contention that, as induction agents, intravaginal
misoprostol and transcervical Foley have similar effectiveness
and similar risk of caesarean section, with a reduced risk of
tachysystole with the use of a transcervical Foley catheter.
Disclosure of interests
None to declare.
Contribution to authorship
NSF and AR performed the primary literature review and
NSF prepared the article. EM performed the data analysis.
DHS, AR, CKK, and ASR assisted in the literature review,
analysis, and the preparation of the article.
Details of ethics approval
This study was exempted from ethics approval as it did not
involve human subjects.
Funding
None.
Acknowledgement
None. j
2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
References
1 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F,
Kirmeyer S, et al. Births: final data from 2006. Natl Vital Stat Rep
2009;57:7. Available at www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_
07.pdf. Last accessed 26 August 2010.
2 Embrey MP, Mollison BC. The unfavorable cervix and the induction
of labor using a cervical balloon. J Obstet Gynaecol Br Commonw
1967;74:448.
3 Gelber S, Sciscone A. Mechanical methods of cervical ripening and
labor induction. Clin Obstet Gynecol 2006;49:64257.
4 Kelly AJ, Kavanagh J, Thomas J. Vaginal prostaglandin (PGE2 and
PGF2a) for induction of labour at term. Cochrane Database Syst Rev
2003;4:CD003101.
5 Hofmeyr GJ, Gulmezoglu AM. Vaginal misoprostol for cervical ripen-
ing and induction of labor. Cochrane Database Syst Rev 2003;1:
CD000941.
6 Boulvain M, Kelly A, Lohse C, Stan C, Irion O. Mechanical methods
for induction of labor. Cochrane Database Syst Rev 2001;4:
CD001233.
7 Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of
bias. Dimensions of methodological quality associated with esti-
mates of treatment effects in controlled trials. JAMA 1995;273:
40812.
8 Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring incon-
sistency in meta-analyses. BMJ 2003;327:55760.
9 Sterne JA, Egger M. Funnel plots for detecting bias in meta-analysis:
guidelines on choice of axis. J Clin Epidemiol 2001;54:104655.
10 Duval S, Tweedie R. Trim and fill: a simple funnel-plot based method
of testing and adjusting for publication bias in meta-analysis. Bio-
metrics 2000;56:45563.
11 Chung JH, Huang WH, Rumney PJ, Garite TJ, Nageotte MP. A pro-
spective randomized controlled trial that compared misoprostol,
Foley catheter, and combination misoprostol-Foley catheter for labor
induction. Am J Obstet Gynecol 2003;189:10315.
653
 Fox et al.
12 Gelisen O, Caliskan E, Dilbaz S, Ozdas E, Dilbaz B, Ozdas E, et al.
Induction of labor with three different techniques at 41 weeks of
gestation or spontaneous follow-up until 42 weeks in women with
definitely unfavorable cervical scores. Eur J Obstet Gynecol Reprod
Biol 2005;120:1649.
13 Owolabi AT, Kuti O, Ogunlola IO. Randomised trial of intravaginal
misoprostol and intracervical Foley catheter for cervical ripening and
induction of labour. J Obstet Gynaecol 2005;25:5658.
14 Adeniji OA, Oladokun A, Olayemi O, Adeniji OI, Odukogbe AA,
Ogunbode O, et al. Pre-induction cervical ripening: transcervical
Foley catheter versus intravaginal misoprostol. J Obstet Gynaecol
2005;25:1349.
15 Kashanian M, Akbarian AR, Fekrat M. Cervical ripening and induc-
tion of labor with intravaginal misoprostol and Foley catheter cervi-
cal traction. Int J Gynaecol Obstet 2006;92:7980. Epub 2005 Oct
21.
16 Prager M, Eneroth-Grimfors E, Edlund M, Marions L. A randomised
controlled trial of intravaginal dinoprostone, intravaginal misoprostol
and transcervical balloon catheter for labour induction. BJOG
2008;115:144350. Epub 2008 Aug 19.
17 Sciscione AC, Nguyen L, Manley J, Pollock M, Maas B, Colmorgen
G. A randomized comparison of transcervical Foley catheter to
intravaginal misoprostol for preinduction cervical ripening. Obstet
Gynecol 2001;97:6037.
18 Greybush M, Singleton C, Atlas RO, Balducci J, Rust OA. Preinduc-
tion cervical ripening techniques compared. J Reprod Med 2001;
46:117.
654 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
19 Moraes Filho OB, Albuquerque RM, Cecatti JG. A randomized trial
comparing vaginal misoprostol versus Foley catheter plus oxytocin
for labor induction. Acta Obstet Gynecol Scand 2010;89:104552.
20 Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance
from the median, range and size of sample. BMC Med Res Meth-
odol 2005;5:13.
21 ACOG Practice Bulletin Number 106. Intrapartum Fetal Heart Rate
Monitoring: Nomenclature, Interpretation, and General Management
Principles. Washington, DC: American College of Obstetricians and
Gynecologists, 2009.
22 ACOG Practice Bulletin Number 107. Induction of Labor. Washing-
ton DC: American College of Obstetricians and Gynecologists, 2009.
23 Cullen M. Letter to Health Care Practitioners: Important Drug Warn-
ing Concerning Unapproved Use of Intravaginal or Oral Misoprostol
in Pregnant Women for Induction of Labor or Abortion. Skokie, IL:
Searle, 2000.
24 ACOG Committee opinion no. 248. Response to Searles Drug
Warning on Misoprostol. Washington, DC: American College of
Obstetricians and Gynecologists, 2000.
25 Levy R, Kanengiser B, Furman B, Ben Arie A, Brown D, Hagay ZJ.
A randomized trial comparing a 30-mL and an 80-mL Foley catheter
balloon for preinduction cervical ripening. Am J Obstet Gynecol
2004;191:16326.
26 Delaney S, Shaffer BL, Cheng YW, Vargas J, Sparks TN, Paul K, et al.
Labor induction with a Foley balloon inflated to 30 mL compared
with 60 mL: a randomized controlled trial. Obstet Gynecol 2010;
115:123945.