Transvaginal ultrasonographic evaluation of the cervix

before labor: Presence of cervical wedging is associated

with shorter duration of induced labor
Fereshteh Boozarjomehri, MD, Han Timor-Tritsch, MD, Conrad R. Chao, MD, and
Harold E. Fox, MD
New York, New York

OBJECTIVE: Our purpose was to test the hypothesis that transvaginal ultrasonographically determined
characteristics of the cervix are associated with duration of induced labor.
STUDY DESIGN: Fifty-three patients scheduled for induction of labor underwent transvaginal
ultrasonography and digital cervical examinations before labor induction. Cox proportional-hazards
multiple regression analysis was performed to determine the variables that made a significant contribution
to the prediction of latent-phase and total labor duration. In the analysis the possible confounding effects
of exogenous prostaglandin, previous vaginal delivery, and previous termination of pregnancy were
controlled.
RESULTS: Latent-phase and total labor duration were significantly associated with the presence of
cervical wedging noted on transvaginal ultrasonography and administration of prostaglandin but not with
the result of digital examination of cervical effacement or dilatation. Latent-phase duration was also
associated with cervical length measured by transvaginal ultrasonography. The presence of wedging was
significantly associated with shorter latent (15.9 ± 1.7 vs 34.1 ± 3.8 hours, p = 0.0001) and total
(22.0 ± 1.8 vs 38.3 ± 3.6 hours, p = 0.0001) labor length.
CONCLUSION: The presence of wedging and decreased cervical length observed by transvaginal
ultrasonography is associated with a shorter duration of induced labor and may be useful in the
evaluation of induction candidates. (AM J OesTET GVNECOL 1994;171 :1081-7.)

Key words: transvaginal ultrasonography, cervical wedging, shorter labor

Digital examination has been the standard method of
assessment of the cervix before and during induction of
labor. Studies have demonstrated differences between
digital and transvaginal ultrasonographic assessment of
the cervix.'-4 We hypothesized that characteristics of
transvaginal ultrasonographic cervical assessment in
candidates for induction of labor are associated with
duration of labor.
Material and methods
During the 4 months of the study all induction
candidates seen during research times were assessed for
eligibility to be included in the study. Fifty-four patients
with a viable fetus, intact fetal membranes, and no
vaginal bleeding were asked to participate. One patient
From the Division of Maternal-Fetal Medicine, Department of Ob-
stetrics and Gynecology, College of Physicians and Surgeons of
Columbia University, and the Sloane Hospital for Women of the
Presbyterian Hospital.
Presented at the Fourteenth Annual Meeting of the Society of
Perinatal Obstetricians, Las Vegas, Nevada, January 24-29, 1994.
Reprint requests: Ilan E. Timor-Tritsch, MD, Department of Obstet-
rics and Gynecology, Sloane Hospital for Women at Columbia
Presbyterian Medical Center, 622 W. 168th St., New York, NY
10032.
Copyright © 1994 by Mosby-Year Book, Inc.
0002-9378/94 $3.00 + 0 6/6/57839
declined the institutional review board-approved con-
sent. Fifty-three pregnant patients in the third trimester
(51 patients > 38 weeks of gestation, one at 34 weeks,
one at 35 weeks) were studied. The indications for the
induction were postdates (34), preeclampsia or preg-
nancy-induced hypertension (7), oligohydramnios (5),
and other medical or fetal problems necessitating de-
livery (diabetes mellitus, Rh sensitization, seizure disor-
der, fetal hydrocephalus, macrosomia, intrauterine
growth retardation, fetal diaphragmatic hernia) (7).
Digital cervical evaluation was performed by the pri-
vate physician or the admitting physician before induc-
tion. Induction of labor was defined as initiation of
labor by administration of intravaginal prostaglandin
gel or intravenous oxytocin. The agent was selected on
the basis of the initial digital evaluation of the cervix.
Induction of labor was performed according to stan-
dard practice in this hospital. The prostaglandin dose
was 4 mg of gel administered vaginally every 4 hours for
three doses. Volumetrically controlled oxytocin was ad-
ministered intravenously at 1 mU/min and increased by
1 mU/min every 30 minutes until labor was established.
Thirty-eight patients received both prostaglandin and
oxytocin; 10 were given oxytocin only and five patients
were delivered after prostaglandin administration only.

1081
1082 Boozarjomehri et al.
Fig. 1. Transvaginal ultrasonography images of different shapes of cervix. A, Nonwedging. B,
Wedging. C, U-shape. D, Mucus plug in internal os obscuring wedge pattern. E, Hypertrophic cervical
glands giving the appearance of wedging cervix. F, Schematic representation of lower uterine
segment, cervix, and vagina.
In our study the effacement and dilatation components
of the Bishop5 score were studied in comparison to
transvaginal ultrasonographic cervical length and inter-
nal os descriptive anatomy. Dilatation in digital evalu-
ation was defined as the ability of the examiner to open
or be able to assess the internal os of the cervix by
digital examination. Effacement was defined as the
cervical length estimated by the examiner.
All transvaginal ultrasonography procedures were
performed by one of the authors (F.B.), before induc-
tion, by means of standard technique. 6 • s We used an
Hitachi EVB 410 ultrasonography machine (Hitachi,
Tokyo) with a 6.5 MHz transvaginal transducer. The
best image quality was obtained with the area of interest
between 2 and 7 cm from the tip of the probe, which is
the focal zone of the 6.5 MHz probe. B• 9 The length of
the cervix by transvaginal ultrasonography was mea-
sured from the internal os to the external os, the
furthest points at which the cervical walls were juxta-
posed. B • 10 In cases of cervical wedging the thickness of
the anterior or posterior lip ofthe cervix (depending on
which one was better visualized) was used for consistent
measurement of cervical length. The length was mea-
sured during uterine diastole. Dilatation in transvaginal
ultrasonography was defined 'as visualization of any
opening in the entire cervical canal. The first recorded
image of the cervix in the sagittal section (which was the
only image used for statistical evaluation) was obtained
before induction. This was followed by periodic sooo-
grams every 4 to 6 hours in the early part of induction
with milder contractions and every 0.5 to 1 hour once
October 1994
Am J Obstet Gynecol
any cervical change was noted on transvaginal ultra-
sonography. The number of examinations in each pa-
tient varied depending on clinical need for examina-
tion, as determined by the physicians managing the
labor, or on the rate of progress of the latent phase of
labor. Each scan lasted 1 to 5 minutes. Onset of labor
was defined as the time when induction started. The
study of cervical effacement and dilatation was contin-
ued through completion of the latent phase of labor,
which was defined as 90% to 100% effacement and 3 to
4 cm dilatation of the cervix as measured by both I
transvaginal ultrasonography and digital examination.
This study took from a few hours to several days in each
case.
The subjects were categorized in two groups accord-
ing to the configuration of the internal os on the initial
transvaginal ultrasonographic cervical image only.
(1) Nonwedgingwas defined as a closed internal os (Fig.
1, A) . (2) Wedging or funneling was defined as any
triangle "V pattern" at the area of the internal os with
its apex anywhere along the cervical canal (Fig. 1, B). In
characterizing different patterns of opening of the in-
ternal os, we observed a "U pattern" of the internal os,
which seemed to be exaggerated "wedging" or "bal-
looning" of the upper portion of the cervix and short-
ening of the cervical canal" (Fig. 1, C). We classified
both V and U patterns as "wedging."
Statistical analysis
Cox regression. To assess the effect of cervical wedging
on labor length while controlling for confounding vari-
ables and censored observations, Cox proportional-
 Volume 171, Number 4 Boozarjomehri et aI. 1083
Am J Obstet Gynecol

Table I. Characteristics of patients with and without cervical wedge

Mean ± SEM Wedge present Wedge absent Significance
No. of patients 31 22
Age (yr) 24.9 ± 1.0 25.4 ± 1.2 p= 0.754
Gestational age (wk) 40.3 ± 0.3 39.7 ± 0.4 P = 0.214
Parity 0.77 ± 0.19 0.27 ± 0.16 P = 0.026
Previous vaginal delivery 14 (45%) 3 (14%) P = 0.034
Previous voluntary termination 18 (58%) 3 (14%) P = 0.002
Dilatation (em) 1.00 ± 0.19 0.48 ± 0.14 P = 0.022
Effacement (%) 42 ± 4 39 ± 6 P = 1.000
Length by transvaginal ultrasonography (mm) 28.0 ± 1.0 34.8 ± 1.5 P < 0.001
Prostaglandins given 22 (71%) 21 (91%) P = 0.059
Time to active phase (hr) 15.9 ± 1.7 34.1 ± 3.8 P < 0.001
Time to delivery (hr) 22.0 ± 1.8 38.3 ± 3.6 P < 0.001

Table II. Multivariable model of latent phase and total labor duration
Exp (B) 95% confidence limit

Variable* Significance Exp (B) Lower I Upper

Duration of latent phase
Variables in the equation
Wedge presence p = 0.0097 1.7140 1.1394 2.5783
Previous voluntary termination P = 0.0136 1.6024 1.1018 2.3303
Cervical length by transvaginal ultrasonography P = 0.0413 0.9383 0.8827 0.9975
Use of prostaglandin P = 0.0027 0.5505 0.3728 0.8131
Variables not in the equation
Previous vaginal delivery P = 0.9254
Cervical dilatation (digital examination) P = 0.3285
Cervical effacement (digital examination) P = 0.4196
Duration of total labor
Variables in the equation
Wedge presence p= 0.0000 2.0981 1.4872 2.9600
Use of prostaglandin p= 0.0017 0.5396 0.3670 0.7934
Variables not in the equation
Previous voluntary termination P= 0.0670
Previous vaginal delivery P = 0.3352
Cervical dilatation (digital examination) P = 0.4482
Cervical effacement (digital examination) P = 0.4460
Cervical length by transvaginal ultrasonography P = 0.3667
Exp (B) = e to the B power. For continuous variables (dilatation, effacement, length) Exp B indicates percent change in hazard
rate for I-unit change in variable. Values < 1 indicate decrease in rate of achievement of active phase or delivery for each increase
in that variable; values > 1 indicate increase in those rates for each increase in variable. In case of cervical length Exp B = 0.9383
indicates that likelihood of progression to active phase is less by approximately 6.2% per hour for each millimeter increase in cervical
length. For dichotomous variables (wedge, prostaglandin, termination of pregnancy, delivery) Exp B indicates relative risk of
progression to active phase or delivery for that variable. In case of wedge presence Exp (B) = 1.7140 indicates that relative
likelihood of progression to active phase for patient with wedging is 1.71 times that of patient without wedging. Variables for which
confidence intervals do not include 1 are significantly related to the outcome (latent phase or total labor length).
*For dichotomous variables presence of attribute was coded as 1 and absence of attribute was coded 'as O.

hazards multiple regression analysis l2 was performed,
with length of latent phase and duration of total labor
as dependent variables in separate analyses and pres-
ence of wedging, history of voluntary termination of
pregnancy, history of previous vaginal delivery, initial
cervical length as measured by transvaginal ultrasonog-
raphy, initial cervical dilatation as measured by digital
examination, initial cervical effacement as measured by
digital examination, and use of prostaglandin as inde-
pendent variables.
Other analyses. Least-squares regression analysis was
performed to examine the relationships between vari-
abIes suspected of having linear correlations (transvagi-
nal ultrasonographically derived parameters and their
clinical examination counterparts). Mean values of par-
ity, effacement, and dilatation (the three variables for
which the data were not normally distributed in both
wedge and nonwedge groups) were compared by
Mann-Whitney U test. Normally distributed continuous
variables such as length and dilatation by transvaginal
ultrasonography, age, and gestational age were com-
pared with unpaired t test. Significance was inferred in
cross tabulations by X2 or Fisher's exact test with Yates'
correction as appropriate (fable I).
 1084 Boozarjomehri et al
45
40
35
en L..
5 30
~
c:
0
25
:oJ
03
L..
:J 20
Cl
L..
0 15
.0
03
...J
10
5 5
0 o
WEDGE NO WEDGE
Latent Phase
Fig. 2. Latent and total labor duration in wedge and nonwedge groups (n
Results
Characteristics of patients with and without wedg-
ing. Thirty-one of the 53 patients exhibited wedging
(demographic data presented in Table I) . Patients dem-
onstrating wedging were not different in maternal age
or gestational age from nonwedge patients but were
more likely to have had a previous delivery, and there
was a strong trend toward increased parity in the
wedging group; however, in both groups average parity
was less than one, indicating the relatively high preva-
lence of nulliparity in this study population. Patients
with wedging were more likely to have had a previous
voluntary termination of pregnancy. There was a trend
toward greater use of prostaglandins in the nonwedge
patients (Table I).
The presence of wedging was significantly associated
with a greater mean cervical dilatation (Table I). Cer-
vical effacement was not different between wedge and
nonwedge patients. On the other hand, transvaginal
ultrasonographic cervical length was significantly
greater in the nonwedge patients. In addition, cervical
length, as assessed by transvaginal ultrasonography,
showed no relationship to cervical effacement measured
by digital examination (r = 0.227, P = 0.102). Cervical
dilatation assessed by transvaginal ultrasonography also
showed no relationship to cervical dilatation measured
by digital examination (r = 0.168, P = 0.230).
Univariate analysis. The presence of a wedge, as
demonstrated by transvaginal ultrasonography, was as-
sociated with a significantly shorter duration of the
latent phase (15.9 ± 1.0 vs 34.1 ± 3.8 hours, P =
0.0001) and total labor (22.0 ± 1.8 vs 38.3 ± 3.6
October 1994
Am J Obstet Gynecol
45
40
I.~ 35
30
25
20
15
10
WEDGE NO WEDGE
Total Labor
= 53).
hours, P = 0.0001) duration (Table I and Fig. 2). Cer-
vical dilatation as assessed by digital examination was
also associated with shorter latent (r = -0.4215,
P = 0.003) and total (r = - 0.3987, P = 0.003) labor.
Cervical effacement by digital examination was not
significantly associated with duration of either latent or
total labor duration (r = - 0.0820, P = 0.576 and r =
- 0.0720, P = 0.608, respectively) .
The original question posed in this study was to
determine the value of cervical wedging in the predic-
tion of induced labor duration. Numerous factors might
I
confound this study (digital examination, cervical
length by transvaginal ultrasonography, historic and
demographic factors). We controlled for the effect of
possible confounders by Cox proportional-hazards mul-
tiple regression analysis.
The analysis for latent-phase duration (Table II)
revealed that of the variables examined presence of
wedge and previous voluntary termination of preg-
nancy were significantly associated with shorter latent
labor duration [Exp (B) > 1, see footnote to Table II].
Prostaglandin use and increasing transvaginal ultra-
sonographically measured cervical length were signifi-
cantly associated with a longer latent phase [Exp (B)
< 1]. Parity (number of previous vaginal deliveries) and
findings on digital cervical examination did not dem-
onstrate a significant relationship to the duration of the
latent phase. Similarly, for total labor duration (Table
II) the presence of wedging was significantly associated
with shorter labor length, and the use of prostaglandin
was associated with longer labor length . History of
voluntary termination of pregnancy, parity, digital cer-
 Volume 171. Number 4 Boozarjomehri et al. 1085
Am J Obstet Gynecol

1,2

(1)
1.0
en
I1l
.r;
....c..c .8

~
...J
.!: .6
01
c
'c;
'Cij .4
E
(1)
a::
en
1: .2
(1)

~
c.. WEDGE
0,0
• PRESENT

-,2 o ABSENT
a
Time (hours)

Fig. 3. Survival function plot for duration of latent phase. '

1,2

1,0
"'0
(1)
'-
(1)
.2: .8
Q3
"'0
C
::J
01 .6
c
'c;
'Cij
E
(1)
.4
a::
en
1:
(1) .2
~
c..
0,0 WEDGE
• PRESENT

-.2 o ABSENT
a 20 40 60 80 100

Time (hours)

Fig. 4. Survival function plot for total labor duration.

vical examination, and transvaginal ultrasonographic Comment

assessment of cervical length were not significantly
associated with the total duration of labor. Survival
function plots (Figs. 3 and 4), stratified for the presence
of wedging, demonstrated that for essentially all time
periods significantly more patients with wedging pro-
gressed to the active phase or were delivered compared
with patients without wedging.
The Bishop scoring system,S in the case of a poor
Bishop score, is not helpful in predicting the response
to induction of labor. Several studies addressed the
relationship between preinduction cervical scoring sys-
tems and the course of labor. According to some ob-
servers 13, 15 the Bishop score has a poor predictive value
for the outcome of induction. Paterson-Brown et aI.'
1086 Boozarjomehri et al.
have found that among the Bishop score components
only dilatation and length (effacement) have shown a
significant correlation with successful vaginal delivery.
Lang et al. 16 found that of the five components in the
Bishop score, dilatation was found to be the most
important component, and it was also believed that it
is the most simple, accurate, and reproducible com-
ponent.
Anatomically, in closed cervices only the distal one
half of the true cervical length (vaginal portion) is
palpable (Fig. 1, F)" 6. 17; therefore neither the configu-
ration of the internal os (e.g., wedging, V or U shape)
nor the entire length of the cervix can be judged by
palpation alone. The technique of transvaginal ultraso-
nographic assessment of the cervix is easily applicable
to all patients. During scanning the vaginal transducer
is in close proximity to the cervix; it avoids the pitfalls
of a transabdominal scan requiring a full bladderlO. 18. 19
and the shadowing of the perineal scan in which the
content of the rectosigmoid colon may interfere with
the image. 2o
As to the discrepancy between cervical dilatation as-
sessed by digital examination and the dilatation seen on
transvaginal ultrasonography, it may be related to
stretching of the cervical os during digital examination,
which implies cervical softening and therefore ripening.
This observation is also reported by Anderson and Ans-
bacher. 7 It is apparent that these are different observa-
tions that may be similar but not congruent. The correla-
tion between cervical effacement by digital examination
and transvaginal ultrasonography, as far as the initial
measurement of cervical length is concerned, was poor
both in the "wedged" and "nonwedged" groups. This is
in agreement with previously published studies 14 and is
possibly because only 50% ofthe cervix (vaginal portion)
is palpable by digital examination," 6.17 and also because
effacement is a subjective evaluation with high interob-
server variability.2 The measurement of cervical length
by transvaginal ultrasonography is a reproducible and
objective evaluation. 7 The sonologist must carefully as-
sess wedging, which at times may be obscured by mucus
or confused with cervical glands (Figs. 1, D and E). Care-
ful real-time imaging and liberal use ofthe different gain
controls clarifies these conditions.
Our study suggests that the length of the latent phase
correlates with transvaginal ultrasonographically mea-
sured cervical length, whereas length of total labor does
not. This is consistent with the observation of Paterson-
Brown et al. 4 that a relationship could not be demon-
strated between induction-to-delivery interval and cer-
vicallength measured by transvaginal ultrasonography.
Although duration of spontaneous labor is known to
be shorter in multiparous women, this is not necessarily
true in those undergoing induction. In the study by
Lang et al. 16 the following is stated:
October 1994
Am J Obstet Gynecol
The influence of parity on duration of labor was
found to be very constant and highly significant,
whereas it seemed to have only little influence on
inducibility, and the only factor of significant importance
of inducibility was the preiabor cervical condition.
Similarly, in our results parity did not demonstrate a
significant relationship to induced latent-phase and
total labor duration. By means of transvaginal ultra-
sonographically defined characteristics of the cervix we
studied the preiabor cervical condition and demon-
strated the association of the presence of a wedge with
significantly shorter induced latent and total labor. We
therefore conclude that cervical wedging detected by
transvaginal ultrasonography is an early anatomic sign
of cervical maturation or ripening. Our finding suggests
that transvaginal ultrasonographic cervical assessment
may be helpful in planning induction for women with
long-closed cervices.
REFERENCES
1. Lim BH, Mahmood TA, Smith NC, Beat I. A prospective
comparative study of transvaginal ultrasonography and
digital examination for cervical assessment in the third
trimester of pregnancy. ] Clin Ultrasound 1992:20:599-
603.
2. Kushnir 0, Vigil DA, Izquierdo L, Schiff M, Curet LB.
Vaginal sonographic assessment of cervical length changes
during normal pregnancy. AM] OBSTET GYNECOL 1990:162:
991-3.
3. Jackson GM, Ludmir ], Bader TJ. The accuracy of digital
examination and ultrasound in the evaluation of cervical
length. Obstet Gynecol 1992:79:214-8.
4. Paterson-Brown S, Fisk NM, Rodeck CH, Rodeck E. Pre-
induction cervical assessment by Bishop's score and trans-
vaginal ultrasound. Eur ] Obstet Gynecol Reprod Bioi
1991:40:17-23.
5. Bishop E. Pelvic scoring for elective induction. Obstet
Gynecol 1964:24:266-8.
6. Sonek ]D, lams ]D, Blumenfeld M, ] ohnson F, Landon M,
Gabbe S. Measurement of cervical length in pregnancy:
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examination. Obstet Gynecol 1990:76:172-5.
7. Anderson HF, Ansbacher R. Ultrasound: a new approach
to the evaluation of cervical ripening. Semin Perinatol
1991:2:140-8.
8. Anderson HF, Nugent CE, Wanty SD, Hayashi RH. Pre-
diction of risk for preterm delivery by ultrasonographic
measurement of cervical length. AM ] OBSTET GYNECOL
1990:163:859-67.
9. Timor-Tritsch IE, Rottem S. Transvaginal sonography.
New York: Elsevier, 1987:1-13.
10. Anderson HF. Endovaginal and transabdominal ultra-
sonography of the uterine cervic during pregnancy.] Clin
Ultrasound 1991:19:77-83.
11. Brown ]E, Thieme GA, Shah DM, Fleischer AC, Boehm
FH. Transabdominal and transvaginal endosonography:
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pregnancy. AM] OBSTET GYNECOL 1986:155:721-6.
12. Pedhazur E. Multiple regression in behavioral research.
Fort Worth, Texas: Harcourt-Brace, 1982.
13. Friedman EA, Niswander KR, Bayonet-Rivera NP, et al.
Relationship of prelabour evaluation to inducibility and
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15. Dhall K, Mittal SC, Kumar A. Evaluation of preinduction
scoring system. Aust N Z j Obstet Gynecol1987 ;27 :309-11.
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Ultrasound differentiation of the competent from the
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scanning. Am J Perinatol 1986;3:289-95.

Double-blind comparison of intracervical and intravaginal

prostaglandin E2 for cervical ripening and induction
of labor
Kurt A. Hales, MD: William F. Rayburn, MD," b Gayla L. Turnbull, RN,"
H. Dix Christensen, PhD," b and Edna Patatanian, RPh C

Oklahoma City, Oklahoma

OBJECTIVE: Our purpose was to compare the safety and effectiveness of prostaglandin E2 delivered
sequentially as an intracervical (0.5 mg) or intravaginal (2.5 mg) gel.
STUDY DESIGN: Hospitalized patients with an unfavorable cervix (Bishop score 054) at <!:35 weeks and
requiring induction of labor were assigned to receive two 2.5 ml doses of gel intracervically and
intravaginally in a double-blind, placebo-controlled manner. Second and third doses were given at 6-hour
intervals until there were either regular uterine contractions or a Bishop score change > 3 points.
RESULTS: The 100 evaluable cases received prostaglandin E2 either intracervically (n = 52) or
intravaginally (n = 48). Difficulty with exact gel instillation was present with intracervical gel only, where
spillage occurred in 85% of cases. Compared with intracervical therapy prostaglandin E2 given
intravaginally was more likely to significantly change the Bishop score (60.4% vs 40.4%, P = 0.04) and
stimulate regular contractions (72.9% vs 48.1%, P = 0.01). Uterine hyperstimulation was present in one
case in each group.
CONCLUSION: Although each was safe, instillation of prostaglandin E2 gel was better at a higher
intravaginal dose than a lower intracervical dose because of its greater ease of administration and higher
likelihood of cervical change. (AM J OBSTET GYNECOL 1994;171 :1087-91.)

Key words: Prostaglandin E2 , cervical ripening, induction of labor

Control of the onset of labor represents a major
challenge to the obstetrician. A pregnancy requiring
induction of labor with an unfavorable cervix presents a
management dilemma similar to the inhibition of pre-
term labor. Prostaglandin E2 (PGE 2) has been shown to
be efficacious in promoting preinduction cervical rip-
From the Departments of Obstetrics and Gynecology,· Pharmacology, b
and Hospital Pharmacy,' UniversityofOklahoma College ofMedicine.
Supported by the John W. Records Perinatal Research Fund.
Presented at the Fourteenth Annual Meeting of the Society of
Perinatal Obstetricians, Las Vegas, Nevada, January 24-29, 1994.
Reprint requests: Kurt A. Hales, MD, Santa Barbara Cottage
Hospital, Perinatal Center, P.O. Box 689, Santa Barbara, CA
93102.
Copyright © 1994 by Mosby-Year Book, Inc.
0002-9378/94 $3.00 + 0 6/6/57840
ening and in initiating labor. I -3 Various routes of deliv-
ery and doses of the drug have been tried, but topical
application as either an intracervical or intravaginal gel
in low doses has gained the most widespread accep-
tance. Use of such preparations is safe, with uterine
hyperstimulation being the primary yet uncommon and
reversible side effect. I. 2 An intracervical preparation
(Prepidil, Upjohn, Kalamazoo, Mich.) is now available
commercially and, because of its lower dose (0.5 mg vs
2.5 mg), may be associated with less uterine hyper-
stimulation than a widely used intravaginal preparation.
Few studies with PGE 2 have been performed compar-
ing success with cervical ripening when it is given
intracervically or intravaginally. These have been un-
dertaken in an unblinded manner using a single dose.

1087