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Morning versus evening induction of labour for improving outcomes

  1. Jannet JH Bakker1,*,
  2. Birgit Y van der Goes1,
  3. Maria Pel1,
  4. Ben Willem J Mol2,
  5. Joris AM van der Post1

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 28 FEB 2013

Assessed as up-to-date: 19 MAY 2012

DOI: 10.1002/14651858.CD007707.pub2


How to Cite

Bakker JJH, van der Goes BY, Pel M, Mol BWJ, van der Post JAM. Morning versus evening induction of labour for improving outcomes. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD007707. DOI: 10.1002/14651858.CD007707.pub2.

Author Information

  1. 1

    Academic Medical Center, Department of Obstetrics and Gynaecology, Amsterdam, Netherlands

  2. 2

    Academic Medical Centre, University of Amsterdam, Obstetrics and Gynaecology, Amsterdam, Netherlands

*Jannet JH Bakker, Department of Obstetrics and Gynaecology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, Netherlands. j.j.bakker@amc.nl.

Publication History

  1. Publication Status: New
  2. Published Online: 28 FEB 2013

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Characteristics of included studies [ordered by study ID]
Bakker 2009

MethodsRandomised controlled trial.


Participants371 term pregnant women with an indication for induction of labour with intravenous oxytocin.


InterventionsStart of induction in the evening ( 21:00 hours).


OutcomesDuration of labour.

Instrumental delivery rate.

Adverse neonatal outcome.

Indications for paediatric consultations and neonatal admissions.

Duration second stage.

Intrapartum infections.

Use of pain relief.

Patient's satisfaction.


NotesStratification on parity.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "Randomisation was conducted by drawing sequentially numbered sealed opaque envelopes, containing the allocation code, on a two-folded paper, provided by the Data Management Services of the Academic Medical Centre with permutated block randomisation in a 1:1 ratio."

Allocation concealment (selection bias)Low riskQuote: "Randomisation was conducted by drawing sequentially numbered sealed opaque envelopes, containing the allocation code, on a two-folded paper, provided by the Data Management Services of the Academic Medical Centre with permutated block randomisation in a 1:1 ratio."

Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the intervention participants and personnel were not blinded. Staff behaviour may have been affected by the time of induction.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskDue to the nature of the outcome assessor/ statistician was not blinded.

Incomplete outcome data (attrition bias)
All outcomes
Low riskThe data were analysed according to the intention-to-treat principle, there were no withdrawals.

Selective reporting (reporting bias)Low riskAll of the study’s pre-specified outcomes and all expected outcomes of interest to the review have been reported.

4 women were excluded after randomisation, selected reporting is however, not likely due to the low numbers.

Other biasUnclear riskNone.

Dodd 2006a

MethodsRandomised controlled trial.


Participants620 term pregnant women and an indication for induction with prostaglandins (misoprostol or PGE2).


InterventionsStart induction in the evening (20:00 hours).


OutcomesVaginal birth not achieved within 24 hours.

Uterine hyperstimulation with associated fetal heart rate changes.

Mode of delivery.

Neonatal and maternal complications.


NotesStratification on parity.

Nested trial.

Randomisation for timing of start induction and type of prostaglandin (misoprostol versus PGE2).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "The randomisation schedule was generated by a non clinical researcher using a computer-generated sequence."

Allocation concealment (selection bias)Low riskThe allocation was written on a card, folded, and placed inside sequentially numbered, sealed opaque envelopes.

Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the intervention participants and personnel were not blinded, staff behaviour may have been affected by the time of induction.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskDue to the nature of the intervention the outcome assessor was not blinded, the statistician was blind to the allocated time of induction.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskData reported to be analysed on an intention-to treat basis although data of women who had an spontaneous onset of labour after randomisation but before scheduled induction time were not taken in account. There were no withdrawals.

Selective reporting (reporting bias)Low riskAll of the study’s pre-specified outcomes and all expected outcomes of interest to the review have been reported.

Authors state that data were analysed on an intention-to-treat, data of the women who entered labour before time of start induction however, were not included in the analysis.

Other biasUnclear riskNone.

Oei 2000

MethodsRandomised controlled trial.


Participants158 term pregnant women and an indication for induction with prostaglandins (PGE2).


InterventionsStart induction in the evening (22:00 hours).


OutcomesDelivery during evening or night hours.

Time to delivery.

Use of pain relief.

Mode of delivery.

Patient's preference.


NotesStratification on parity.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskQuote: "we used simple randomisation with random table numbers."

Allocation concealment (selection bias)Low riskConcealment was ensured by using of sequentially numbered opaque sealed envelopes.

Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the intervention participants and personnel were not blinded, staff behaviour may have been affected by the time of induction.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskDue to the nature of the outcome assessor/statistician was not blinded.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskData were analysed on an intention-to treat basis, there were no withdrawals.

Selective reporting (reporting bias)Low riskAll of the study’s pre-specified outcomes and all expected outcomes of interest to the review have been reported.

Data of the women who entered labour before time of start induction were not included in the analysis.

Other biasUnclear riskNone.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Backe 1991No randomised comparison.

Eisenhauer 2010Retrospective cohort study.

Fraser 1989No comparison; prospective cohort study examining timing start of spontaneous labour.

Kato 1987Randomised comparison of spontaneous versus induced labour.

Kupietz 1994Comparison of 2 groups who were induced with prostaglandins in the morning and in the evening.

Groups divided by preference of the woman, no randomisation.

Levey 2010No randomisation; comparison of 2 hospital protocols of induction of labour with Prostin.

Matijevic 1991Case control study, 32 women induced with prostaglandin E2 in the evening were matched with 33 women induced in the morning.

Ostrowski 1984Non randomised comparison of 2 groups women with different patient characteristics.

Sekiba 1970Report of daylight delivery; no comparison.

Thorsell 2011Retrospective cohort study.

 
Comparison 1. Morning versus evening start of induction with prostaglandins

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Apgar less than 7 at 5 minutes2746Risk Ratio (M-H, Fixed, 95% CI)0.20 [0.02, 1.67]

 2 Admission to NICU2746Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.04, 3.87]

 3 Caesarean section2Risk Ratio (M-H, Random, 95% CI)Totals not selected

 4 Instrumental vaginal delivery2Risk Ratio (M-H, Random, 95% CI)Totals not selected

 5 Use of epidural anaesthesia2Risk Ratio (M-H, Random, 95% CI)Totals not selected

 6 Need for blood transfusion1620Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.32, 2.59]

 7 Vaginal birth not achieved 24 hours1620Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.83, 1.17]

    7.1 Primiparae
1365Risk Ratio (M-H, Fixed, 95% CI)1.00 [0.84, 1.20]

    7.2 Multiparae
1255Risk Ratio (M-H, Fixed, 95% CI)0.92 [0.60, 1.43]

 8 Delivery outside office hours1126Risk Ratio (M-H, Fixed, 95% CI)1.17 [0.83, 1.65]

 9 Dissatisfaction with time start induction1108Risk Ratio (M-H, Fixed, 95% CI)0.21 [0.05, 0.89]

 10 Bad quality of sleep2728Risk Ratio (M-H, Random, 95% CI)0.24 [0.04, 1.46]

 
Comparison 2. Morning versus evening start of induction with intravenous oxytocin

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Apgar score less than 7 at 5 minutes1371Risk Ratio (M-H, Fixed, 95% CI)1.97 [0.36, 10.61]

 2 Neonatal admission1371Risk Ratio (M-H, Fixed, 95% CI)1.48 [1.02, 2.14]

 3 Caesarean section1371Risk Ratio (M-H, Fixed, 95% CI)1.13 [0.64, 1.99]

 4 Instrumental vaginal delivery1371Risk Ratio (M-H, Fixed, 95% CI)1.11 [0.66, 1.88]

 5 Use of epidural anaesthesia1371Risk Ratio (M-H, Fixed, 95% CI)0.87 [0.51, 1.48]

 6 Use of antibiotics because of signs of intrauterine infection1371Risk Ratio (M-H, Fixed, 95% CI)1.97 [0.36, 10.61]

 7 Duration of labour (minutes)1371Mean Difference (IV, Fixed, 95% CI)-12.68 [-61.67, 36.31]

    7.1 Primiparae
1242Mean Difference (IV, Fixed, 95% CI)-14.0 [-98.17, 70.17]

    7.2 Multiparae
1129Mean Difference (IV, Fixed, 95% CI)-12.0 [-72.24, 48.24]