The percentage of women undergoing an induction of labor (IOL) is estimated to be 20% and
continues to rise. Simultaneously, the cesarean delivery (CD) rate has continued to increase
(2). Induction is a known risk factor for CD. Despite numerous studies evaluating time
periods to define a failed IOL, there are no guidelines or accepted definitions of when to
call an IOL failed given the incremental gain in vaginal delivery when IOL is prolonged.
While decreasing the CD rate is an important primary focus in obstetrics, attention must also
be paid to the overall length of labor given that prolonged labor is associated with adverse
maternal and neonatal outcomes. Furthermore, a prolonged labor is associated with an increase
in direct hospital costs and healthcare utilization. The use of cervical ripening agents,
such as vaginal prostaglandin and mechanical dilators, has been demonstrated to reduce labor
time and CD rate. In addition to specific individual agents, certain dosing and regimens for
IOL and active labor have been compared to evaluate whether a particular dose or regimen can
decrease the length of labor and decrease the CD rate. Most of these regimens; however, focus
on individual induction agents and few have compared the efficacy of using more than one
agent simultaneously. Given the associated risks of prolonged labor and limited data
evaluating the use of combined cervical ripening agents, our objective is to evaluate the
difference in time to delivery among women who undergo an IOL with four different methods.