Cervical Ripening in Pregnancy: ACOG Clinical Practice Guideline No. 9.

Purpose: The purpose of this document is to review current methods for cervical ripening and to summarize the effectiveness of these approaches based on appropriately conducted outcomes-based research. This document focuses on cervical ripening in individuals with term, singleton, vertex pregnancies with membranes intact, because this is the population in whom most studies were conducted. For more information on recommended timing of delivery based on maternal, fetal, and obstetric conditions and on labor management, refer to: American College of Obstetricians and Gynecologists (ACOG) Committee Opinion No. 831, Medically Indicated Late-Preterm and Early-Term Deliveries (1); Practice Bulletin No. 217, Prelabor Rupture of Membranes (2); Obstetric Care Consensus No. 10, Management of Stillbirth (3); Practice Bulletin No. 205, Vaginal Birth After Cesarean Delivery (4); and Clinical Practice Guideline No. 8, First and Second Stage Labor Management (5).

Target population: Individuals with term, singleton, vertex pregnancies with membranes intact.

Methods: This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two maternal-fetal medicine subspecialists and one specialist in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics. ACOG medical librarians completed a comprehensive literature search for primary literature within the Cochrane Library, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, Ovid MEDLINE, and PubMed and searched for guidelines from ACOG and other organizations. Studies that moved forward to the full-text screening stage were assessed by the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

Recommendations: This Clinical Practice Guideline includes an overview of cervical ripening indications, contraindications, and methods and provides recommendations for pharmacologic, mechanical, and combination method cervical ripening in individuals with term, singleton, vertex pregnancies with membranes intact. Recommendations are classified by strength and evidence quality.