Foley Catheter for Starting Labor

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Foley Equivalent to Misoprostol for Induction, but With Less Tachysystole [2011] - A transcervical Foley catheter induces labor as effectively as intravaginal misoprostol but with a lower rate of uterine tachysystole, according to a new meta-analysis.

Foley balloon plus saline expedites vaginal delivery

Induction of labor using a foley balloon, with and without extra-amniotic saline infusion.
Karjane NW, Brock EL, Walsh SW.
Obstet Gynecol. 2006 Feb;107(2):234-9.

OBJECTIVE: To compare transcervical Foley bulb with and without extra-amniotic saline infusion for induction of labor in patients with an unfavorable cervix. METHODS: Women who presented for induction of labor with Bishop score less than 5 were randomly assigned to receive Foley alone or Foley with extra-amniotic saline infusion for induction of labor. Primary outcome was time from start of induction to vaginal delivery. Secondary outcomes were cesarean delivery rates, incidence of chorioamnionitis, Apgar scores at 1 and 5 minutes, and adverse events. RESULTS: One hundred forty women completed the study. Time from induction to vaginal delivery was 16.58 (+/- 7.55) hours in the extra-amniotic saline infusion group compared with 21.47 (+/- 9.95) hours in the Foley group (P < .01). Chorioamnionitis occurred in 4 of 66 (6.1%) women in the extra-amniotic saline infusion group compared with 12 of 74 (16.2%) women in the Foley group (P = .067). Cesarean delivery rate was 21.2% versus 20.1% in the extra-amniotic saline infusion and Foley groups, respectively (P = 1.0). Median 1-minute and 5-minute Apgar scores were 9 in both groups. Adverse events were rare and unrelated to method of induction. CONCLUSION: Induction of labor by using Foley with extra-amniotic saline infusion results in shorter induction-to-vaginal-delivery time than Foley alone, without affecting cesarean delivery rates. LEVEL OF EVIDENCE: II-1.

* Obed J.Y., & Adewole, I.F. (1994). The Unfavourable Cervix: Improving the Bishop Score with the Foley's Catheter. W. Afr. J. Med. vol. 13; No. 4: 209-212.

I need to know: exactly where is that one puts the foley balloon? In the thick, uneffaced, cervical canal, between the internal and external os? Up past the internal os between the baby's head and the cervix? And does one place the foley by feel? Visualize with a speculum exam? Does one manipulate the foley manually? With a ring forceps? Can you use it with ROM?

1. anterior cervix, can place with your fingers and without speculum.
2. posterior cervix, use speculum and ring forceps.
3. use 24 or 26 french 30cc ribbed balloon catheter (the ones the urologists use for the old fashioned TURP patients) and 60 cc of sterile H20 (the irrigation kind) in a 60 cc luerlock syringe.
4. inflate the balloon with 20-30 cc h20 prior to inserting foley, then withdraw the h20. makes it easier to get h20 to go in once you have the foley in place. those balloons are stiff at first.
5. maintain sterility as much as humanly possible. lubricate the end of the foley with KY.
6. insert the foley til balloon is above the internal os, between the fetal head and the cervix.
7. blow up the balloon to as close to 60 cc as you can get.
8. tug on the catheter to lodge the balloon against the internal os. May even tape it to her leg, if you want faster results.
9. fold the end of the catheter over and rubberband it, or cervical mucous will leak out and down her leg.
10. We used it with SROM, and I never saw an infection.
11. Client needs to be upright as much as possible til the balloon comes down into the vagina (about 4 hours). The only failure I ever had in 3 years of using this method for ripening was a woman I could not get to get up. She laid in bed and watched TV for the entire induction process, ate her meals, and then was sectioned for failure to progress and an unripe after two days of induction at 42 1/2 weeks.
12. I recommend no VE's til 4-5 hours after the foley insertion. Then check her and if the balloon is in the vagina, remove h20 with syringe, remove foley, and go on with induction. It will be in the vagina in four hours, if it has been placed properly and she has been up. If she says it is in her vagina before 4 hours, check her. It probably is. You can also put a black mark at the level of her labia when you place it and if it extends away from the labia about two inches, it is probably in the vagina.
13. if using prostin with it, place the foley, then squirt the prostin at the cervix.
14. I have place it into fingertip cervixes.

We use a 24 or 26 French (big) with a 30 cc ribbed balloon. This will actually hold 60 cc of sterile saline. (just as a 5 cc balloon on the usual foley will hold 10 cc of saline). I usually folded up the end of the catheter and put a rubberband around it, just so the cervical fluids don't leak down her leg. I want her upright while the balloon is working. Using this system, I only ever had one woman (of at least 100) who was not 4 cm, very soft, and at least 80% effaced once the head came down on the cervix, at the end of the procedure. Usually takes about four hours. When you pull the water out of the balloon and take the foley out, it is usually because the balloon is now in the vagina. The head will be high, at this point, because the balloon was taking up space until it came through the cervix into the vagina. I have actually started this procedure on primips who were essentially closed and thick. Used a speculum and ring forceps to get a 22 french with a 30 cc ribbed balloon into one woman who was closed. Figured a 24 might not go. She delivered about 10 hours later, vaginally.

While we are on the subject...Do any of you have experience with attaching a 500cc bag of fluid to the catheter for "weighting down" purposes - to increase the tension I am assuming...?

I think it is a bit cruel myself, but was informed by the residents that it is the "proper" way to do it.

Not the proper way where I work. The cath is just taped to the leg. Still feels a little awkward, I've been told, but not as bad as that!

nope, we did not do it with any weight on it. If you keep them upright, you do not need weight. The 60 cc of fluid seems to be enough weight. Taping the catheter to her thigh does the same thing, however. As to "proper way to do it", I learned this method from one of my backup MD's who had done her residency in Mississippi and the bag of fluid was not a part of the package she had learned, so was not "the proper way to do it" at that residency program.

I used a large Foley (ie a 35 ml balloon), and checked the balloon first so I can make sure it doesn't leak. I visualized the cervix with a speculum, and inserted the foley so that the balloon area (which is back from the tip) was *past* the internal os. Basically I inserted it until I got some resistance. I probably inserted 4 inches to make sure I was through the internal os in this 33 week, uneffaced cervix.

Then I blew it up, and pulled it down until it was really taut...as taut as I could get it. Getting it really taut and taping it down was the hardest part.

It fell out about 4 hours later when she was 3-4.

Try inserting the foley through the cervix via a speculum and using a ring forcep. Works well. Tip the cervix forward with the speculum as you insert it. Needs to be at least a 22 F catheter and 24 or 26 is better.

You need to insert the foley so that the balloon is *past* the internal os, and then put traction on it. If the balloon is within the canal, inflating
the balloon just pushes it out of the cervix.

through the cervix. put in 30-40 cc h20 and tape it to her leg with silk tape (non allergenic). Plug the end of the catheter. Usually not necessary to put any traction on. keep her up and around.

Basically we use a 30+ cc balloon foley. Test the balloon first by blowing up with sterile water/saline. Withdraw the water/saline.

I have chosen to insert it with the aid of a speculum. This is not necessary, but works for me.

The key is to have the balloon inserted *past* the internal os. I do this by inserting the catheter quite far, blowing up the balloon, and then withdrawing until I feel the pressure of the balloon on the internal os.

I then tape the catheter to the thigh, so constant pressure of the balloon on the cervix is provided.

The Foley generally falls out at 3-4 cm, which is the diameter of the balloon. If the cervix is well effaced, labor generally kicks in quite nicely. but if the cervix is still long, then you may have problems.

Speaking of devices, I was surprised to see the article about using a foley catheter for manual dilation of the cervix in the CAM newsletter. Sorry, I don’t remember if it was intended for background information as alternatives in obstetrics and/or hospital and medical management or suggested as a possibility for out-of-hospital management.

Clearly not physiological management and turns out specifically NOT in the scope of practice for a California licensed midwife.

From the LMPA:

2507.

(b) . . . . The practice of midwifery does not include the assisting

of childbirth by any artificial, forcible, or mechanical means, . . .

I realize that CAM supports and promotes midwifery licensed and unlicensed . . . anyone else wonder about this? Or did I read its intention incorrectly?

This is an interesting question! We have not used Foleys for ripening but have considered it as their use seems to be a good way to get some dilation, especially if we are up against the 42 week mark and likely facing a hospital induction. I'd so much rather have a mama start an induction at 2-3 CM! The law reads that we cannot use mechanical means to assist childbirth, I interpret this to mean forceps and vacuum and wouldn't have thought to include a foley for ripening, especially since it is deemed low risk enough for mamas to be sent home with one in place. What would be the downside of using them for ripening, other than possible ROM and maybe increased uterine infections (I'm guessing.) I'm interested to hear what others think.

It's a good point to bring this up. Personally, I prefer herbs to anything inserted inside the cervix, including sweeping membranes, although I think I still have some large-balloon foley catheters sitting around, just in case.

When I put on my "OB interpretation hat" and consider what others have said many times about how the LMPA was modeled after the CNM law, I come to the conclusion that the clause about no "artificial, forcible, or mechanical means" means no vacuum, forceps or fundal pressure for the birth itself.

I'm sure others with more experience will contradict me, and they're probably right. But when you think about the fact that the medical community practices elective induction as if it has no risks, and hospital midwives routinely manage even pharmaceutical inductions, and OBs are mostly around for the birth itself and not the initiation or progress of labor, I doubt they're worrying about the use of balloons for induction.

OR . . . you could read that clause really conservatively and conclude that we couldn't recommend the use of breast pumps to start labor, or even sex at term, which many would consider "artificial". And would my recommending commercial herbal formulas for the last month of pregnancy also be considered "artificial"?

My background as a math major always makes me think of the true meaning of "induction", which is that you successfully prove a base case, prove that if it's true for "N" above the base, then it's also true for "N + 1". IN THEORY, an honest induction merely nudges the mama across the base threshold of labor, and then labor proceeds on its own because once you've got one good labor contraction, that will cause the next. So for a balloon induction, it's no longer even an issue when you get to the actual childbirth part.
Anyway, your point really highlights how vague our law is. I don't know if the guidelines are much clearer.

Well there was just a workshop at CAM on Foley catheter induction and we all practiced on models!! it was fun. I think it is totally within our scope to do Foleys.

Foley Catheter for Starting Labor

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