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A randomized trial of Foley Bulb for Labor Induction

in Premature Rupture of Membranes in Nulliparas (FLIP)
Jennifer M. H. Amorosa, MD; Joanne Stone, MD; Stephanie H. Factor, MD, MPH; Whitney Booker, MD;
Meredith Newland; Angela Bianco, MD

BACKGROUND: In premature rupture of membranes (PROM), the risk
of chorioamnionitis increases with increasing duration of membrane
rupture. Decreasing the time from PROM to delivery is associated with
lower rates of maternal infection. The American College of Obstetricians
and Gynecologists suggests that all women with PROM who do not have a
contraindication to vaginal delivery have their labor induced instead of
being managed expectantly. Although the use of oxytocin for labor in-
duction has been demonstrated to decrease the time to delivery compared
with expectant management, no studies have evaluated the effectiveness
of cervical ripening with a Foley bulb to additionally decrease the time to
delivery.
OBJECTIVE: To determine whether simultaneous use of an intra-
cervical Foley bulb and oxytocin decreases time from induction start to
delivery in nulliparous patients with PROM compared with the use of
oxytocin alone.
STUDY DESIGN: A randomized trial was conducted from August 2014
to February 2016 that compared the use of concurrent Foley bulb/oxytocin
vs oxytocin alone in nulliparous patients
34 weeks’ gestational under-
going labor induction for PROM. Our primary outcome was time from
induction to delivery. Secondary outcomes were mode of delivery,
tachysystole, chorioamnionitis, postpartum hemorrhage, Apgar scores,
and admission to the neonatal intensive care unit.
RESULTS: A total of 128 women were randomized. Baseline char-
acteristics were similar between groups. We found no difference in
induction-to-delivery time between women induced with concurrent
Foley bulb/oxytocin vs oxytocin alone (median time 13.0 hours [inter-
quartile 10.7, 16.1] compared with 10.8 hours [interquartile range
7.8, 16.6], respectively, P ¼ .09). There were no significant differences
in mode of delivery, rates of postpartum hemorrhage, chorioamnionitis,
or epidural use. Both groups had similar rates of tachysystole as well as
total oxytocin dose. There were no differences in neonatal birth weight,
Apgar scores, cord gases, or admissions to the neonatal intensive care
unit.
CONCLUSION: This is the first randomized trial to compare
concurrent Foley bulb/oxytocin vs oxytocin alone in nulliparous
patients undergoing induction of labor for PROM. We found no
difference in time from induction to delivery in patients induced with
concurrent Foley bulb/oxytocin vs oxytocin alone. In nulliparous
patients with PROM, this study suggests that addition of a Foley
bulb to oxytocin does not decrease the time from induction start to
delivery.
Key words: Foley bulb, induction of labor, labor induction, nulliparous,
premature rupture of membranes, PROM

P remature rupture of membranes

(PROM) or rupture of membranes
before the onset of labor affects 8% of
pregnancies.1 The risk of chorioamnio-
nitis increases with increasing duration
of membrane rupture, and multiple
studies have demonstrated that
decreasing the time from PROM to de-
livery is associated with lower rates of
maternal infection.2-5 Therefore, the
American College of Obstetricians and
Gynecologists suggests that all women
with PROM who do not have a contra-
indication to vaginal delivery have their
labor induced instead of being managed
Cite this article as: Amorosa JMH, Stone J, Factor SH,
et al. A randomized trial of Foley Bulb for Labor Induction
in Premature Rupture of Membranes in Nulliparas (FLIP).
Am J Obstet Gynecol 2017;217:360.e1-7.
0002-9378/$36.00
ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.04.038
expectantly.6 Although the use of
oxytocin for labor induction has been
demonstrated to decrease the time to
delivery compared with expectant man-
agement, no studies have evaluated the
effectiveness of cervical ripening with
the use of a Foley bulb to additionally
decrease the time to delivery.
The use of 2 induction agents
concurrently compared with the use of
one has been demonstrated to decrease
time to delivery in pregnant women
without PROM. Connolly et al7 in their
study of women undergoing induction
found a decreased time to delivery
among women receiving concurrent
Foley bulb and oxytocin compared with
sequential Foley bulb followed by
oxytocin. In a 4-arm study of women
undergoing induction, Levine et al8
compared time to delivery among
women assigned to 4 different induction
protocols: (1) concurrent Foley bulb and
misoprostol; (2) concurrent Foley bulb
and oxytocin; (3) misoprostol alone; and
(4) Foley bulb alone. The groups with
concurrent administration of 2 agents
had shorter time to delivery than the
groups with sequential administration of
agents. The use of concurrent Foley bulb
and oxytocin has never been studied in
women with PROM.
The purpose of this study was to
determine whether simultaneous use of
an intracervical Foley bulb inflated to 60
cc and oxytocin decreases the time from
induction start to delivery in nulliparous
patients with PROM compared with the
use of oxytocin alone.
Materials and Methods
This was a single-center, nonblinded,
randomized clinical trial in which we
compared the efficacy of Foley bulb plus
oxytocin vs oxytocin alone in patients
with PROM. The study was approved by
the Icahn School of Medicine at Mount
Sinai Medical Center’s Institutional

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Review Board and was registered with
the clinical trials registry (ClinicalTrials.
gov #NCT02098421). Women age 18
and older with a viable cephalic singleton
gestation of 34 weeks’ gestational age or
greater who presented with PROM be-
tween August 2014 and February 2016
were evaluated for participation by labor
floor providers. Patients were eligible for
participation if their cervix was dilated
less than 3 cm or, if the primary provider
wished to defer the initial cervical ex-
amination because of ruptured mem-
brane status, the patient was having
contractions less than 3 times every 10
minutes. Patients were ineligible to
participate if they had a multifetal
gestation, a known anomalous fetus, a
fetus with malpresentation, a latex al-
lergy, unexplained vaginal bleeding or
contraindication to vaginal delivery
(such as a placenta previa), had received
latency antibiotics, had had previous
uterine surgery (including previous ce-
sarean delivery or myomectomy), or
were in spontaneous labor (regular
uterine contractions with cervical
change). If eligible patients indicated
that they were interested in hearing more
about the study, they were approached
by a member of the research team, who
explained the study and obtained
informed consent from agreeable
patients.
Once the patient consented to partic-
ipate in the study, participants were
randomized to receive either concurrent
Foley bulb and oxytocin or oxytocin
alone. The randomization envelopes
were prepared before the start of the
study by the use of a random numbers
generator from OpenEPi, Version 3
(http://www.OpenEpi.com). Cards allo-
cating patients to either “oxytocin plus
Foley” or “oxytocin alone” were placed
in sequentially numbered, sealed opaque
envelopes. After signing consent, par-
ticipants were given the next ordered
envelope.
Patients in the Foley bulb and
oxytocin group had a 16-F, 30-cc Foley
bulb inserted digitally or under direct
visualization with the aid of a sterile
speculum. The Foley was threaded
through the internal cervical os and filled
with 60 mL of normal saline. The
FIGURE 1
Study enrollment, allocation, and analysis
Enrollment
Pitocin + Foley group (n=62):
♦ Received allocated intervention (n=61)
♦ 1 person treated off protocol
Lost to follow-up (n=0)
Analyzed (n=61)
♦ Excluded from analysis (n=1): one paƟent
<18 yo inadvertently recruited
Flow chart demonstrating patient recruitment through analysis.
Amorosa et al. Foley for labor induction in PROM (FLIP). Am J Obstet Gynecol 2017.
diameter of the Foley balloon with this
volume of saline is w4 cm. The catheter
of the Foley bulb was then taped to the
patient’s thigh under tension. Oxytocin
was started within 1 hour of Foley bulb
placement. In the oxytocin alone group,
oxytocin was started as soon as possible
after consent was obtained.
In both groups, oxytocin was titrated
according to our institution’s standard
induction protocol in which the
oxytocin infusion is started at 2 mU/
min. This dose is doubled every 30 mi-
nutes to a maximum dose of 16 mU/min
(2e4e8e16) and then may be increased
by 2 mU/min every 30 minutes to a
maximum dose of 30 mU/min or until
regular uterine contractions occur. Fetal
heart rate and contraction patterns are
monitored continuously in all patients
receiving oxytocin. Further labor
SEPTEMBER 2017 American Journal of Obstetrics & Gynecology
SMFM Papers
Approached (n=144)
Declined to participate (n=16)
Randomized (n=128)
Allocation
Pitocin Only group (n=66):
♦ Received allocated intervention (n=65)
♦ 1 person treated off protocol
Follow-Up
Lost to follow-up (n=0)
Analysis
Analyzed (n=66)
management was at the discretion of the
private provider.
Demographic characteristics, preg-
nancy history, labor course, delivery
data, and neonatal outcomes were
collected via patient interview and/or
chart review by the study team. After
each delivery, the fetal heart rate tracing
was reviewed for periods of tachysystole
(>5 uterine contractions in 10 minutes,
averaged over 30 minutes).
The primary outcome measure was
time from start of induction to delivery.
Secondary outcomes included mode of
delivery, tachysystole, chorioamnionitis,
postpartum hemorrhage, neonatal
Apgar scores, and admission to the
neonatal intensive care unit (NICU).
The sample size was estimated a priori
based on the primary outcome. We
assumed a normal distribution of
360.e2
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induction to delivery times with a mean

TABLE 1
induction to delivery time of 16.0  9
Baseline demographics
hours with oxytocin based on previously
Foley þ oxytocin Oxytocin alone published data.4,9-11 We estimated that
Characteristics n ¼ 61 (%) n ¼ 66 (%) 57 women would be needed in each
Maternal age, y mean (SD) 30.4 (5.3) 29.5 (6.3) group for 80% power to detect a 30%
difference in mean induction to delivery
Maternal age category, y
time for the 2 groups using a 2-tailed t-
18e19 2 (4) 4 (6) test and an a of 0.05. We chose to use a
20e29 21 (34) 24 (36) 30% difference as one that would be
30e39 35 (57) 35 (53) generally accepted as clinically
significant.
40e49 3 (5) 3 (5)
A modified intention-to-treat
Maternal prepregnancy BMI approach was used for the analysis,
<18.5 (underweight) 3 (5) 1 (2) which included all participants who were

18.5 and <25 (healthy weight) 35 (57) 46 (71) 18 years or older at the time of induction.
One participant was younger than 18

25 to < 30 (overweight) 16 (26) 11 (17)
years but was inadvertently enrolled and
30 to < 35 (obese) 3 (5) 1 (2) randomized and was excluded from this

35 (morbidly obese) 4 (7) 6 (9) modified intention-to-treat analysis. The
Gestational age at delivery, median (IQR) 39.3 (38.1, 40.0) 39.2 (38.0, 40.0) primary outcome, time from the start of
induction to delivery, was analyzed with
34w0d-36w6d 8 (13) 7 (11)
Kaplan-Meier analysis and the Wilcoxon
37w0d-41w6d 53 (87) 59 (89) rank sum test. Secondary outcomes were
Estimated fetal weight at initiation of 3359.5 (322.56) 3316.4 (300.01) compared with the c2 test, Fisher exact
study, g mean (SD) test, Student t test, and Wilcoxon rank-
Small-for-gestational age (<2500 g) 0 0 sum, as appropriate. SAS, version 9.4
Normal (
2500 and 4500 g) 58 (100) 66 (100) (SAS Institute Inc, Cary, NC) was used
for the analysis. A P value of .05 was
Large-for-gestational age (>4500) 0 0
considered significant.
Race
White 32 (52) 39 (59) Results
Black 6 (10) 9 (14)
A total of 128 women were enrolled from
August 2014 to February 2016
Asian 9 (15) 8 (12)
(Figure 1). Of these, 62 women were
American Indian/Alaskan 0 0 assigned to receive Foley bulb plus
Pacific Islander/Hawaiian 0 0 oxytocin, and 66 were assigned to receive
Ethnicity
oxytocin alone. Of the 62 patients ran-
domized to the Foley bulb plus oxytocin
Hispanic/Latina 11 (18) 12 (18) group, one was excluded from the anal-
Non-Hispanic/Latino 42 (69) 53 (80) ysis because she was younger 18 years of
Marital status age. Of the remaining 61 patients in the
Foley bulb plus oxytocin group, 53
Married 45 (74) 46 (70)
received both the Foley bulb and the
Single 13 (21) 14 (21) oxytocin per protocol (ie, initiated less
Domestic partner 2 (3) 6 (9) than 1 hour apart, and 8 received both
Insurance status the Foley bulb and the oxytocin but
initiated at greater than 1 hour apart). Of
Private 46 (75) 42 (64)
the 66 patients assigned to receive
Medicaid or self-pay 15 (25) 24 (36) oxytocin alone, 65 received the oxytocin
Time from rupture to induction start, h per protocol, and 1 had a Foley bulb
median (IQR) 5.5 (3.8, 8.7) 5.5 (4.2, 9.1) placed per personal provider decision.
The 2 groups were similar with regard
Amorosa et al. Foley for labor induction in PROM (FLIP). Am J Obstet Gynecol 2017. (continued)
to baseline characteristics, including age,

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prepregnancy body mass index, esti-

TABLE 1 mated fetal weight, and gestational age
Baseline demographics (continued) (Table 1). All of the women were
Foley þ oxytocin Oxytocin alone nulliparous and the median Bishop’s
Characteristics n ¼ 61 (%) n ¼ 66 (%) score was similar in the 2 groups.3 Both
Time from rupture to oxytocin, h groups had been ruptured for approxi-
mately the same length of time before
median (IQR) 5.6 (3.8, 9.0) 5.5 (4.2, 9.1)
the start of the induction. In addition,
Bishop score, median (IQR) 3 (1, 4) 3 (1, 4) both groups had been ruptured for
Dilation, cm similar lengths of time before oxytocin
0 13 (21) 14 (29) was started.
There was no difference in
1-2 47 (77) 35 (71)
induction-to-delivery time between
3e4 1 (2) 0 women induced with a combination of
BMI, body mass index; IQR, interquartile range. the Foley bulb plus oxytocin when
Amorosa et al. Foley for labor induction in PROM (FLIP). Am J Obstet Gynecol 2017. compared with those induced with
oxytocin alone (median time 13.0 hours
[interquartile range {IQR} 10.7, 16.1]
compared with 10.8 hours [IQR 7.8,
TABLE 2 16.6], respectively, P ¼ .09) (Table 2;
Maternal outcomes Figure 2). The log rank test indicates
that there is no difference between the
Foley þ oxytocin Oxytocin alone
Characteristic n ¼ 61 (%) n ¼ 66 (%) P value curves in time from the start of in-
duction to delivery in the 2 groups.
Primary outcome
Consistent with that finding, the curves
Induction to delivery, h cross.
median (IQR) 13.0 (10.7, 16.1) 10.8 (7.8, 16.6) .09a When only women who followed the
Secondary outcomes assigned protocol were analyzed, there
was also no difference in induction-to-
Mode of delivery
delivery time between the 2 groups.
Normal vaginal delivery 36 (59) 43 (65) .91b There were also no differences in mode
Cesarean delivery 18 (30) 16 (24) of delivery, rates of postpartum hem-
Forceps assisted 4 (7) 4 (6) orrhage, chorioamnionitis, endome-
tritis, or epidural use. Both groups had
Vacuum assisted 3 (5) 3 (5)
similar rates of tachysystole, and the
Reasons for cesarean delivery total and maximum doses of oxytocin
Arrest of descent 3 (5) 2 (3) .67b were similar between both groups
Arrest of dilation 11 (18) 8 (12) .35c (Table 2).
There was no difference in time from
Nonreassuring fetal heart tracing 4 (7) 5 (8) 1.00b
start of induction to delivery between the
Postpartum hemorrhage 5 (8) 2 (3) .26b 2 groups when the data were stratified by
Chorioamnionitis 6 (10) 3 (5) .31b the maternal characteristic of prepreg-
Endometritis 2 (3) 2 (3) 1.00b nancy body mass index (Table 3). In
women who delivered vaginally, those
Epidural use 61 (100) 64 (97) .50b
receiving oxytocin alone had shorter
Other delivery-related outcomes mean time to delivery than those in the
Tachysystole 7 (11) 8 (12) .89c combination group (10.6 hours [IQR
Max dose of oxytocin, mU/min 7.1, 14.2] vs 13.2 hours (IQR 10.8, 15.9),
whereas there was no difference in those
median (IQR) 12.0 (8.0, 18.0) 12.0 (8.0, 18.0) .74a
who delivered by cesarean delivery. In
Total dose of oxytocin, mL patients who started the induction at
median (IQR) 237.5 (102.5, 431.5) 222.8 (78.0, 438.0) .83a 0 cm dilation, there was a significantly
Meconium 4 (7) 6 (9) .75b longer median time from start of in-
duction to delivery in the Foley bulb plus
a
Analyzed with Wilcoxon rank sum test; Analyzed with the Fisher exact test; Analyzed with the c test.
b c 2

Amorosa et al. Foley for labor induction in PROM (FLIP). Am J Obstet Gynecol 2017. oxytocin group compared with the
oxytocin alone group (15.4 hours [IQR

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FIGURE 2
Kaplan-Meier time curve for start of induction to delivery

There was no significant difference in time from induction start to delivery in nulliparous patients with PROM who were induced by the use of either a
combination of concurrent foley bulb plus oxytocin vs oxytocin alone.
PROM, premature rupture of membranes.
Amorosa et al. Foley for labor induction in PROM (FLIP). Am J Obstet Gynecol 2017.

13.2, 17.5] in the Foley bulb plus
oxytocin group vs 11.8 hours [IQR 9.4,
14.2] in the oxytocin alone, P ¼ .02).
There were no differences in neonatal
birth weight, Apgar scores, or admission
to the neonatal intensive care unit
(Table 4). Umbilical cord gases were
similar in the 2 groups.
Comment
There was no difference in the time
from start of induction until delivery in
patients with PROM who were induced
with a combination of a Foley bulb plus
oxytocin vs oxytocin alone. Although
no significant differences were observed
in mode of delivery, labor complica-
tions, or maternal adverse outcomes
such as chorioamnionitis and post-
partum hemorrhage, twice as many
patients in the Foley plus oxytocin
group had a postpartum hemorrhage or
delivery affected by chorioamnionitis.
However, this study was not powered to
specifically address these outcomes, and
the overall numbers were small. In
addition, no differences were found in
adverse neonatal outcomes such as
admission to the NICU, cord gas values,
or Apgar scores. Among patients who
started their induction at 0 cm dilation,
patients who were induced with a
combination of Foley bulb plus
oxytocin had a significantly longer time
to delivery than those who received
oxytocin alone; however, the number of

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TABLE 3
Median time and IQR in hours from start of induction to delivery by maternal characteristics
Foley þ oxytocin, Oxytocin alone,
Characteristic n median hours (IQR) N median hours (IQR) P valuea
Mode of delivery
Vaginal 43 13.2 (10.8, 15.9) 50 10.6 (7.1, 14.2) .02
Cesarean delivery 18 12.3 (10.5, 17.0) 16 16.0 (9.8, 18.2) .57
Dilation
0 13 15.4 (13.2, 17.5) 14 11.8 (9.4, 14.2) .02
1e2 47 12.0 (10.1, 15.9) 35 11.0 (8.2, 17.7) .86
Maternal prepregnancy BMI
<18.5 3 7.0 (5.2, 15.9) 1 6.1 1.0

18.5 and <25 35 13.0 (10.8, 15.2) 46 10.8 (7.2, 16.7) .14

25 to <30 16 12.2 (10.2, 16.3) 11 11.3 (8.7, 16.6) .86
30þ 7 18.5 (11.3, 21.1) 7 10.7 (5.9, 15.1) .15
BMI, body mass index; IQR, interquartile range.
a
Analyzed with the Wilcoxon Rank Sum test.
Amorosa et al. Foley for labor induction in PROM (FLIP). Am J Obstet Gynecol 2017.

patients in this group was very small. A
subgroup analysis of the patients who
began their induction at 0 cm dilation
showed similar doses of total oxytocin
whether they received oxytocin alone or
oxytocin with concurrent Foley balloon.
To our knowledge, there have been no
previous studies specifically comparing
the concurrent use of oxytocin and Foley
bulb with oxytocin alone for labor in-
duction in patients with PROM. There
have been other studies that compared
other dual agent inductions in PROM.
Our finding that concurrent Foley and
oxytocin compared with oxytocin alone
did not shorten induction times is
similar to the results of a study by Tan
et al,12 in which concurrent dinopro-
stone and oxytocin was compared
against induction with oxytocin alone in
term PROM patients. They randomized
116 term, nulliparous patients with
PROM to receive either 3 mg of dino-
prostone pessary plus oxytocin vs a
placebo plus oxytocin. There was no
significant difference in time from in-
duction to delivery between the 2 groups.
Similar to our study, there also were
no significant differences in mode of
delivery and rates of postpartum hem-
orrhage. There were also no differences
in Apgar scores and NICU admissions.
Membrane rupture is associated with cervical examination before the start of
prostaglandin release locally at the site their oxytocin because of provider
of the membrane—this mechanism preference. It is possible that this subset
alone is enough to trigger labor onset in of patients had a more favorable Bishop
most patients, as 60% will go into labor score than the other patients enrolled in
within 24 hours and 95% within 72 the study and could have skewed the
hours.1,13 It is plausible that the pros- results to shorter induction times in the
taglandin release thought to be stimu- oxytocin alone group as a whole. This is
lated by the Foley balloon is not unlikely however, as we compared the
necessary as perhaps the optimal phys- patients who had an initial examination
iologic amount already is released at in the oxytocin alone group vs those
time of membrane rupture. who did not have an initial examination
There are several limitations to this and found similar total times from in-
study. First, 17 of 66 patients in the duction start to delivery. In the 49
oxytocin-alone group did not have a women who had a cervical examination
TABLE 4
Neonatal outcomes
Foley þ oxytocin Oxytocin alone
Characteristics n ¼ 61 (%) n ¼ 66 (%) P value
Birth weight, g, mean (SD) 3163.6 (457.5) 3101.8 (500.5) .47a
1-minute Apgar score, median (IQR) 9 (9, 9) 9 (9, 9) .14b
5-minute Apgar score, median (IQR) 9 (9, 9) 9 (9, 9) .18b
Admission to the NICU 4 (7) 8 (12) .37c
Cord gas pH, mean (SD) 7.25 (0.06) 7.25 (0.07) .77a
IQR, interquartile range; NICU, neonatal intensive care unit.
a
Analyzed with the Student t test; b Analyzed with the Wilcoxon rank-sum test; c Analyzed with the Fisher exact test.
Amorosa et al. Foley for labor induction in PROM (FLIP). Am J Obstet Gynecol 2017.

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before the start of their oxytocin, the
median time from the start of induction
to delivery was 11.0 hours (IQR 8.4
hours, 16.6 hours). In the 17 women
who did not have a cervical examina-
tion before the start of their oxytocin,
the median time form the start of in-
duction to delivery was 10.8 hours
(IQR 6.1 hours, 14.3 hours). There was
no statistical difference in these times
based on the Wilcoxon rank sum test
(P ¼ .44).
Second, there is a potential for selec-
tion bias in our study—we do not have
data available to compare the women
with PROM who participated in our
study with all women with PROM at our
institution. Another potential imitation
of the study has to do with institution-
specific protocols. Our oxytocin proto-
col for labor induction may vary from
other institutions and our protocol is to
fill Foley bulbs to 60 cc, whereas other
institutions may use other standard
volumes.
This study used a sample size calcu-
lation that was based on the assumption
that times from the start of induction to
delivery would be normally distributed.
The times from the start of induction to
delivery observed in this study were not
normally distributed. This study found
that patients induced with a combina-
tion of Foley and oxytocin had a non-
statistically significant longer time from
induction start to delivery. A larger
study may have found that increase in
time actually was statistically signifi-
cant. This study, on its own, suggests
that the addition of Foley does not
decrease time from the start of induc-
tion to delivery, which was the clinically
relevant outcome we were studying.
Based on the results of this study, the
addition of Foley is not recommended
to shorten induction times in patients
with PROM.
360.e7 American Journal of Obstetrics & Gynecology SEPTEMBER 2017
Many obstetrical providers question
whether the introduction of the Foley
bulb in patients with PROM may in-
crease rates of maternal complications
such as infection and postpartum hem-
orrhage. Although twice as many pa-
tients in the Foley plus oxytocin group
had their delivery complicated by either
chorioamnionitis or postpartum hem-
orrhage in this study, the overall
numbers were small, and the difference
did not meet statistical significance. A
much larger study would be needed to
address these specific questions.
We found no difference in time from
induction to delivery in nulliparous pa-
tients with PROM who were induced
either using a combination of concur-
rent Foley bulb plus oxytocin versus
oxytocin alone. These findings address a
frequently asked question about whether
there is utility in using Foley bulbs to
assist with cervical ripening in patients
with PROM in an effort to shorten the
duration of labor induction. This study
suggests that Foley bulbs should not be
used in induction of labor for PROM in
nulliparous patients, as no additional
benefit is conferred. n 247-52.
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Author and article information
From the Division of Maternal Fetal Medicine, Department
of Obstetrics, Gynecology and Reproductive Science,
Mount Sinai Hospital, New York, NY.
Received March 4, 2017; accepted April 24, 2017.
The authors report no conflict of interest.
Corresponding author: Jennifer M. H. Amorosa, MD.
amorje@valleyhealth.com