A 32-year-old primigravida at 41 weeks of gestation presents to the labor ward for induction of labor. The cervix is unfavorable (Bishop score 6). Which is the most common pharmacological agent used for cervical ripening before induction of labor in India?

Explanation

## Cervical Ripening Agents for Labor Induction **Key Point:** Misoprostol is the most commonly used and preferred agent for cervical ripening in India due to its cost-effectiveness, stability at room temperature, and ease of administration. ### Mechanism of Action Misoprostol is a synthetic prostaglandin E₁ analogue that: - Increases myometrial contractility - Softens and effaces the cervix - Promotes cervical dilation ### Dosing and Route - **Vaginal:** 25 mcg every 3–6 hours (most common in India) - **Oral:** 25 mcg every 3–4 hours - **Buccal:** 25 mcg every 3–4 hours ### Advantages of Misoprostol | Feature | Benefit | |---------|----------| | **Cost** | Significantly cheaper than dinoprostone | | **Stability** | No refrigeration required | | **Administration** | Easy vaginal/oral/buccal placement | | **Efficacy** | High success rate for cervical ripening | | **Availability** | Widely available in India | **High-Yield:** Misoprostol is preferred in resource-limited settings and is the de facto standard in India for cervical ripening before labor induction. ### Comparison with Other Agents | Agent | Route | Cost | Stability | Use in India | |-------|-------|------|-----------|---------------| | **Misoprostol** | Vaginal/Oral/Buccal | Low | Room temp | Most common | | **Dinoprostone** | Intracervical gel | High | Refrigerated | Less common | | **Oxytocin** | IV infusion | Moderate | Refrigerated | For augmentation, not ripening | | **Mifepristone** | Oral | Moderate | Room temp | Limited use in India | **Clinical Pearl:** Misoprostol should be avoided or used with caution in women with prior uterine scar (VBAC) due to increased risk of uterine rupture. **Warning:** Dinoprostone is rarely used in India due to high cost and need for refrigeration, despite being FDA-approved. Oxytocin is not suitable for cervical ripening in an unfavorable cervix—it is used only for augmentation of labor after cervical ripening or in favorable cervices.