3-Hourly Foley Balloon Tugging for Cervical Ripening: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Scheduled intermittent Foley balloon tugging (30 seconds of forceful traction every 3 hours during a planned 12-hour placement) has been proposed to shorten induction of labor. We synthesized the randomized evidence on this question. Methods: We searched MEDLINE/PubMed, EMBASE, CENTRAL, Web of Science, and Scopus from inception to June 2026 for randomized controlled trials (RCTs) comparing 3-hourly Foley tugging with standard passive care. Primary outcomes were induction-to-birth interval and cesarean delivery. Risk of bias was assessed with RoB 2 and certainty of evidence with GRADE. Mean differences (MD) and risk ratios (RR) were pooled using DerSimonian–Laird random-effects models, with fixed-effect, Hartung–Knapp, leave-one-out, and substituted-estimate sensitivity analyses. The protocol was registered on the Open Science Framework (10.17605/OSF.IO/S37DZ). Results: Three RCTs including 610 women (305 per arm) were eligible. Tugging did not significantly shorten the induction-to-birth interval (MD −1.36 hours, 95% CI −3.21 to 0.50, I² = 0%) or reduce cesarean delivery (RR 0.91, 95% CI 0.72 to 1.14, I² = 37%). Additional cervical ripening (two trials, 484 women) did not differ significantly (RR 0.94, 95% CI 0.80 to 1.11). Maternal satisfaction and neonatal acidemia did not differ significantly between arms. Findings were unchanged in all sensitivity analyses. Certainty of evidence was moderate for induction-to-birth interval and low for the remaining outcomes. Conclusion: Current randomized evidence does not show that scheduled 3-hourly Foley tugging shortens induction or lowers cesarean delivery, although it appears safe and acceptable and a modest benefit is not excluded. Routine adoption cannot be recommended, larger multicenter trials are needed.