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Dr. Deepa Arora Medical Officer,Royal Hospital Supervisor- Dr. Anita Zutshi Senior Consultant, Royal Hospital
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Induction of labour – Experience at Royal Hospital Oman

Dec 31, 2015

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Induction of labour – Experience at Royal Hospital Oman. Dr. Deepa Arora Medical Officer,Royal Hospital Supervisor- Dr. Anita Zutshi Senior Consultant, Royal Hospital. Induction of Labour. Iatrogenic stimulation of Uterine contractions to accomplish delivery prior to the onset of labour. - PowerPoint PPT Presentation
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Page 1: Induction of labour – Experience at Royal Hospital  Oman

Dr. Deepa AroraMedical Officer,Royal Hospital

Supervisor- Dr. Anita ZutshiSenior Consultant, Royal Hospital

Page 2: Induction of labour – Experience at Royal Hospital  Oman

Induction of LabourIatrogenic stimulation of Uterine

contractions to accomplish delivery prior to the onset of labour.

Increasing rates of IOL all over the world

In the United States, the rate of IOL has ed from 9.5% of births in 1990 to 22.1% of births in 2004 .

Reasons : Availability of better cervical ripening agents. Arrangement of convenient time for delivery by Patient

and clinician. More relaxed attitude towards marginal indications for

IOL. Increasing patient/provider concerns about the risks of

fetal demise near term/post term.

Page 3: Induction of labour – Experience at Royal Hospital  Oman

Introduction ( Contd.)

Concerns with Elective Induction of Labour at term are

Reported increased rate of LSCS.Iatrogenic prematurityCost effectiveness Maternal- Fetal medical benefits such as

reduction in still birth rate have not been proven.

Page 4: Induction of labour – Experience at Royal Hospital  Oman

Induction of LabourLabour may be induced for either

maternal/fetal indication.

IOL is undertaken when both following criteria are met

Continuing the pregnancy is believed to be associated with greater maternal/fetal risk than intervention to deliver the pregnancy

There is no contraindication to vaginal birth.

Page 5: Induction of labour – Experience at Royal Hospital  Oman

Contraindications :

when the maternal/ fetal risk associated with labour or vaginal delivery is believed to be greater than the risk associated with Caesarean delivery e.g. :

Prior Classical Uterine incision. Active Genital Herpes infection. Placenta/Vasa Previa. Umbilical cord prolapse. Transverse Fetal lie.

Induction of Labour

Page 6: Induction of labour – Experience at Royal Hospital  Oman

Objectives of the Study

Indications of IOL Success Rate Rate of LSCS Frequency of Complications

in patients who underwent IOL in comparison to patients with spontaneous onset of labour.

Page 7: Induction of labour – Experience at Royal Hospital  Oman

IOL- Materials and methods

Study population - all patients undergoing IOL at Royal Hospital from 1st January, 2009 to 31st March, 2009.(n=147)

Control group comprised of the patients who went in labour spontaneously during the same period . (n=1468).

Demographic characteristics, antenatal or medical complications, methods employed for IOL, success rate, rate and nature of complications ,rate of LSCS, non progress of labour were studied & compared in both groups.

Page 8: Induction of labour – Experience at Royal Hospital  Oman

Total Deliveries= 1783LSCS,

319, 18%

Vaginal delivery,

1464, 82%

Spontaneous labour, 1468,

83%

El. LSCS, 168, 9%

IOL,147, 8%

1st January to 31st March, 2009

Page 9: Induction of labour – Experience at Royal Hospital  Oman

IOL- Protocol at Royal Hospital

All patients planned for IOL are admitted the evening before.

A baseline CTG is done.

Since cervical status is one of the most important factors for predicting the likelihood of successfully inducing labour ,vaginal examination is done to assess the Bishop score and decide the method of IOL.

Calder’s modified Bishop score is used.

Page 10: Induction of labour – Experience at Royal Hospital  Oman

Calder’s Modified Bishop Score

0 1 2 3

1 Dilatation of internal os ( cm.)

<1 1-2 2-4 >4

2 Length of cervix

( cm.)

>4 2-4 1-2 <1

3 Consistency of cervix

Firm average soft -

4 Position of cervix posterior Mid,

anterior

- -

5 Station of head -3 -2 -1,0 -

Page 11: Induction of labour – Experience at Royal Hospital  Oman

Methods of Induction :

Doses Nullipara Multipara G. Mutipara

1st dose 2 mg 1 mg 1 mg

2nd dose 1 mg 1 mg 1 mg

3rd dose 1 mg 1 mg

Total dose 4 mg 3 mg 2 mg

Induction Of Labour - Protocol ( contd.)

1.Intravaginal application of PGE 2 gel.

Page 12: Induction of labour – Experience at Royal Hospital  Oman

Oxytocin is of little clinical value prior to amniotomy.

Oxytocin is not given until at least 6 hours after the last PG application, to avoid hyperstimulation.

2. ARM followed by i.v. Syntocinon if Cx favourable ( Bishop’s Score > 6)

Amniotomy is not performed when-Presenting part is high, risk of cord prolapse.Breech with flexed legs

Induction Of Labour - Protocol ( contd.)

Oxytocin

Page 13: Induction of labour – Experience at Royal Hospital  Oman

Syntocinon infusion in PrimigravidaDilute 10 units of syntocinon in 500 ml of Hartman’s

Time after starting min Oxytocin(milliunit/min) Volume infused(ml/hr)

0 1 3

30 2 6

60 4 12

90 8 24

120 12 36

150 16 48

180 20 60

210 24 72

240 28 84

270 32 96

Page 14: Induction of labour – Experience at Royal Hospital  Oman

Synto infusion in Multigravida and Previous LSCSDilute 5 units of syntocinon in 500 ml Hartman’s

Time after starting min Oxytocin(milliunit/min) Volume infused(ml/hr)

0 1 3

30 2 6

60 4 12

90 8 24

120 12 36

150 16 48

180 20 60

Page 15: Induction of labour – Experience at Royal Hospital  Oman

Syntocinon Infusion in GrandmultiparaDilute 5 units Syntocinon in 500 ml Hartman’s

Time after starting

In minutes

Oxytocin dose

(milliunits/min.)

Volume infused

( ml/hour)

0 1 3

30 2 6

60 4 12

90 8 24

120 12 36

Page 16: Induction of labour – Experience at Royal Hospital  Oman

Uterine Hyperstimulation

Vaginal douche- removing the drug used

Discontinue syntocinon infusion

Continuous CTG, i.v. line, nasal oxygen

In presence of abnormal FHR & Uterine hyperstimulation, tocolysis ( S/C Terbutaline 0.25 mg) to be considered

In suspected acute fetal compromise, delivery should be accomplished as soon as possible with possible LSCS.

Defined as 5 or more uterine contractions per minute.

Management

Page 17: Induction of labour – Experience at Royal Hospital  Oman

Age Groups IOL Spont. Labour

< 20 years 0.68 %(1) 1.84 % (27)

20-25 years 33.33 % (49) 27.12 %(398)

26-30 years 38.78 % (57) 36.00 %(528)

31-35 years 19.05 % (28) 22.14 %(325)

36-40 years 6.12 % (9) 8.92 %(131)

> 40 years 2.04 % (3) 4.00 %(59)

OBSERVATIONS

Page 18: Induction of labour – Experience at Royal Hospital  Oman

OBSERVATIONS -Age Groups0.

681.

84

33.3

3

27.1

238

.78

3619

.05 22.1

4

6.12 8.

92

2.04 4

<20 20-25 26-30 31-35 36-40 >40

Percent in studygroup

Percent in controlgroup

Page 19: Induction of labour – Experience at Royal Hospital  Oman

Observations- Parity

Parity % of IOL pt. % spont. labour

P0 52.38 % 32.31 %

P1 18.37 % 22.46 %

P2 8.84 % 11.38 %

P3-4 12.93 % 22.16 %

P5 & above 7.48 % 11.69 %

Page 20: Induction of labour – Experience at Royal Hospital  Oman

OBSERVATIONS - Parity

52.3

8

32.3

1

18.3

7

22.4

6

8.84 11.3

8

12.9

3

22.1

6

7.48 11

.69

P0 P1 P2 P3-4 >P4

Percent of IOL patients

Percent of Spontaneously Labouring patients

Page 21: Induction of labour – Experience at Royal Hospital  Oman

Observations-Gestation in Weeks

Gestational age % in IOL group % in control gp.

26-34 weeks 2.04 % 0.61 %

34-37 weeks 10.20 % 6.46 %

37-39 weeks 29.25 % 38.46 %

39-41 weeks 28.57 % 48.31 %

> 41 weeks 29.94 % 6.16 %

Page 22: Induction of labour – Experience at Royal Hospital  Oman

OBSERVATIONS - Gestational age

2.04

0.61

10.2

6.46

29.2

5

38.4

6

28.5

7

48.3

1

29.9

4

6.16

26-34 34-37 37-39 39-41 >41

Percent study group

Percent control group

Page 23: Induction of labour – Experience at Royal Hospital  Oman

Medical Complications Complication % in Study gp. %in control gp.

Diabetes 8.16 % (12) 7.69 % (113)

Hypertension 13.61 % (20) 4.91 % ( 72)

Heart Disease 2.72 % ( 4) 0.95 % ( 14)

Asthma 0.68 % ( 1) 0.48 % ( 7)

Epilepsy 1.36 % ( 2) 0.61 % ( 9)

DVT 0.68 % ( 1) 0.27 % ( 4)

Sickle disease 2.72 % ( 4) 0.34 % ( 5)

Miscellaneous 4.76 % ( 7) 5.04 % ( 74)

Page 24: Induction of labour – Experience at Royal Hospital  Oman

OBSERVATIONS - Medical Complications

2.72 %

13.61%

2.72 %

0.68 %

4.76 %

0.68 %

1.36 %

8.16%

0.27 %

0.61 %

0.95 %

5.04 %

0.34 %

0.48 %

4.91%

7.69 %

Misc.

SCD

DVT

Epilepsy

Asthma

Heart dis.

HTN

DM

Percent in control group

Percent in Study group

Page 25: Induction of labour – Experience at Royal Hospital  Oman

Misc. Medical ComplicationsStudy group Control groupSchizophrenia 0.68%

AdrenalTumour 0.68%

Ureteric stent, hydronephrosis

0.68%

Thrombophilia 2.72%

Hepatitis 1.86%

Anaemia 1.86%

Thyroid disease 0.93%

Haemophilia 0.31%

Page 26: Induction of labour – Experience at Royal Hospital  Oman

Medical Complications- IOLDiabetes 12 Epilepsy 2

Ch. Hypertension 9 PIH 11

Heart Disease 4 Adrenal Tumour 1

Thrombophilia 4 Schizophrenia 1

Sickle cell Dis. 4 DVT 1

Asthma 1 Hydronephrosis 1

Page 27: Induction of labour – Experience at Royal Hospital  Oman

Study group (n= 147)

Method of IOL Number of patients

With Dinoprostone ( PGE2) Gel 141

With Artificial Rupture of membranes 3

With Oxytocin infusion 2

With Misoprostol Tablets

( PGE1) vaginal 1

Page 28: Induction of labour – Experience at Royal Hospital  Oman

Indications for IOL, n=147

2.72

2.72

4.08

2.04

10.2

3.4

3.4

8.84

8.16

4.76

19.74

29.94

Misc.

Prev.ANC

Maternal dis.

SCD

HTN

DM

IUD

reduced FM

IUGR

Oligohyd

ROM

Postdate

Page 29: Induction of labour – Experience at Royal Hospital  Oman

Indication for IOL, n=147

Post Date Pregnancy 29.94 % ( 44)

Ruptured Membranes 19.74 % ( 29)

Oligohydramnios 4.76 % ( 7)

Growth Restricted Fetus 8.16 % ( 12)

Reduced Fetal movements 8.84 % ( 13)

Intrauterine fetal death 3.40 % ( 5)

Diabetes at term 3.40 % ( 5)

Hypertension 10.20 %( 15)

Sickle disease at term 2.04 % ( 3)

Other maternal disease 4.08 % ( 6)

Previous pregnancy factors 2.72 % ( 4)

Miscellaneous 2.72 % ( 4)

Page 30: Induction of labour – Experience at Royal Hospital  Oman

Preinduction Bishop Score

< 4 4 - 6 6 - 8 > 8

81 60 5 1 IOL with Syntocinon

1 case with Bishop score < 4 had FAILED IOL.

Page 31: Induction of labour – Experience at Royal Hospital  Oman

OBSERVATIONS -Preinduction Bishop Score

4-6 score, 60, 41%<4 score,

81, 55%

>8 score, 1, 1%

6-8 score, 5, 3%

Page 32: Induction of labour – Experience at Royal Hospital  Oman

Dose of PGE 2 received

Most of our patients(47%) responded to the 2nd dose of 1st course of PGE 2 gel,

Almost 25% responded to the 1st dose itself and 15% to the 3rd dose of the 1st course.

2 patients with Sickle cell disease required 2 full courses of PGE 2 gel, and were successful.

Our single failed induction patient had received 3 doses of PGE 2 gel and the mode of induction was changed to PGE 1.

Page 33: Induction of labour – Experience at Royal Hospital  Oman

Dose of PGE 2 received ( mg)

25.85

46.94

14.97

5.44

0.68 0.68 1.36

1 2 3 4 5 6 7

Page 34: Induction of labour – Experience at Royal Hospital  Oman

<1500 gm 2.04 %

1501-2500 gm 19.05 %

2501-3500 gm 63.26 %

3501-4000 gm 14.29 %

>4000 gm 1.36 %

Birth weight in Study group, n=147

Page 35: Induction of labour – Experience at Royal Hospital  Oman

BIRTH WEIGHT

3

28

93

21

2

<1500 gm 1501-2500gm

2501-3500gm

3501-4000gm

>4000 gm

Page 36: Induction of labour – Experience at Royal Hospital  Oman

Foetal OutcomeStudy group Control group

Apgar score < 7 at 5 mt – 7 IUFD – 5Anomalous - 2

Apgar score < 7 at 5 mt 12 IUFD - 6Anomalous - 3Asphyxia - 3

Page 37: Induction of labour – Experience at Royal Hospital  Oman

Abnormal CTG 36 , 24.49%

Meconeum stained Liqour 20 , 13.61%

Apgar score less than 7 at 5 minutes 7 , 4.76%

Uterine Hyperstimulation 1 , 0.68%

Precipitate Labour 8 , 5.44%

Tears and Lacerations 23 ,15.65%

Rupture Uterus 0

Complications in study group

Page 38: Induction of labour – Experience at Royal Hospital  Oman

ResultsTotal no. of pt. LSCS

Study group 147 46 ( 31.29%)

Control group 1468 151 (10.3%)

Using the chi-square test, found that the risk of LSCS in patients who had IOL was highly significant. Chi- square = 55.24

Relative Risk = 3.04, p>>0.05 .95% CI ranged from 13.35 % - 28.66 %

Page 39: Induction of labour – Experience at Royal Hospital  Oman

Results SVD LSCS

Study group 101 (68.71%) 46 (31.29%)

Control group 1317 (89.70%) 151 (10.30%)

Page 40: Induction of labour – Experience at Royal Hospital  Oman

Results

LSCS rate Non progress

Study group 46 (31.29 %) 10 (6.8 %)

Control group 151 (10.3 %) 39 (2.65 %)

Relative Risk of NPOL is 1.56.Chi-square for NPOL is 7.98, suggesting

significant risk of NPOL in patients who had IOL.

No scar dehiscence/rupture in Prev. scar pts ( 9, 6%)

Page 41: Induction of labour – Experience at Royal Hospital  Oman

Results ( Contd.)Commonest indication for IOL

Postdate pregnancy, ROM,PIH

Reported PGE 2 vaginal application advantage

Fewer maternal side effects and Favourable neonatal outcomes

In this short period there was no incidence of compromised neonatal outcome in IOL group.

Page 42: Induction of labour – Experience at Royal Hospital  Oman

Results ( Contd.)

Failure rate in IOL group at RH - 0.68% Reported failure rate

Warke et al, 1999 – 1.33 %Prince et al, 1984 – 6 %

Failure rate

Page 43: Induction of labour – Experience at Royal Hospital  Oman

CONCLUSIONInduction is safe in multigravida / grand

multigravida / prev. scar patientRate of complications due to IOL ( % of

complications / uncomplicated)Maternal

Rate of hyperstimulation – minimal ( 0.68%) CS rate higher as IOL is planned in

complicated pregnancy which has a higher CS rate

Rupture uterus – no case in this period

Page 44: Induction of labour – Experience at Royal Hospital  Oman

Recommendation - Counselling for IOL

Healthcare professionals should explain the following points:– the reasons for induction being offered– when, where and how induction could be carried out– the arrangements for support and pain relief (recognising

that women are likely to find induced labour more painful than spontaneous labour)

– the alternative options if the woman chooses not to have induction of labour

– the risks and benefits of induction of labour in specific circumstances and the proposed induction methods

– that induction may not be successful and what the woman’s options would be.

NICE guidelines, July 2008

Page 45: Induction of labour – Experience at Royal Hospital  Oman

Recommendations(level A), are as follows:

1. For cervical ripening and labor induction, prostaglandin E (PGE) analogues are effective.

2. When labor induction is indicated, low-dose or high-dose oxytocin regimens are appropriate.

3. Regardless of Bishop score, the most efficient method of labor induction before 28 weeks of gestation appears to be vaginal misoprostol. However, infusion of high-dose oxytocin is also an acceptable option.

4. For cervical ripening and induction of labor, an appropriate initial dose of misoprostol is approximately 25 µg, with frequency of administration not to exceed 1 dose every 3 to 6 hours.

5. For induction of labor in women with premature rupture of membranes, intravaginal PGE2 appears to be safe and effective.

6. In women with previous cesarean delivery or major uterine surgery, the use of misoprostol should be avoided in the third trimester because it has been linked to a greater risk for uterine rupture.

7. The Foley catheter is a reasonable, effective option to promote cervical ripening and labor induction.

ACOG Revised Guidelines for IOL, July 2009

Page 46: Induction of labour – Experience at Royal Hospital  Oman

(level B), 1.is that misoprostol, 50 µg every 6 hours, to induce labor

may be appropriate in some situations. However, higher doses are linked to a greater risk for uterine tachysystole with fetal heart rate (FHR) decelerations and other complications.

9. A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery

ACOG Revised Guidelines for IOL, July 2009

Page 47: Induction of labour – Experience at Royal Hospital  Oman

References

1.Systematic Review: Elective Induction of Labor Versus Expectant Management of Pregnancy- Aaron B. Caughey, et al 18 August 2009 | Volume 151 Issue 4 | Pages 252-263

Annals of Internal Medicine2.Fazia et al, Intracervical PGE2 gel for cervical ripening and

IOL, P J Med Sci,2008 vol.24,No.2,241-2453.TurnerJE, et al- PGE2 in tylose gel for cervical ripening before

IOL J Reprod. Med. 1987;32 (11): 815-8214. Warke et al, PGE2 gel in ripening of cervix in IOL. J Postgrad Med. 1999;45(1) :05-95.Prince et al. Cervical ripening with intravaginal PGE2 gel. Obstet. Gynaecol. 1984; 63: 697-702

6. ACOG Revised Guidelines for IOL,July 20097. NICE guidelines, July 2008

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