induction of labour – experience at royal hospital oman
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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 PresentationTRANSCRIPT
Dr. Deepa AroraMedical Officer,Royal Hospital
Supervisor- Dr. Anita ZutshiSenior Consultant, Royal Hospital
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.
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.
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.
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
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.
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.
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
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.
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 -
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.
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
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
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
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
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
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
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
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 %
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
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 %
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
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)
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
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%
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
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
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
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)
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.
OBSERVATIONS -Preinduction Bishop Score
4-6 score, 60, 41%<4 score,
81, 55%
>8 score, 1, 1%
6-8 score, 5, 3%
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.
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
<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
BIRTH WEIGHT
3
28
93
21
2
<1500 gm 1501-2500gm
2501-3500gm
3501-4000gm
>4000 gm
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
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
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 %
Results SVD LSCS
Study group 101 (68.71%) 46 (31.29%)
Control group 1317 (89.70%) 151 (10.30%)
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%)
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.
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
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
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
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
(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
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