Printer Friendly

Comparative study of labour progress and delivery outcome among induced versus spontaneous labour in nulliparous women using modified who partograph.

BACKGROUND

Labour is a natural physiological process characterised by progressive increase in frequency, intensity and duration of uterine contractions resulting in effacement and dilatation of the cervix with descent of the foetus through the birth canal. This physiological process may at times become pathological. Failure to recognise would result in prolonged labour with resultant increase in foetomaternal morbidity and mortality.

More than 22% of all gravid women undergo induction of labour in the US and the overall rate of induction of labour in US has more than doubled since 1990 to 2006. [1]

Induction of labour is the artificial initiation of uterine contractions prior to their spontaneous onset.

The ability to induce labour safely and efficiently is one of the most important developments in Obstetrics during the 2nd half of this century. [2] Despite the advances in basic knowledge, we have not come far in providing the obstetrician with safe, reliable and cost effective methods to induce labour with subsequent vaginal delivery. Oxytocin and prostaglandins are released during labour as a normal physiologic process. Hence, we have attempted to study these agents in detail. [3]

The development of safe and effective regimen for oxytocin administration has provided long desired control of induction of labour. Regarding oxytocin, its familiarity, safety and reliability has scored it as the agent of choice to induce labour. The major deficiency of oxytocin is a high failure rate in women with lower cervical scores and this has led to the search of other agents and methods of labour induction. [3]

Prostaglandins have achieved considerable attention for induction in women with unfavourable cervices. These are considered to be directly involved in the initiation of labour. In term pregnancy with an unfavourable cervix and an inactive myometrium, it seems logical to use this to ripen the cervix or induce labour or both. [3]

According to most authorities, the best way to monitor labour is with the help of a partograph. Partograph is a composite graphical record of key data (Maternal and foetal) during labour entered against time on a single sheet of paper. An accurate record of the progress in labour can be obtained by it. Any delay or deviation from normal may be detected quickly and managed accordingly.

There is scarcity of literature comparing spontaneous versus induced labour among nulliparous women. It is pertinent to compare the outcome of labour among these groups using WHO partograph.

Aims and Objectives

The main objectives of the study were to compare the progress and outcome of induced versus spontaneous labour among nulliparous women using the modified WHO partograph. To compare partographically, the outcome of labour by various induction methods in terms of Success rate, Failure rate, Maternal complications, Foetal complications, Induction--Delivery interval and Mode of delivery.

MATERIALS AND METHODS

This prospective, comparative study was carried out at Department of Obstetrics and Gynaecology, VSSIMSAR, Burla for the duration of 2 years from November 2014 to October 2016. The study included all nulliparous pregnant women at term requiring induction of labour with singleton foetuses in vertex presentation. The women were eligible to be recruited once they got admitted to this hospital. Those with unfavourable cervix had induction with oral misoprostol (25 mg) or vaginal misoprostol (25 mg) or oxytocin (5 mIU) as per hospital protocol given below.

For conveniently comparison purpose and as per case load in this hospital during 2 years' period of study, equal number of sample size i.e. 75 for each group (total 300) were decided to be taken for all four groups (Labour induced with oral prostaglandin, labour induced with vaginal prostaglandin, labour induced with IV oxytocin and labour with spontaneous onset).

75 nulliparous women requiring induction of labour who fulfilled the inclusion criteria were serially recruited for each group (Labour induced with oral misoprostol, labour induced with vaginal misoprostol, labour induced with oxytocin) and compared with 75 consecutive nulliparous women who had spontaneous labour using modified WHO partograph.

The data of progress of labour and foetomaternal outcome obtained from each group were compared by using statistical measure.

Inclusion Criteria

Nulliparous with singleton vertex presenting pregnancy, either in latent phase of spontaneous labour or having an indication for induction of labour as laid down in the ACOG practice bulletin 114, 2009 are [1] Abruptio placentae, Chorioamnionitis, Foetal demise, Gestational hypertension, Preeclampsia, eclampsia, Premature rupture of membranes, Post-term pregnancy, Maternal medical conditions (eg, diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome), Foetal compromise (eg, severe foetal growth restriction, isoimmunisation, oligohydramnios) and Logistic reasons like Risk rapid labour, History rapid labour, Distance from the hospital, Psychosocial indication.

Exclusion Criteria

All multiparous patients and nulliparous pregnant women having a contraindication for induction of labour as laid down in the ACOG practice bulletin 20091 are placenta or vasa praevia, Abnormal foetal lie, cord presentation, prior classical uterine incision, prior myomectomy or uterine unification surgery entering the endometrial cavity, active genital herpes infection and invasive cervical carcinoma.

Protocol of Induction with Oral Misoprostol

Induction with oral misoprostol was started with the initial dose of 25 micrograms. Dosage was repeated every 4 hours until an adequate contraction pattern set in (3 contraction in 10 minutes).

Maximum allowable doses were six (150 micrograms of the drug). If labour did not ensue, even after 4 hours following last dose it was considered as failed induction and other methods of induction like oxytocin was tried.

Protocol of Induction with Vaginal Misoprostol

Patients assigned to the intravaginal misoprostol group had 25 micrograms tablet or one fourth of a 100 microgram inserted into the posterior fornix of the vagina. If the patient was not in adequate labour (Fewer than 3 contractions in 10 minutes) and the Bishop's score was < 6, misoprostol administration was repeated every 4 hours. The maximal dose of misoprostol was 150 micrograms (6 doses).

If labour did not ensue even after 4 hours following last dose, it was considered as failed induction.

Protocol of Induction with Oxytocin

Oxytocin was delivered in a high dose manner according to the arithmetic escalation protocol given in the "Management of Labour" by Arulkumaran. [4] The infusion rate was begun at 5 milliunits/minute and increased in 5 milliunits/minute increments every 30 minutes depending on the frequency and strength of contractions. Maximum dose allowed was 40 milliunits per minute.

RESULTS

The groups were comparable for their age, weight, height, gestational age and their pre-induction Bishop's score.

In majority of the cases, it was PROM followed by PostDatism as the main indication.

Subjects in the oxytocin group more likely had vaginal delivery (53%) within 12 hours of the start of induction. But subjects in the oral misoprostol group more likely had vaginal delivery (50%) within 12 hours of the start of induction.

The oxytocin group showed a better improvement in the Bishop's score after a 6-hour period when compared to vaginal misoprostol group.

Three (4%) women in the oral misoprostol group had failed induction and two had foetal distress, so total five women underwent caesarean section.

Four (5.3%) women in the vaginal misoprostol group had failed induction and two had foetal distress, so total six women underwent caesarean section.

Two (2.7%) women in oxytocin group had failed induction and three had foetal distress, so total five women underwent caesarean section.

In present study failed induction were more in the vaginal misoprostol group (5.3%) and less in the oxytocin group (2.7%).

Four women of spontaneous labour underwent caesarean section because of foetal distress.

Caesarean rate was high in induced groups as compared to spontaneous group.

Instrumental delivery was more in case of spontaneous group when compared to induced delivery groups.

DISCUSSION

"The spontaneous onset of labour is a robust and effective mechanism ... and should be given to operate on its own. We should only induce labour when we are sure that we can do better."

Sir Alec Turnbull (1976)

The present study was compared specifically with studies done by Ralph et al, [5] Luis et al, [6,7] Adair et al, [8] Butt et al, [9] Suk et al [10] and Abramovici et al [11] and Ernest. [12]

Our demographic pattern came close to that of Ralph et al, Butt et al and Luis et al.

In present study, the pre-induction Bishop scores were comparable to that of Ralph. We could not compare it with other studies, as they had different cut-off criteria.

Lower mean age of the participants can be attributed to higher number of primigravidae in present study group.

In the present study, majority of the cases indications was premature rupture of membranes or postdatism as per ACOG inclusion and exclusion criteria.

In the present study, the induction delivery interval is significantly shorter statistically in the oxytocin group when compared with the misoprostol groups, which is agreed with those of Butt et al and Abramovici et al where they studied oral misoprostol with oxytocin induction.

Subjects in the oxytocin group more likely had vaginal delivery (53%) within 12 hours of the start of induction.

In the present study, the routes of delivery did differ significantly between the four study groups. Vaginal misoprostol group had highest caesarean rate of 8% comparable with Luis et al, followed by equal in both oxytocin group and oral misoprostol group (6.7%).

Oxytocin group had less number of babies born with Apgar < 7 at 5 mins as compared to vaginal misoprostol comparable with the results of Luis et al.

In present Study, the Apgar scores at 1 and 5 minutes were not significant between the groups.

No neonatal deaths occurred in the present study.

Maternal complications were found to be lowest in oxytocin group. Even though 4 cases of tachysystole occurred with the use of oxytocin and 3 cases with vaginal misoprostol, the effect was reversible in minutes without any maternal and foetal morbidities and mortalities.

CONCLUSION

We can draw from this study that while induced labour may increase the chance of caesarean section, it does not adversely affect foetomaternal outcome. We therefore conclude that induced labour can be a safe procedure among nulliparous women, if labour is partographically monitored.

In the present study, it has been observed that oxytocin was a better inducing agent because it was associated with shorter induction to delivery time, route of delivery does not differ and less maternal and perinatal complications. Oxytocin administration could be halted at any time and then again restarted. In addition, with the half-life of oxytocin being in minutes, the dosage and frequency could be easily controlled. However, oxytocin administration was an invasive procedure, costlier and caused restricted ambulation of the patient.

REFERENCES

[1] ACOG Committee on Practice Bulletins--Obstetrics. ACOG practice bulletin No. 107: induction of labor. 2009;114(2 Pt 1)):386-97.

[2] Biswas A. Induction of labour: recent trends. Chapter2. In: Gupta DS. edr. Recent advances in obstetrics & gynecology. New Delhi: Jaypee Brothers 1999:13-31.

[3] O'Brien WF, Knuppel RA, Cohen GR. Plasma prostaglandin metabolite levels after use of prostaglandin E2 gel for cervical ripening. Am J Obstet Gynecol 1986;155(5):1037-40.

[4] Biswas A, Arulkumaran SG. Induction of labour. Chapter-14. In: Arulkumaran SG. edr. The management of labour. Orient Longman 1996: p. 213.

[5] Kramer RL, Gilson GJ, Morrison DS, et al. A randomized trial of misoprostol and oxytocin for induction of labor: safety and efficacy. Obstet Gynecol 1997;89(3):387-91.

[6] Sanchez-Ramos L, Chen AH, Kaunith AM, et al. Labor induction with intravaginal misoprostol in term premature rupture of membranes: a randomized study. Obstet Gynecol 1997;89(6):909-12.

[7] Sanchez-Ramos L, Peterson DE, Delke I, et al. Labour induction with prostaglandin E1 misoprotosal compared with dinopostone vaginal insert: a randomised trial. Obstet Gynecol 1998;91(3):401-5.

[8] Adair CD, Weeks JW, Barrilleaux S, et al. Oral or vaginal misoprostol administration for induction of labor: a randomised, double-blind trial. Obstet Gynecol 1998;92(5):810-3.

[9] Wing DA, Paul RH. Induction of labor with misoprostol for premature rupture of membranes beyond thirtysix weeks gestation. Am J Obstet Gynecol 1998;179(1):94-9.

[10] Wing DA, Rahall A, Jones MM, et al. Misoprostol: an effective agent for cervical ripening and labor induction. Am J Obstet Gynaecol 1995;172(6):1811-6.

[11] Abramovici D, Goldwasser S, Mabie BC, et al. A randomised comparision of oral misoprostol versus foley catheter and oxytocin for induction of labour at term. AJOG 1999;181(5 Pt 1):1108-12.

[12] Orji EO, Olabode TO. Comparative study of labour progress and delivery outcome among induced versus spontaneous labour in nulliparous women using modified WHO partograph. NJOG 2008;3(1):24-8.

Ojaswini Patel (1), Sharmila Pradhan (2), Bulu Naik (3)

(1) Associate Professor, Department of Obstetrics and Gynaecology, VSSMSAR, Burla, Odisha.

(2) Assistant Professor, Department of Obstetrics and Gynaecology, VSSMSAR, Burla, Odisha.

(3) Postgraduate Student, Department of Obstetrics and Gynaecology, VSSMSAR, Burla, Odisha.

Financial or Other, Competing Interest: None.

Submission 10-02-2017, Peer Review 07-03-2017, Acceptance 13-03-2017, Published 20-03-2017.

Corresponding Author:

Dr. Bulu Naik, Room No. 102, Resident Doctors Hostel, VSSIMSAR, Burla-768017, Sambalpur, Odisha.

E-mail: bulubelmunda@gmail.com

DOI: 10.14260/jemds/2017/407

Caption: Graph 2. Mode of Delivery

Caption: Graph 3. Perinatal Outcome
Table 1. Demographic Data

Characteristics           Oral          Vaginal       Oxytocin
                          Misoprostol   Misoprostol

Age (yrs.)                22.6          22.5          22.4
Weight (kg)               57.3          56.3          56.6
Height (cm)               155.7         156.4         156.4
Gestational Age (weeks)   39.4          39.2          39.1
Pre-Induction   [less     16 (21)       21 (28)       20 (27)
                than or
                equal
                to] 3
Bishop          4-5       57 (76)       48 (64)       46 (61)
Score N (%)     6-7       2 (3)         6 (8)         9 (12)

Characteristics           Spontaneous   Significance
                          Labour

Age (yrs.)                22.45         P = 0.947
Weight (kg)               58.5          P = 0.156
Height (cm)               156.5         P = 0.453
Gestational Age (weeks)   39.2          P = 0.636
Pre-Induction   [less     20 (27)
                than or
                equal
                to] 3
Bishop          4-5       31 (41)
Score N (%)     6-7       24 (32)

Table 2. Indications for Induction

Indications   Oral          Vaginal       Oxytocin
              Misoprostol   Misoprostol

PROM          24            21            51
PD            21            24            12
PE            17            18            9
IUD           13            12            3
Total         75            75            75

[X.sub.2] = 30.986, p = 0.000

Table 3. Induction to Delivery Interval

                   Oral               Vaginal           Oxytocin
I-D Interval       Misoprostol        Misoprostol       (n = 70)
(min)              (n = 70)           (n = 69)          N (%)
                   N (%)              N (%)

300-480            6 (8.6)            3(4)              11 (16)
5-8 hrs.
481-720            29 (41)            15 (22)           26 (37)
8-12 hrs.
721-960            17 (24)            15 (22)           24 (34)
12-16 hrs.
961-1440           18 (25.7)          24 (35)           9 (13)
16-24 hrs.
1441-2250          --                 12 (17)           --
24-37.5 hrs.
Mean [+ or -] SD   804 [+ or -] 276   1080 [+ or -]    696 [+ or -] 239
                                      503
F = 21.15, P = 0.000 (< 0.05)

Table 4. Change in Bishop's Score

Change in     Oral          Vaginal       Oxytocin
Bishop's      Misoprostol   Misoprostol
                                          N (%)
Score         N (%)         N (%)
Less than 3   24 (32)       30 (40)       24 (32)
3-6           51 (68)       39 (52)       30 (40)
More than 6   --            6 (8)         21 (28)
Total         75            75            75

[X.sub.2] = 34.893, p = 0 .000 (< 0.05)

Table 5. Mode of Delivery

Groups        Normal      Instrumental   LSCS      Total
              Delivery    (F+V) (%)      (%)
              (%)

Oral          65 (86.7)   5 (6.7)        5 (6.7)   75
Misoprostol
Vaginal       65 (86.7)   4 (5.3)        6 (8%)    75
Misoprostol
Oxytocin      65 (86.7)   5 (6.7)        5 (6.7)   75
Spon-
taneous       63 (84)     8 (10.7)       4 (5.3)   75
Labour

[X.sub.2] = 2.083, P = 0.912

Table 6. Perinatal Outcome

Perinatal Outcome    Oral          Vaginal   Oxytocin   Spontaneous
                     Misoprostol   Miso-     N (%)      Labour N (%)
                     N (%)         prostol
                                   N (%)

Birth Weight (gms)   2624          2742      2757       2720
(Mean)
Apgar at 1' (Mean)   6.5           6.2       6.5        6.4
Apgar < 7 at 1'      30 (47.6)     46 (73)   39 (54)    45 (60)
Apgar at 5' (Mean)   8.4           8.2       8.4        8.7
Apgar < 7 at 5'      4 (6)         3 (4.7)   6 (8)      6 (8)
Meconium             4 (6)         6 (9.5)   6 (8)      3 (4)
Resuscitation        6 (9.5)       6 (9.5)   7(9.7)     5 (6.6)
NICU Admission       7 (11)        6 (9.5)   5 (7)      6 (8)

Table 7. Maternal Complications

               Oral       Vaginal              Spont-
Compli         Miso-      Miso-     Oxytocin   aneous
cations        Prostol    prostol   N (%)      Labour
               N (%)      N (%)                N (%)

Cervix Tear    4 (5.3)    3 (4)     1 (1.3)    3(4)
Tachysystole   --         3 (4)     4 (5.3)    --
Postpartum
Haemo-         4 (5.3)    3 (4)     2 (2.7)    2(2.7)
rrhage
Vaginal Wall                                   3(4)
Tear
Prolonged      --         1 (1.3)   --
3rd Stage
Total          8 (10.7)   10 (13)   7 (9.3)    8(10.7)

Table 8. Demographic Comparison

                          Present   Ralph   Abramovici   Butt
                          Study     et al   et al        et al

                   Oral   22.6      --      22.1         28.5
Age (Mean,         Vag.   22.5      26.2    --           --
Years)             Oxy    22.4      25.4    21.9         28.6
                   Spnt   22.45     --      --           --
                   Oral   57.3      --      93.6         83
Weight             Vag.   56.3      --      --           --
(Mean, kg)         Oxy    56.6      --      94.7         84
                   Spnt   58.5      --      --           --
                   Oral   155.7     --      165.4        163
Height             Vag.   156.4     --      --           --
(Mean kg)          Oxy    157.4     --      165.9        154
                   Spnt   156.5     --      --           --
Gestational age    Oral   39.4      --      40.2         39.4
                   Vag.   39.2      39.6    --           --
(Mean, Weeks)
Years)             Oxy    39.1      38.3    39.7         39.6

                   Spnt   39.2      --      --           --

Pre--              Oral   21        --      --           --
Induction Bishop   Vag.   28        58      --           --
Score
Score              Oxy    27        38      --           --
(%, [less than
or equal to] 3)    Spnt   --        --      --           --

                          Luis    Suk     Adair   Ernest
                          et al   et al   et al

                   Oral   --      28.9    24.4    28.44
Age (Mean,         Vag.   23.7    --      24.5    --
Years)             Oxy    23.1    30.7    --      --
                   Spnt   --      --      --      28.43
                   Oral   --      --      --      --
Weight             Vag.   86      --      --      --
(Mean, kg)         Oxy    91.2    --      --      --
                   Spnt   --      --      --      --
                   Oral   --      --      --      --
Height             Vag.   163.3   --      --      --
(Mean kg)          Oxy    162.3   --      --      --
                   Spnt   --      --      --      --
Gestational age    Oral   --      38.9    37.8    39.52
                   Vag.   38.8    --      38.3    --
(Mean, Weeks)
Years)             Oxy    38.8    39.4    --      --

                   Spnt   --      --      --      39.38

Pre--              Oral   --      --      --      --
Induction Bishop   Vag.   --      --      --      --
Score
Score              Oxy    --      --      --      --
(%, [less than
or equal to] 3)    Spnt   --      --      --      --

Table 9. Induction to Delivery Interval Comparison

                   Mean Induction Delivery
                   Interval (Min)
                   Oral   Vaginal   Oxytocin

Present study      804    1080      696
Butt et al         720    --        501
Suk et al          660    --        1116
Luis et al         --     662       1105
Abramovici et al   1104   --        864
Adair et al        750    844       --

Table 10. Mode of Delivery Comparison

                             Oral   Vaginal   Oxy.   Spont
                             Miso   Miso             Labour
                                                     L

Present       Normal VD      86.7   86.7      86.7   84
              Instrumental   6.7    5.3       6.7    10.7
Study
              C--section     6.7    8         6.7    5.3
Ralph et al   Normal VD      --     63        58     --
              Instrumental   --     13        14     --
              C--section     --     23        29     --
Luis et al    Normal VD      --     58        54     --
              Instrumental   --     20        25     --
              C--section     --     22        21     --
Suk et al     Normal VD      70     --        68     --
              Instrumental   25     --        25     --
              C--section     5      --        8      --
Abramovici    C--section     24     --        23     --
et al
Adair et al   C--section     18     15        --     --
Ernest        Normal VD      64.7   --        --     72.1
              Instrumental   --     --        --     7.3
              C--section     35.3   --        --     20.6

Table 11. Perinatal Outcome Comparison (A)

                                 Apgar          Apgar
                                 < 7 at 1 min   < 7 at 5 min

Present       Oral (n = 63)      30 (47.6)      4 (6)
              Vaginal (n = 63)   46 (73)        3 (4.7)
              Oxytocin
Study                            39 (54)        6 (8)
              (n = 72)
              Spont. Labour      45 (60)        6 (8)
              (n = 75)
Butt et al    Oral               16.4           16.4
              Oxytocin           16.4           16.4
Suk et al     Oral               --             --
              Oxytocin           --             --
Luis et al    Vaginal            17.2           1.6
              Oxytocin           13.8           1.5
Ralph et al   Vaginal            13             0
              Oxytocin           18             5
Abramovici    Oral               8.2            8.16
et al         Oxytocin           8.1            9.1
Adair et al   Oral               14             2.1
              Vaginal            10             3

                                 Resus-     NICU
                                 citation   Admission

Present       Oral (n = 63)      6 (9.5)    7 (11)
              Vaginal (n = 63)   6 (9.5)    6 (9.5)
              Oxytocin
Study                            7 (9.7)    5 (7)
              (n = 72)
              Spont. Labour      5 (6.6)    6 (8)
              (n = 75)
Butt et al    Oral               --         18.2
              Oxytocin           --         16.15
Suk et al     Oral               --         7.5
              Oxytocin           --         10
Luis et al    Vaginal            --         4.7
              Oxytocin           --         9.2
Ralph et al   Vaginal            --         --
              Oxytocin           --         --
Abramovici    Oral               --         5.2
et al         Oxytocin           --         13.2
Adair et al   Oral               --         18.3
              Vaginal            --         12.9

Table 12. Perinatal Outcome Comparison (B)

Characteristic                  Apgar Score   Apgar Score
                                at 1 min      at 5 mins

Present Study    Oral           6.5           8.4
                 Vaginal        6.2           8.2
                 Oxytocin       6.5           8.4
                 Spont Labour   6.4           8.7
Ernest Study     Oral           8.72          9.45
                 Spont Labour   7.68          8.93

Graph 1. Change in Bishop's Score

                      <3    3-6   >6

ORAL MISOPROSTOL      32%   40%   32%
VAGINAL MISOPROSTOL   68%   52%   40%
OXYTOCIN              0%    8%    28%

Note: Table made from bar graph.
COPYRIGHT 2017 Akshantala Enterprises Private Limited
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2017 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Original Research Article
Author:Patel, Ojaswini; Pradhan, Sharmila; Naik, Bulu
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Mar 20, 2017
Words:3395
Previous Article:Effect of Tinospora cordifolia in chronic bronchitis patients.
Next Article:A study of relation of serum testosterone levels and erectile dysfunction in male patients in type 2 diabetes mellitus.
Topics:

Terms of use | Privacy policy | Copyright © 2020 Farlex, Inc. | Feedback | For webmasters