1. Dr. Deepa Arora Medical Officer,Royal Hospital Supervisor- Dr. Anita Zutshi Senior Consultant, Royal Hospital

2. Induction of Labour Iatrogenic 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.

3. Introduction ( Contd.) Concerns with Elective Induction of Labour at term are Reported increased rate of LSCS. Iatrogenic prematurity Cost effectiveness Maternal- Fetal medical benefits such as reduction in still birth rate have not been proven.

4. Induction of Labour Labour 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.

5. 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

6. 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.

7. IOL- Materials and methods Study population - all patients undergoing IOL at Royal Hospital from 1 st January, 2009 to 31 st 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.

8. Total Deliveries= 1783 1 st January to 31 st March, 2009

9. 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.

10. Calder’s Modified Bishop Score 0123 1Dilatation of internal os ( cm.) <11-22-4>4 2Length of cervix ( cm.) >42-41-2<1 3Consistency of cervix Firmaveragesoft- 4Position of cervixposteriorMid, anterior -- 5Station of head-3-2-1,0-

11. Methods of Induction : DosesNullipara MultiparaG. Mutipara 1 st dose2 mg1 mg 2 nd dose1 mg 3 rd dose1 mg Total dose4 mg3 mg2 mg Induction Of Labour - Protocol ( contd.) 1.Intravaginal application of PGE 2 gel.

12. 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

13. Syntocinon infusion in Primigravida Dilute 10 units of syntocinon in 500 ml of Hartman’s Time after starting minOxytocin(milliunit/min)Volume infused(ml/hr) 0 13 30 26 60 412 90 824 1201236 1501648 1802060 2102472 2402884 2703296

14. Synto infusion in Multigravida and Previous LSCS Dilute 5 units of syntocinon in 500 ml Hartman’s Time after starting minOxytocin(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

15. Syntocinon Infusion in Grandmultipara Dilute 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

16. 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

17. Age Groups IOLSpont. 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

18. OBSERVATIONS -Age Groups

19. 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 %

20. OBSERVATIONS - Parity

21. 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 %

22. OBSERVATIONS - Gestational age

23. 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)

24. OBSERVATIONS - Medical Complications

25. Misc. Medical Complications Study group Control group Schizophrenia0.68% AdrenalTumour0.68% Ureteric stent, hydronephrosis 0.68% Thrombophilia2.72% Hepatitis1.86% Anaemia1.86% Thyroid disease0.93% Haemophilia0.31%

26. Medical Complications- IOL Diabetes12Epilepsy 2 Ch. Hypertension 9PIH 11 Heart Disease 4Adrenal Tumour 1 Thrombophilia 4Schizophrenia 1 Sickle cell Dis. 4DVT 1 Asthma 1Hydronephrosis 1

27. Study group (n= 147) Method of IOLNumber of patients With Dinoprostone ( PGE2) Gel 141 With Artificial Rupture of membranes 3 With Oxytocin infusion 2 With Misoprostol Tablets ( PGE1) vaginal 1

28. Indications for IOL, n=147

29. Indication for IOL, n=147 Post Date Pregnancy29.94 % ( 44) Ruptured Membranes19.74 % ( 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)

30. 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.

31. OBSERVATIONS -Preinduction Bishop Score

32. Dose of PGE 2 received Most of our patients(47%) responded to the 2nd dose of 1 st course of PGE 2 gel, Almost 25% responded to the 1 st dose itself and 15% to the 3 rd dose of the 1 st 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.

33. Dose of PGE 2 received ( mg)

34. <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

35. BIRTH WEIGHT

36. Foetal Outcome Study groupControl group Apgar score < 7 at 5 mt – 7 IUFD – 5 Anomalous - 2 Apgar score < 7 at 5 mt 12 IUFD - 6 Anomalous - 3 Asphyxia - 3

37. 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

38. Results Total 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 %

39. Results SVD LSCS Study group 101 (68.71%) 46 (31.29%) Control group 1317 (89.70%) 151 (10.30%)

40. 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%)

41. 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.

42. 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

43. CONCLUSION Induction is safe in multigravida / grand multigravida / prev. scar patient Rate 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

44. 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

45. 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

46. (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

47. 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 252-263Aaron B. Caughey, Annals of Internal Medicine 2.Fazia et al, Intracervical PGE2 gel for cervical ripening and IOL, P J Med Sci,2008 vol.24,No.2,241-245 3.TurnerJE, et al- PGE2 in tylose gel for cervical ripening before IOL J Reprod. Med. 1987;32 (11): 815-821 4. Warke et al, PGE2 gel in ripening of cervix in IOL. J Postgrad Med. 1999;45(1) :05-9 5.Prince et al. Cervical ripening with intravaginal PGE2 gel. Obstet. Gynaecol. 1984; 63: 697-702 6. ACOG Revised Guidelines for IOL,July 2009 7. NICE guidelines, July 2008