Role of mifepristone in pre-induction cervical ripening: a double blind placebo-controlled study

Background: Mifepristone has been used for cervical priming and labour induction for long with modest success. This double-blind study compares mifepristone with placebo in causing cervical ripening and inducing spontaneous labour in women past their expected date of delivery.Methods: 200 women at 40 weeks gestation received mifepristone or placebo after Bishop score was assessed. 48 hours later, cervical score was rechecked. Improvement in Bishop score was noted as primary outcome measure. Incidence of spontaneous labour, cesarean delivery and meconium staining of liquor during labour was also monitored.Results: 16 women went into labour before 48 hours and 184 were evaluable. Improvement in Bishop score was noted in significantly more women in mifepristone group (82/94 versus 42/90, p<0.0001). Mean change in Bishop score was 3.22 in mifepristone group and 1.61 in placebo group. This advantage in cervical ripening with mifepristone did not translate into better obstetric outcome. The incidence of spontaneous labour (64/94 mifepristone versus 60/90 placebo), cesarean section (4/94 versus 12/90) and MSL (8/94 versus 10/90) was comparable in the two groups and did not reach statistical significance.Conclusions: Mifepristone has a beneficial effect on cervical ripening in term pregnancies but does not offer obstetric advantage in terms of higher rates of spontaneous labour or vaginal delivery.

Profiling cervical ripening for induction of labour with Foley’s balloon catheter in Ebonyi state, Nigeria: a randomized controlled trial

Background: The ripeness of the cervix is an important prerequisite to a successful labour induction. Use of extra-amniotic Foley catheter is a mechanical method of cervical ripening with proven efficacy. This study compared the difference in efficacy between 30 ml and 60 ml of water for inflation of Foley catheter balloon when used for cervical ripening during induction of labour.Methods: A single-blind randomized controlled study where 260 term pregnant women with intact membranes and unfavourable cervix were selected for induction of labour and randomized into two equal groups (30 ml- and 60 ml- groups) from October, 2019 to July 2020. Each participant had cervical ripening with the catheter bulb inflated with either 30 ml or 60 ml of sterile water (as assigned to the individual). After achieving favourable cervix (BS ≥6), oxytocin titration was commenced and the labour monitored with the outcomes well documented and statistically analysed.Results: Mean duration to favourable Bishop Score significantly reduced in the 60 ml group (10.8 hours±2.99) as against 12.7 hours±10.0 in 30ml group (p=0.038). Mean duration of active phase of labour was significantly reduced in 60 ml group (5.6 hours±2.4) as against 8.4 hours±3.2 in 30 ml group (p=0.010). Caesarean delivery rate was significantly reduced in the 60 ml groups (p=0.027).Conclusions: The use of 60 ml inflated Foley’s balloon catheter when compared with 30mls to ripen the cervix effectively reduced the duration to favourable Bishop Score, duration of the active phase of labour and the rate of Caesarean sections.

A new indication for elective induction of labor COVID-19 pandemic effect

Background: Induction of labour is performed in certain circumstances which involve greater risks of waiting for the onset of spontaneous labour than the risks due to shortening the duration of pregnancy by induction. The objective of this study was to evaluate the maternal and fetal outcome in patients undergoing elective induction during COVID-19 pandemic.Methods: This prospective observational study was conducted on 60 ANC patients with singleton pregnancy and POG >39 weeks coming to OPD with negative COVID-19 RT-PCR report. To avoid the burden of repeat testing after one week and risk of exposure to COVID-19 virus from community, patients were induced. All the data was recorded and analyzed.Results: Most of the patients were in age group of 20-25 years (50%) and only 6.7% of the patients were older than 30 years. 32 (53.3%) patients were multiparous and 50% of the patients were having Bishop score between 2-5 and only 8.3% had bishop score of more than 5. 47 patients (78.3%) underwent normal vagina delivery whereas 12 patients (20%) underwent LSCS. Failure of Induction was the indication for LSCS in 5 patients (41.7%).Conclusions: Elective induction was found to be better option in COVID-19 negative patients. All pregnant women should be monitored for development of symptoms and signs of COVID-19 particularly if they have had close contact with a confirmed case. Pregnancy and childbirth generally do not increase the risk for acquiring SARS-CoV-2 infection but may worsen the clinical course of COVID-19 compared with nonpregnant individuals of the same age.

Outcome of induction and associated factors among induced labours in public Hospitals of Harari Regional State, Eastern Ethiopia: A two years’ retrospective analysis

Background Induction of labor (IOL) is an essential intervention to reduce adverse maternal and neonatal outcomes. It is also improved pregnancy outcomes, especially in resource-limited countries, where maternal and perinatal mortality is unacceptably high. However, there is a scarcity of evidence regarding the outcome of induction of labor and its predictors in low-income countries like Sub-Saharan Africa. Therefore, this study was aimed at assessing the outcome of induction of labor and associated factors among mothers who underwent labor induction in public Hospitals of Harari Regional State, Estern Ethiopia. Methods A facility-based cross-sectional study was conducted from 1 to 30 March, 2019 in Harari Regional State, Eastern Ethiopia. A total of 717 mothers who underwent induction of labor in public Hospitals of Harari Regional State, Eastern Ethiopia from January 2017 to December 2018 were enrolled in the study. Data were collected using a pretested structured questionnaire. The collected data were entered into Epi-data version 3.1 and exported to SPSS version 24 (IBM SPSS Statistics, 2016) for further analysis. A multivariable logistic regression analysis was performed to estimate the effects of each predictor variable on the outcome of induction of labor after controlling for potential confounders. Statistical significance was declared at p-value <0.05. Results Overall, the prevalence of success of induction of labor was 65% [95% CI (61.5, 68.5)]. Pre-eclampsia/eclampsia was found to be the most common indication for induction of labor (46.70%) followed by pre-labor rupture of fetal membrane (33.5%). In the final model of multivariable analysis, predictors such as: maternal age < 24 years old [AOR = 1.93, 95%CI(1.14, 3.26)], nulliparity[AOR = 0.34, 95%CI(0.19, 0.59)], unfavorable Bishop score [AOR = 0.06, 95%CI(0.03, 0.12)], intermediate Bishop score [AOR = 0.08, 95%CI(0.04, 0.14)], misoprostol only method [AOR = 2.29, 95%CI(1.01, 5.19)], nonreassuring fetal heart beat pattern [AOR = 0.14, 95%CI (0.07, 0.25)] and Birth weight 3500 grams and above[AOR = 0.32, 95% CI (0.17, 0.59)] were statistically associated with the successful outcome of induction of labor. Conclusion The prevalence of successful of induction of labor was relatively low in this study area because only two-thirds of the mothers who underwent induction of labor had a successful of induction. Therefore, this result calls for all stakeholders to give more emphasis on locally available induction protocols and guidelines. In addition, pre-induction conditions must be taken into consideration to avoid unwanted effect of failed induction of labour.

Efficacy Study of Mifepristone in Pre-induction Cervical Ripening and Induction of Labour

This study was carried out to see the safety and efficacy of mifepristine as pre-induction cervical ripening agent along with misoprostol in induction of labour. It was a study done from January to June 2020 in Department of Obstetrics and Gynecology, Nepal Medical College Teaching Hospital. Total 120 patients were included in this study. Out of which, 60 women were be kept in test group who were induced by mifepristone and misoprostol and 60 women were kept in control group induced by misoprostol only. Patient characteristics, improvement of bishop score, maternal and neonatal outcome was recorded. Chi- square and T- Test were used to compare the result. Patient characteristics and the Bishop score at zero-hour of both the groups were similar. The mean bishop score 48 hours after use of mifepristine in test group was significantly increased in test group vs control group (P<0.0001). There were total 12(20%) patient who went in to labour with mifepristone only without the use of misoprostol. Total number of normal delivery was more (p value=0.003) and cesarean was less (p=0.013) in test group than in control group. The instrumental delivery in both test and control group were same. The adverse effect and neonatal outcome was similar in both the regime. Thus mifepristone as pre-induction cervical ripening agent is a safe and efficient drug

Clinical predictive factors for vaginal delivery following induction of labour among pregnant women in Jordan

Background Induction of labour (IOL) is an important and common clinical procedure in obstetrics. In the current study, we evaluate predictors of vaginal delivery in both nulliparous and multiparous women in north Jordan who were induced with vaginal prostaglandins. Method A prospective study was conducted on 530 pregnant women at King Abdullah University Hospital (KAUH) in north Jordan. All pregnant mothers with singleton live fetuses, who had induction of labour (IOL) between July 2017 and June 2019, were included in the study. Mode of delivery, whether vaginal or caesarean, was the primary outcome. Several maternal and fetal variables were investigated. The safety and benefit of repeated dosage of vaginal prostaglandin E2 (PGE2) tablets, neonatal outcomes and factors that affect duration of labour were also evaluated. Pearson χ2 test was used to investigate the significance of association between categorical variables, while student’s t-test and ANOVA were applied to examine the mean differences between categorical and numerical variables. Linear regression analysis was utilized to study the relation between two continuous variables. A multivariate regression analysis was then performed. Significance level was considered at alpha less than 0.05. Results Nulliparous women (N = 254) had significantly higher cesarean delivery rate (58.7% vs. 17.8%, p < 0.001) and longer duration of labour (16.1 ± 0.74 h vs. 11.0 ± 0.43 h, p < 0.001) than multiparous women (N = 276). In nulliparous women, the rate of vaginal delivery was significantly higher in women with higher Bishop score; the mean Bishop score was 3.47 ± 0.12 in nulliparous women who had vaginal delivery vs. 3.06 ± 0.10 in women who had cesarean delivery (Adjusted odds ratio (AOR) = 1.2, 95% CI: 1.03–1.28, p = 0.03). In multiparous women, the rate of vaginal delivery was significantly higher in women with higher Bishop scores and lower in women with higher body mass index (BMI). The mean Bishop score was 3.97 ± 0.07 in multiparous women who had vaginal delivery vs. 3.56 ± 0.16 in women who had cesarean delivery (AOR = 1.5, 95% CI: 1.1–2.1, p = 0.01). The mean BMI was 30.24 ± 0.28 kg/m2 in multiparous women who had vaginal delivery vs. 32.36 ± 0.73 kg/m2 in women who had cesarean delivery (AOR = 0.89, 95% CI: 0.84–0.96, p = 0.005). 27% of nulliparous women who received more than two PGE2 tablets and 50% of multiparous women who received more than two PGE2 tablets had vaginal delivery with no significant increase in neonatal morbidity. Conclusion Parity and cervical status are the main predictors of successful labour induction. Further studies are required to investigate the benefit of the use of additional doses of vaginal PGE2 above the recommended dose for IOL.

Predicting the Antepartum Factors Resulted in Failed Labor Induction in Nulliparous Term Pregnancies

Objectives: This study aimed to evaluate the feasibility of using a computerized machine to predict a successful normal vaginal delivery and determine the antepartum factors involved in failed labor induction in nulliparous term women. Methods: This prospective cohort study was conducted in Yas Hospital affiliated with Tehran University of Medical Sciences from 2017 to 2019. The data used for the computerized system were obtained during the admission of the term nulliparous women with singleton pregnancy in cephalic presentation. The cesarean delivery rate, as well as maternal and perinatal outcomes, were evaluated. The input variables were maternal age, gravida, gestational age at birth, necessity and type of labor induction, presentation of the baby at birth, Bishop Score, fetal weight, and fetal head circumference, and maternal disorders. The outputs were vaginal deliveries or cesarean sections. Results: The rate of cesarean section was 41.8% (n = 287). Higher maternal age (OR = 1.044, P = 0.018, CI = 1.007 - 1.082), lower Bishop Score (OR = 0.192, P < 0.001, CI = 0.139 - 0.256) and non-occiput anterior position (OR = 82.194, P < 0.001, CI = 15.888 - 425.214) were significantly associated with failed induction. Conclusions: The result of this study may be beneficial for healthcare providers to predict the delivery route, the risk of labor induction failure and make a personal decision according to each individual.

Comparative study of single versus double time application of dinoprostone E2 gel on the induction of labor in term pregnancy and it’s fetomaternal outcomes

Background: Labor is defined as a cascade of effective uterine contractions leading to progressive effacement and dilatation of cervix resulting in the expulsion of the fetus, placenta and the membranes. The aim of the study was to evaluate the effect of single time and double time application of dinoprostone E2 gel and to compare fetomaternal outcomes after single and double application of dinoprostone E2 gel and its complications.Methods: This was a prospective observational study conducted on 200 pregnant females with a period of gestation ≥37 completed weeks between 1st January 2020 to 31st January 2021. Group A included females undergoing single time application of PGE2 gel and in group B, second dose applied after 6 hrs of first dose if there was no improvement in Bishop score. If necessary, oxytocin for augmentation of labor was started only 6 hrs after the last dose.Results: Mean age in group A was 24.38±4.37 years and in group B was 24.02±3.76 years and this difference was not found statistically significant (p>0.05). Majority of cases had vaginal delivery. In group A, 28% cases had LSCS delivery while in group B, 17% cases had LSCS delivery (p>0.05). There was significant increase in mean Bishop score after second dose of PGE2 gel in double application group by 3.24 assessed at 12 hours after induction. Double times application of gel resulted in a smaller number of failed inductions i.e.; 23 out of 100 cases in single application group and 7 out of 100 cases in double application group. Main maternal complication was nausea and vomiting which was 5% cases in group A and 11% cases in group B.Conclusions: Double times application of dinoprostone gel resulted in improved Bishop score, facilitates the process of induction, increased number of successful inductions, shortened application delivery interval and decreased cesarean section rate compared to single application. There was slight increase in maternal and fetal complications with double times application.

Current practice of induction of labour and maternal outcome in ≥37 week of gestation: an observational study

Background: As we know induction is done when benefit to mother and fetus overweigh benefits of continuing the pregnancy. According to NICE guidelines, induction of labor leads to 15% of instrumental deliveries and 22% of total LSCS. In new civil hospital, Surat (according to 2017) failure of induction of labor was 2nd most common indication of LSCS. The objective of this study were to analyse labor induction with respect to indication for induction of labor and its maternal outcome so that we optimize our protocol of labor and reduce our LSCS rates for the same, can reduce feto-maternal morbidities also.Methods: This was prospective observational descriptive study carried out over duration of 6 month. 200 consecutive cases of consenting women requiring induction of labour and fulfilling inclusion criteria were selected. Induction was done with prostaglandin analogous. Data were collected includes age, parity, gestational age, bishop score, indication of induction, and maternal outcome. And data was analyzed by using EMI software.Results: Timely induction of labor can reduce maternal morbidity and ensure the delivery of a healthy baby. Among 200 consenting women 58.5% were multigravida and 41.5% were primigravida. Most common indication of induction among study participants is prolong rupture of membrane which is 35.5%. Among them 71.4% had vaginal delivery having poor bishop score. Most common indication for LSCS were fetal distress (34.8%).Conclusions: We concluded that elective induction of labor was associated with lower rates of LSCS and improved maternal and neonatal outcome.