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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 19
| Issue : 2 | Page : 96-98 |
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Induction of labor: Our experience
Sushil Chawla, Santosh Kumar Singh, Monica Saraswat, Sakthi Vardhan
Department of Obstetrics and Gynaecology, AFMC, Pune, Maharashtra, India
| Date of Web Publication | 13-Feb-2018 |
Correspondence Address:
Dr. Santosh Kumar Singh
Department of Obstetrics and Gynaecology, AFMC, Pune, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmms.jmms_51_17
Introduction: Induction of labor is a deliberate attempt to terminate the pregnancy with the aim of vaginal delivery in cases of valid indication. Different methods are being used ranging from nonpharmacological to pharmacological for the same. Induction on demand by patients is also rising in our country. Objectives: The aim of this study is to ascertain the common indications for induction of labor at a tertiary care teaching hospital. Materials and Methods: A prospective observational study, with the study group being all the patients who underwent induction of labor and the total population including all the women delivering at our center, in 1 year. The induction was done using “Dinoprostone” gel or tablet “Misoprostol”. Results: Postdated pregnancy was the reason for induction of labor in 36% of the patients. Hypertensive disorders and gestational diabetes mellitus are other common conditions requiring induction of labor. Pregnancy following assisted reproductive techniques form an important group requiring induction of labor in present day practice. Conclusion: Hypertensive disorders and postdated pregnancy are the most common indication for induction of labor.
Keywords: Indications for induction, induction of labor, postdated pregnancy
How to cite this article:
Chawla S, Singh SK, Saraswat M, Vardhan S. Induction of labor: Our experience. J Mar Med Soc 2017;19:96-8 |
| Introduction | |  |
Modern obstetrics aims at improving the safety of the mother and the fetus during antenatal period and labor. Induction of labor refers to the iatrogenic stimulation of uterine contractions before the onset of spontaneous labor with or without ruptured membranes to accomplish vaginal delivery. Induction of labor is a challenge to the clinician, mother, and the fetus and has to be supervised carefully. It is considered when vaginal delivery is felt to be the appropriate route of delivery.[1]
Labor may be induced due to maternal or fetal indications. Induction of labor without a medical indication is termed elective induction of labor and appears to be increasing rapidly. The rate of inducing labor varies widely in different institutions depending on choices of obstetricians and indications for Induction. Induction of labor in the U.S. has increased from 9.5% in 1990 to 22.1% in 2004.[2],[3],[4]
This study was undertaken with the objective to ascertain the common indications for the induction of labor at a tertiary care center, and assess the outcome of the labor.
| Materials and Methods | | |
A prospective observational study was carried out in a 900 bedded hospital with 100 beds in the department of obstetrics and gynecology. The study included all the patients who were admitted to the hospital for delivery, during the period from January 1, 2016 to December 31, 2016. All the patients who delivered at our center formed the total population and the study group comprised of the patients who underwent induction of labor for various indications with no exclusion criteria. The protocol at our center practices not to take the pregnancies beyond 41 weeks of gestation from the last menstrual period and thus, we begin the process of induction any time from 40 weeks 5 days to 41 weeks, unless there is a specific indication for the induction of labor earlier than this period of gestation (POG).
The method of the induction depended on the Bishop's score. If Bishop's score was unfavorable, “Dinoprostone” gel was used for cervical ripening every 6 h for a total of 4 doses in all the cases except in cases of prelabor rupture of membranes, where tablet “Misoprostol” 25 mcg every 4 h orally to a maximum of 6 doses was used. The patients who had favorable cervix (Bishop's score >7) were induced with “Oxytocin” infusion only. “Oxytocin” infusion in the high- or low- dose protocol was required for induction/augmentation of labor. The patients who did not respond to the above protocol over 48 h or those showing signs of fetal compromise or labor dystocia on partographic monitoring were taken up for cesarean delivery.
Patients were monitored in labor clinically – and the progress of labor was charted on a partogram. The patients' vital parameters were monitored, and per abdomen examination was done one hourly giving special attention to fetal heart sounds and uterine activity. The center practices not to take the pregnancies beyond 41 completed weeks POG after confirming the dates.
Data was collected for the indication for induction of labor, POG at induction, method of induction used, the mode of delivery, and indication for operative delivery.
| Results | | |
There were a total of 2423 deliveries during this period. A total of 579 women who underwent induction of labor for a variety of indications were included in the study group. A total 23.9% of women who delivered at our center underwent induction of labor. A total of 30 patients were induced using oral misoprostol, and in 54 patients with favorable Bishop's score we used Oxytocin infusion and the rest were induced using dinoprostone gel.
[Table 1] shows the demographic characteristics of the women in our study. Nearly 60% of women were in the 21–30 years of age. Nearly 54.7% and 39.5% of women were induced at POG 37–40 weeks and 40–41 weeks, respectively. Two patients were induced after 41 completed weeks, as they presented to us later than 41 weeks. Nearly 53% of women were primigravidae.
[Table 2] shows the indications for the induction of labor. Postdated pregnancy, hypertensive disorders of pregnancy and diabetes in pregnancy were the commonest reasons leading to induction of labor. Pregnancy conceived after in vitro fertilization and embryo transfer formed an important indication for induction in 8.6% of cases. These patients with no obstetric or medical complication during the pregnancy are being induced at our center between 37 and 38 weeks POG.
During the study 27% of the patients had a Cesaerian delivery, and 20 (3.3%) women had an instrumental delivery in the study group. The Cesaerian delivery was done due to fetal distress, failure of induction, labor dystocia in 25%, 50%, and 25%, respectively, of all the cases [Table 3].
| Discussion | | |
Every obstetrician's effort has been to recognize the correct time for the delivery, and take anticipatory action to reduce the perceived materno-fetal morbidity.
The difference in the protocols practiced by various obstetric units makes the comparison of labor induction indications, rates and complications almost impossible. This occurs because the terms are not clear for example (i) an oxytocic drug given following spontaneous membrane rupture prelabor, should it be called labor induction or augmentation (ii) labor that follows prostaglandins given to ripen the cervix is be called spontaneous or induced; (iii) attempts to ripen an unfavourable cervix and induce labor that fail, resulting in caesarean section, should it be called failed induction or elective caesarean section.[5],[6],[7],[8]
Induction of labor is probably the most common interventional procedure in obstetrics. Guerra et al. reported an elective induction rate of 16.7% in Latin American facilities, while we found nearly 50% of inductions in Asian facilities were elective, highest being in Sri Lanka (77.2%). This is followed by Thailand (44.6%), Japan (41.0%), India (32.1%) and China (20.4%). This is consistent with 24% rate of induction at our center.[8]
Our study shows that postdatism is the most common cause for induction of labor and the findings are similar to most studies done earlier. This is followed by hypertensive disorders of pregnancy, which cause significant maternal and perinatal morbidity. The results from our center have shown that pregnancy following ART procedures are going to be an independent group requiring induction due to the preexisting risk factors or simply due to the anxiety of the couples and obstetrician alike. Studies by Laughon et al. and Berhan and Dwivedi said that the pattern of medical indications for inductions in higher-income countries is evolving with changing demographics and pregnancy complications.[4],[5] In African and Asian facilities, prelabor rupture of membranes (27.3% and 19.3%) was the most common indication.[7]
The method of choice for induction of labor has varied in different studies, WHO has recommended the use of prostaglandins for induction and among PG's, tab “Misoprostol” being cheap and not requiring special storage conditions has been studied in the unscarred uterus for induction in various trials.[1] In our study, we had used prostaglandins for induction of labor as the method of choice. Various studies have raised the question of increasing rates of lower segment caesarean section (LSCS) and fears about the rates rising even further due to elective induction of labor at 41 weeks or more have been raised. These appear to be laid to rest by several authors, and some studies have found an overall reduction in LSCS rates by up to 20%.[7],[8] In our series of patients, the LSCS rate was only 24% in the patients who were induced for various indications, during the study.
| Conclusion | | |
Postdated pregnancy and hypertension in pregnancy are the main indications for the induction of labor at our center. Pregnancies following assisted reproductive techniques is a new group necessitating elective induction at our center.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | WHO. WHO Recommendations for Induction of Labour. Geneva, Switzerland: WHO Press; 2011.  |
| 2. | Mackenzie IZ. Induction of labour at the start of the new millennium. Reproduction 2006;131:989-98. [ PUBMED] |
| 3. | Talaulikar VS, Arulkumaran S. Failed induction of labor: Strategies to improve the success rates. Obstet Gynecol Surv 2011;66:717-28. [ PUBMED] |
| 4. | Laughon SK, Zhang J, Grewal J, Sundaram R, Beaver J, Reddy UM, et al. Induction of labor in a contemporary obstetric cohort. Am J Obstet Gynecol 2012;206:486.e1-9. |
| 5. | Berhan Y, Dwivedi AD. Currently used oxytocin regimen outcome measures at term & post-term. I: Outcome indicators in relation to parity & indication for induction. Ethiop Med J 2007;45:235-42. |
| 6. | Beckmann M. Predicting a failed induction. Aust N Z J Obstet Gynaecol 2007;47:394-8. |
| 7. | Rouse DJ, Owen J, Hauth JC. Criteria for failed labor induction: Prospective evaluation of a standardized protocol. Obstet Gynecol 2000;96:671-7. |
| 8. | Guerra GV, Cecatti JG, Souza JP, Faúndes A, Morais SS, Gülmezoglu AM, et al. Elective induction versus spontaneous labour in Latin America. Bull World Health Organ 2011;89:657-65. |
[Table 1], [Table 2], [Table 3]
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