OUTCOME OF INDUCTION OF LABOUR IN PRIMIPAROUS
WOMEN
Safinaz Hamada Abdelrahman Abdoun, Medical Faculty VI
Obstetrics and Gynaecology Department Supervisor: Laura Malakauskiene, MD, PhD LSMU Kaunas 2016/2017
Table of Contents
1. TITLE ... 1 2. TABLE OF CONTENT ... 2 3. SUMMARY ... 3-4 4. CONFLICT OF INTEREST ... 4 5. CLEARANCE ISSUED BY THE ETHICS COMMITTEE ... 4-5 6. ABBREVIATIONS ... 6 7. TERMS ... 7 8. INTRODUCTION ... 8-9 9. AIMS AND OBJECTIVES ... 10 10. LITERATURE REVIEW ... 11-13 11. RESEARCH METHODOLOGY AND METHODS ... 14 12. RESULTS AND THEIR DISCUSSION ... 15-21 13. CONCLUSIONS ... 22 14. REFERENCES ... 23-26 15. ANNEXES ... 27-30
SUMMARY
Outcome of induction of labour in primiparous women
Aim of the study: To investigate the outcome of induction in primiparous women, and the risk
of caesarean delivery associated with induction.Objective of the study:
1. To assess the indications for induction and determine the most common indications. 2. To evaluate the different methods of induction.
3. To investigate the course of induction and method of delivery.
4. To evaluate the association of labour induction with the risk of caesarean delivery.
Methodology and Participants: This was a retrospective study among 117 primiparous
women, who were induced between the period of 31st January 2015 and 31st January 2016. Data was collected from the hospitals electronic system. Medical and elective indications as well as the outcome of induction were recorded for each parturient. The data was analysed to assess the success rate of induction of labour and the risk of caesarean delivery associated with induction of labour.Results: 117 women were induced in the study during the specified period of time. Out of the
induced women, 41 were elective induction and 86 were medical induction. The main indication for induction of labour was preeclampsia 20.5% (n = 24), post-date 25.64% (n = 30).The main method of induction used included artificial rupture of membrane (ARM), misoprostol per orally (MISO) alone, oxytocin with or without artificial rupture of membrane, misoprostol followed by oxytocin, or a combination of all which included artificial rupture of membrane followed by
misoprostol per orally, followed by oxytocin. Out of the 117 women, 63.25% of women had vaginal delivery (VD) (n = 74), 3.4% had instrumental delivery (INST) (n = 4), and 33.3% has caesarean delivery(C/S) (n = 39).
One factor that showed an increased risk of caesarean with induction was concluded to be the use of epidural anesthesia. It was found that 47.2% of women who did not receive an epidural were delivered by caesarean section (n = 25), while 22.2% of women who received an epidural were delivered by caesarean (n = 14).
Conclusion:
1. Out of all the indications for induction, the most predominant indications for induction were post term between 40-41 weeks of gestation and pre-eclampsia.
2. The main method of induction used included combination of all which included artificial rupture of membrane followed by misoprostol per orally, followed by oxytocin.
3. The outcome of induction of labour was found to be significantly successful with more than half of women who were induced had a vaginal delivery following induction.
4. There was no significant association with an increased risk of caesarean delivery with
induction of labour. However there was an increased risk of caesarean delivery with those who did not receive an epidural anesthesia and those with medical and obstetrical complications. It was found that women who did not receive an epidural were delivered by caesarean section while women who received an epidural delivered naturally.
CONFLICT OF INTEREST
No conflict of interest reported.ETHICS COMMITTEE CLEARANCE
Title: Outcome of induction of labour in primiparous womenNumber: BEC-MF-425
ABBREVIATION LIST
IOL- Induction of LabourGES.AGE- Gestational Age
ARM- Artificial Rupture of Membrane OXY- Oxytocin VD- Vaginal Delivery INST- Instrumental C/S- Cesarean Section EPD- Epidural MISO- Misoprostol
IND.IND- Indication for Induction
IND. C/S. - Indication for Caesarean Section IND.INS- Indication for Instrumental
B. WT- Baby’s Weight in Grams POS. DATE- Post Date
GDM- Gestational Diabetes Mellitus IUGR- Intra Uterine Growth Restriction PEE- Pre-eclampsia
PROM- Prolonged Rupture of Membrane IUFD- Intra Uterine Fetal Distress
IUD- Intra-uterine Death
OLIGOHYD- Oligohydramnios HT- Hypertension
Y- Yes N- NO
MMI- Maternal Medical Indications FD- Fetal Distress
TERMS
ABO- ABO blood group incompatibility
CHOLESTASIS- Obstruction of cystic duct causing a decrease in bile flow.
DYSTOCIA- Obstructed Labour (failure of the labour to progress)
HELLP- HELLP syndrome- Hemolysis (destruction of red blood cells), Elevated Liver enzymes (which indicate liver damage), and Low Platelet P count.
MACROSOMIA- significantly large newborn, more than 4,000 grams regardless of his/her gestational age.
INTRODUCTION
In recent years, induction of labour has risen gradually in modern obstetrics all over the world. Nonetheless, it is more predominant in developed countries (around 20%) than developing countries.1,2,3
Recent studies have shown that labor induction rates increased gradually from 9.5% to 19.4% in the Unites Kingdom from 2000-2008, and in some institutions, the rate of induction accommodate for over 10% of all births. [1] Despite this fact, labour induction has remained the same in the Netherlands at around 15% between 1995 and 2006.4
In most institutions, the indications for induction of labour are quite similar. Those indications can be divided into medical or elective indications. Medical indications include, post term pregnancy 42 weeks of gestation or over, prolonged rupture of membrane >24 hours, hypertension, pre-eclampsia, intra-uterine growth restriction, intra-uterine fetal distress, gestational diabetes mellitus, macrosomia, iso-imminuisation, intra-uterine fetal death and many other. Elective indications mainly include post-term pregnancy 40-41 weeks of gestation and oligohydramnios.1,3,5,6
Induction of labour has been concluded in some articles that it has an association with an increased risk of caesarean delivery. 4 Considering the fact that the rate of caesarean section has risen
dramatically all over the world. 7 in that case, it is very important to investigate the associated risk of caesarean section with induction of labour, to get a full understanding and to careful consider this risk upon inducing women.
After a thorough review of many research articles that investigated this issue and relevant to this topic, I found the conclusion to be quite inconclusive. On the grounds they concluded different results, some articles concluded that there was indeed an association with induction of labour and an increased risk of caesarean section in all women8,9,10 while others concluded an increased risk only in nulliparous women. 11,12,13,14 Other articles concluded that there was not an increased risk of caesarean section with induction of labour, but as a matter of fact, they found to be an increased risk of caesarean section with women who were a high risk pregnancy, with an adverse obstetrical history or an adverse medical history that had a higher risk of caesarean section upon induction of labour. 14,15,16,17
Further articles were found to be inconclusive with no evidential proof that induction of labour increases the risk for caesarean but at the same time, there were some factors present to be able to not completely dismiss the fact that it has no association. On the other hand, there were some articles that discovered an increased risk of instrumental delivery such as vacuum and forceps, with induction of labour.18,19
As mentioned above, some articles found many other factors that can contribute to an increased risk of caesarean with induction of labour. These include nulliparity as mentioned,11,12,13,14
Maternal age over 30 years, pre-eclampsia, gestational diabetes, macrosomia, prolonged rupture of membrane for 24 hours or more, use of epidural anesthesia.
Some articles also found that there was a direct relationship between the status of the cervix and the success of induction of labour, with women with an unfavourable cervix had a higher risk of caesarean section upon induction of labour.20,21
The purpose of this study was to observe the outcome of induction of laboutr in primiparous women and estimate the association of labour induction and caesarean delivery at a regional hospital of Lithuanian university of health sciences.
The study was undertaken through the use of clinical data derived from electronic obstetric records, and data was recorded for all women induced during a one year period that ranged from 31st January 2015 till January 31st 2016. The gestational age, indication for induction, process of induction, epidural use and outcome of induction were recorded. The aim of this study was to investigate the outcome of induction of labour and any association of an increased risk of caesarean section with induction of labour.
AIMS AND OBJECTIVES
Aim of the study: To investigate the outcome of induction in primiparous women, and the risk
of caesarean delivery associated with induction.Objective of the study:
1. To assess the indications for induction and determine the most common indications. 2. To evaluate the different methods of induction.
3. To investigate the course of induction and method of delivery.
LITERATURE REVIEW
There has been many different dissertations and thesis made regarding this topic with different
researches looking at different aspects of induction. Some looked into the outcome and the association with the increased risk of caesarean delivery with induction of labour. Others looked into the
comparison of induction of labour versus spontaneous onset of labour. The rate of caesarean delivery between induction of labour and spontaneous onset of labour. Induction of Labor at Term Compared With Expectant Management awhile others looked into the Maternal and Neonatal Outcomes of Elective Induction of Labor.
One study looked into the indications and results of labour induction in nulliparous women, and which clinical factors according to obstetricians, residents and clinical midwives, they estimated to be
predictive factors of labour outcome after induction.8
Obstetricians, residents and clinical midwives were interviewed in different teaching hospitals in southwest Netherlands and were given 16 different scenarios of nulliparous pregnant women who had indications for induction. Each scenario included 8 different factors; BMI, maternal age, gestational age, indication for induction, cervix dilation, effacement and position.8
With these factors the indication for induction was decided and the probability of caesarean delivery or spontaneous vaginal delivery was calculated and estimated for each of the scenario.
After evaluating the questionnaires, it was noted that the clinical factors most important when making the decision to induce were post –term pregnancy and preeclampsia.8 The most important factors in
predicting the outcome of induction were gestational age, effacement and dilation of the cervix.8
A systemic review was made on the maternal and neonatal outcome of elective induction of labor.9 The result showed that expectant management of pregnancy was associated with 22 %higher odds of caesarian delivery than elective induction of labor.9 These women where at or beyond 41 weeks of gestation. Among the women that where under 41 weeks of gestation the trials showed no differene in risk of cesarean delivery among women who where induced compared to expectatnt management.9
A retrospective cohort study in California looked into the comparison of elective induction at term versus expectant management.10,11
Many factors and complications were taken into account and compared between the two groups. These factors included cesarean delivery, lacerations, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, or macrosomia at any term gestational age.10,11
It was concluded that women who were induced had a lower risk of receiving caesarean section compared with expectant management.10,11 Therefore a decreased chance of caesarean deliver is associated with elective induction of labour. It was also concluded that elective induction was not associated with increased risk of lacerations, operative vaginal delivery, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, or macrosomia at any term gestational age.10,11
Another retrospective study similar to the previous study also looked into the comparison of elective induction versus spontaneous labour, and the complications and outcomes were analysed for both the mother and the fetus.12,13
Aim of this research was to compare electively induced labor to spontaneous labor and see which one that puts the mother or her fetus at increased risk.12,13
The induction group had a 50 % caesarean delivery rate. Therefore the research didn’t reveal any difference between the 2 groups among nulliparous women with respect to intrapartum maternal complications, postpartum complications and fetal complications.14,15
Upon comparison with spontaneous labour, there is not an increased risk to the mother or fetus with elective induction of labour, however it was advised to discourage induction of labour in women with an unfavourable cervix and a bishop score less than 5.14,15
Another research compared the patterns and outcomes of induction of labor in Africa and Asia.16,17 Data concerning indication for induction, method of induction and outcome were determined and analysed separately for Africa and Asia. Variable methods were used to determine he association with induction and perinatal/maternal outcomes.16,17
It revealed that induction made up 4,4% of delivers in Africa and 12.1% in Asia. There was and increased Apgar scores at 5 minutes, low birth weight, NICU admission and fresh stillbirth with the medically indicated inductions in both regions. However there was a decreased rate of caesarean delivery in Africa.16,17
A cohort study was done to determine whether elective induction of labor in nulliparous woman was associated with changes in fetomaternal outcome when compared to labor of spontaneous onset.18,19
This matched cohort study revealed that spontaneous labor where associated with significantly less operative deliveries compared to induced elective labor in nulliparous women.14,15 Delivery with C-section and transfer of the baby to the neonatal ward where significantly more common when labor was induced electively. Upon comparison of elective induction of labour and spontaneous onset of labour, it was found that 9.9% of women who were induced were delivered by caesarean while 6.5% of women who had spontaneous delivery underwent a caesarean delivery. Transfers of the baby to the neonatal ward were 10.7% for women who were induced and 9.4%for women who had a spontaneous onset of labour. (P<0.01)18,19
Therefore, induction of labour was associated with a higher risk of caesarean delivery upon comparison with spontaneous onset of labour.18,19
A systematic review studied the outcome between the elective induction of labour and expectant management of pregnancy.20,21
Out of the 6,000 articles that were reviewed, only 35 met the criteria to be included into the study. 25 articles were observational studies and 11 were randomized studies.20,21
After review of all articles, it was revealed that expectant management of pregnancy was associated with a higher rate of cesarean delivery compared with elective induction of labor.20,21 This higher risk of caesarean was mainly seen at women at or beyond 41 weeks of gestation who were managed expectantly. Although women 41 weeks of gestation or less were not found to be statistically
significant. Therefore in this case, elective induction of labour was associated with a decreased risk of caesarean delivery, compared to the other studies.20,21
RESEARCH METHODOLOGY AND METHODS
This is retrospective study conducted in obstetrics and Gynaecology department of Lithuanian University of Health Sciences.
The study was carried out between the periods of January 2015 until January 2016.
Study population consisted of 117 women
Excluded from the study were multiparous women, women with multiple gestation, or fetal anomaly. Consent was given from the Bioethics committee to collect all the data as long as no personal
information would be used.
The method used was by collecting clinical data derived from the hospitals electronic records.
The retrieved information included the indication for induction, for example post-date >41 weeks, pre-eclampsia/eclampsia, gestational diabtes etc. Method of induction, whether misoprostol, artificial rupture of membrane, or oxytocin was used. Use of epidural anesthesia, whether it was given or not. Outcome of induction whether it was by vaginal delivery, caesarean section or instrumental. If delivery was by caesarean, then indication for caesarean was also obtained.
The aim of the study was to evaluate the outcome of labor induction, and to depict whether there is an associated risk between induction of labour and caesarean section.
At the time of delivery the gestational age was recorded. Newborns that where born of at least a gestational age of 37 was categorized as term and newborns that where delivered at week 41 or later where categorized as post term.
Statistical analysis was showing the mean statistic values and its correlation with the findings.
Statistical analyses were conducted with the SPSS version 19,1 for Windows (SPSS Inc., Chicago, IL, USA). Statistically significant differences were established when p-value was <0.05
RESULTS AND DISCUSSION:
The study included 117 primiparous women who were induced during the study period. The analysis of the gestational age upon admission is shown in table 1. The minimum gestational age was 23 weeks of gestation and maximum gestation was 42 weeks of gestation; mean being 38 (SD = 3.615).
This study included all different ages of gestation in comparison with other studies which excluded preterm deliveries of <37 weeks.8.9,14,15 While other studies included post term deliveries of >40 weeks of gestation only.17
Table 1. Summary statistics:
Variable Observation s Obs. with missing data Obs. without missing data Minimum gestation Maximum gestation Mean Std. deviation 40 117 0 117 23 42 38.417 3.615
t-test for two independent samples / Two-tailed test:
Figure 1 shows the mean gestational age upon induction, which was between 37-40 weeks of
gestation. The most prevalent gestational age of induction was found to be 40/41 weeks of gestation as shown in figure 4, and was found to have an increased risk of caesarean delivery upon induction, with 62% women who were delivered by caesarean were 40/41 weeks of gestation when induced (n = 24). Fig1. Gestational age upon induction (37-40)
-‐4 -‐3 -‐2 -‐1 0 1 2 0 5 10 15 20 25 30 35 40 45 50 Sta n d ar d ize d r es id u al s 40 40 / Standardized residuals
Indications for induction of labour are shown in Table 2. Out of the 117 women, 86 women (73.5%) were induced due to medical indications, which included 3 post term pregnancy over 41 weeks of gestation (2.56%), 10 prolonged rupture of membrane (8.55%), 24 preeclampsia (20.5%), 14 uterine growth restriction (11.96%), 12 cholestasis (10.26%), 9 gestational diabetes (7.69%), 6 intra-uterine fetal distress (5.13%), 2 hypertension (1.7%), 2 HELPP syndrome (1.7%), 3 macrosomia (2.56%) and 1 ABO incompatibility (0.86%).
41 women (35.04%) were induced to due to elective indications, which included 30 post term pregnancies between 40-41 weeks of gestation (25.64%), 10 oligohydramnios (8.55%), and 1 intra-uterine death (0.86%). This adds up to a total beyond 100% due to multiple indications could be indicated for each woman, for example 6 women (5.13%) were induced due to oligohydramnios and post term pregnancy.
Over all, the most predominant indications for induction were post term between 40-41 weeks of gestation and pre-eclampsia. Post term pregnancy is a common indication for induction for the majority of similar studies.5,6,8,9 One study in US by Lydon-Rochelle MT investigated induction of labor in the absence of standard medical indications and found that majority of inductions were not clinically indicated according to standard protocols or indications were incompletely documented
.
3Table 2. Indications for Induction of Labour
n (%) n (%)
Medical induction group 86 (100)
Elective induction group 41 (35)
Post term >42 weeks of gestation 3 (2.56)
Post term 40-41 weeks of gestation 30 (25.64) Pre-eclampsia 24 (20.5) Oligohydramnios 10 (8.55) Hypertension 2 (1.71) Intra-uterine death 1 (0.86) HELLP 2 (1.71) Prolonged rupture of membrane >24hours 10 (8.55) Intr-uterine growth restriction 12 (11.96) Intra-uterine fetal distress
6 (5.13) Gestatinal diabetes mellitus 9 (7.69) Macrosomia 3 (2.56) Cholestasis 12 (10.26) ABO incompatibility 1 (0.86)
The different method of induction used and their percentages are shown in table 3, which showed no significant differences in the method of induction between the two induction groups (p <0.01). In both the medical induction group and the elective induction group, the methods of induction used were artificial rupture of membrane (ARM), misoprostol per orally (MISO) and oxytocin i/v. The combinations used were misoprostol only 16 (n= 13.68%) respectively, artificial rupture of membrane followed by misoprostol 27 (n = 23.08%) respectively, oxytocin followed by misoprostol 9 (n= 7.69%) respectively, or a combination of all which included artificial rupture of membrane followed by
misoprostol per orally, followed by oxytocin 62 (n= 53%) respectively.
Some older studies used Prostaglandin E2 instead of Misoprostol. One study in particular made a comparison with misoprostol and PGE2, and found that misoprostol was more effective than PgE2 in achieving vaginal delivery. 20
Table 3. Method of Induction
Instrumental (rupture) Medical (Misoprostol)
27 with Miso. 16 Miso. alone
62 combination of all 27 with ARM 62 combination of all
Table 4 shows the indications for c-sections which included 46% fetal distress (n = 18), 35.89% dystocia (n = 14) and 17.95% (n = 7) maternal medical indications.
The most common indication for cesarean delivery was fetal distress (46%) followed by failure for labour to progress (35.89%), as found by many other studies.20,22
Indication for caesarean in the medical indication group was 24.42% (n = 21) and in the elective indication group was 43.9% (n = 18). Therefore there was no significant difference in indication of caesarean delivery found between the two groups (P >0.05).
Table 4. Indication for caesarean section
Medical indication n (%) Elective indication n (%)
Fetal distress (FD) 10 (47.62) 8 (45)
Dystocia 8 (38.09) 6 (33.2)
Maternal medical indication (MMI)
3 (14.29) 4 (23.1)
The main concept of this thesis was to investigate the outcome of induction of labour. After analysis of data, the outcome of induction of labour among our participants who were induced was revealed to be 63.25 % vaginal delivery (n = 74), 33.3% caesarean delivery (n = 39), and 3.4% needed instrumental delivery (n = 4); as shown in table 5. In comparison with other studies that showed an increased rate of caesarean delivery upon induction.
Table 5: Outcome of Induction
Category Frequency Percentages (%) P-value
SVD Yes 74 (63.25 %) 0.001 No 42 (34.5 %) INST. Yes 4 (3.4 %) P < 0.0001 No 113 (95.7 %) C/S Yes 39 (33.6 %) 0.001 No 77 (66.4 %)
When comparing the two groups of labour induction, medical induction and elective induction, as shown in table 6. 89% of women who were induced due to a medical indication delivered vaginally (n = 66), and only 10.8% of women who were induced due to an elective indication delivered vaginally (n = 8). 72% of women induced due to a medical indication were delivered by caesarean sections (n = 28) and 28.2% induced due to an elective indication delivered by caesarean section. 75% of women induced due to a medical indication were delivered by instrumental delivery (n = 3), and 25% of women who were induced due to an elective indication were delivered by instrumental delivery (n = 1). This shows that women in the medical group had a higher risk of casarean than women in the elective group. In contrast with one study that proved both medical and elective induction groups had a higher risk for casarean section.
Table 6. Outcome of induction of labour based on induction group
Medical indication group n (%) Elective indication group n (%)
Vaginal delivery 66 (89) 8 (10.8)
Caesarean section 28 (72) 11 (28)
Instrumental delivery 3 (75) 1 (25)
Another very important concept of this thesis that was investigated was to evaluate the association of labour induction with the risk of caesarean delivery. Displayed in table 7, is the association of use of epidural and risk of caesarean delivery with induction of labour. The factor with the most significant associated with increased rate of caesarean was concluded to be the use of epidural anesthesia. It was found that 47.2% of women who did not receive an epidural were delivered by caesarean section (n = 25), while 22.2% of women who received an epidural were delivered by caesarean (n = 14).
Other factors that had an increased associated risk with caesarean included birth weight of 4,000g or higher, which is shown in figure2.
In contrast with other studies which showed that the use of epidural anesthesia as associated with an increased rate od casarean. One particular study concluded that the earlier epidural analgesia
was given during labor, the higher the probability of a cesarean delivery later on, confirming the results of other studies.18,19
One other study investigated the bishop core and risk of casarean delivery with induction of labour and concluded that women with an unfavourable cervix and a low bishop score had a higher rate of
Table 7: Use of Epidural
Epd. P-value Yes (n = 63) No (n = 53) SVD Yes No 46 (73.0 %) 17 (27.0 %) 30 (56.6 %) 23 (43.4%) 0.064 * Inst. Yes No 4 (6.3 %) 59 (93.7 %) 2 (3.8 %) 51 (96.2 %) 0.425 ** C / S Yes No 14 (22.2 %) 49 (77.8 %) 25 (47.2 %) 28 (52.8 %) 0.005 * Gestational age Mean ± SDMedian (Min. – Max.)
39.0 ± 2.80 39 (23 – 42) 37.75 ± 4.301 39 (23 – 41) 0.222 *** Baby weight Mean ± SD
Median (Min. – Max.)
3275.49 ± 752.239 3425 (576 – 4715)
2983.53 ± 971.34 3225 (580 – 4805)
0.140 ***
*By Chi-square test. **By Fisher's exact test. ***By Mann-Whitney U test.
According the data, it was found to be statistically significant that an increased risk of caesarean section with labour induction was mainly associated with use of epidural. (p <0.005) Other factors which had an increased risk of casarean with induction included gestational age of 40 weeks or over, and weight at birth of 4,000g or more. Shown in fig2 and fig3.
Similar studies revealed that the Maternal age was a significant independent risk factor for cesarean delivery. The higher the maternal age, the higher the risk for cesarean delivery, as found by many other investigators. 7,15,19,20
Fig 2. Big baby's wt, contribution to C/S:
Fig3. Women at 40/41 weeks of gestation who were delivered by c/s
Other factors shown in other studies, that could have been taken into account during this thesis are socio-demographic factors such as insurance type, marital status, race/ethnicity, age group, which were looked at in other similar studies and was found to be little association with an increased risk of
caesarean section and induction of labour. (> 0.01) and the majority of factors associated with 20 25 30 35 40 45 50 0 1000 2000 3000 4000 5000 6000 40 4080 Regression of 40 by 4080 (R²=0.681)
Model(40) Conf. interval (Mean 95%)
Conf. interval (Obs 95%)
-‐4 -‐3 -‐2 -‐1 0 1 2 3 4 Obs1 Obs7 Obs13 Obs19 Obs25 Obs31 Obs37 Obs43 Obs49 Obs55 Obs61 Obs67 Obs73 Obs79 Obs85 Obs91 Obs97 Obs103 Obs109 Obs115 Standardized residuals O b se rv ati o n s Standardized residuals / 40
CONCLUSION
The data was obtained and evaluated using the partruients case histories. The data collected included indication for induction, method used for induction, outcome of induction. If outcome was caesarean delivery, the indication for caesarean was obtained.
1. 117 women were induced for a variety of different reasons. The most predominant indications for induction were post term between 40-41 weeks of gestation and pre-eclampsia.
2. The methods of induction used were artificial rupture of membrane (ARM), misoprostol per orally (MISO) and oxytocin i/v. the most frequently used method of indication was a combination of all which included artificial rupture of membrane followed by misoprostol per orally, followed by oxytocin respectively.
3. After analysis of data, the outcome of induction of labour among our participants who were induced was revealed to be that most women were successfully delivered vaginally, while the remaining were mostly delivered by caesarean delivery.
4. After full analysis, it was not found to be an increased risk of caesarean with induction of labour. However it was found to be statistically significant that other factors had an increased risk of caesarean section with labour induction.
The factor with the most significant associated with increased rate of caesarean was concluded to be the use of epidural anesthesia. It was found women who did not receive an epidural were delivered by caesarean section while women who received an epidural delivered vaginally.
LITERATURE LIST:
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Large differences in obstetrical intervention rates among Dutch hospitals, even after adjustment for population differences (Elferink-Stinkens et al. 97-103) hy: Elferink-Stinkens, P.M. et al. European Journal of Obstetrics & Gynecology and Reproductive Biology 68 (1996): 97-103. Web. [Cited 30 April 2017] Available from: https://www.ncbi.nlm.nih.gov/pubmed/8886689
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7 CHESTNUT, D. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America (Chestnut 205-207) Chestnut, D.H. Yearbook of
Anesthesiology and Pain Management 2007 (2007): 205-207. Web [Cited 30 April 2017] Available from: http://jamanetwork.com/journals/jama/fullarticle/2473490
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ARTHUR S., and AMY L. SWEENY. Obstetrics & Gynecology 95.6, Part 1 (2000): 917-922. Web. [Cited 30 April 2017] Available from: https://www.ncbi.nlm.nih.gov/pubmed/10831992
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ANNEX:
GES.
AGE INDIC IND ARM/Y/N
OXY.Y /N MISO. Y/N VD.Y/ N INST. Y/N C/S Y/N INDC C/S EPD Y/N B. WT 41 POS. DATE/PROM Y Y Y N N Y DYST OCIA Y 4080 39 CHOLESTASI Y Y Y Y N N N Y 3630 42 POS. DATE Y Y Y Y N N N Y 4715 41 GDM/POS.DATE Y Y Y N N Y FD Y 3520 39 GDM Y Y Y Y N N N Y 2775 39 IUGR Y N Y Y N N N Y 2355 37 PEE Y Y Y Y N N N N 3425 39 PEE Y Y Y Y N N N Y 3380 41 PROM/POS. DATE N N Y Y N N N N 3120 41 POS. DATE Y N Y Y N N N N 4040 39 PROM N Y Y Y N N N Y 3480 41 MACROSOMIA/GDM Y Y Y Y N N N Y 4550 33 PEE N N Y N N Y MMI N 1340 38 CHOLESTASI Y Y Y Y N N N Y 3535 41 POS. DATE Y N Y N N Y FD N 3375 36 IUGR N N Y N N Y FD N 2220 41 POS. DATE Y Y Y N Y N N Y 3425 39 HELLP Y Y Y N N Y FD N 3040 38 PEE Y Y Y Y N N N N 2760 39 IUFD Y Y Y Y N N N Y 3985 38 IUGR/TWN Y Y Y Y N N N Y 2570 23 IUD N Y Y Y N N N N 580 40 IUGR Y Y Y N Y N N Y 2850 34 IUFD Y N Y Y N N N N 1200 41 POS. DATE Y Y Y Y N N N N 3220 38 PEE Y Y Y Y N N N Y 3470 38 PEE Y N Y Y N N N Y 3090 41 IUGR Y Y Y Y N N N N 2815 38 CHOLESTASI Y N Y Y N N N Y 2605 39 ABO Y N Y Y N N N N 2445 41 POS. DATE Y Y Y Y N N N Y 3570 37 IUFD Y Y Y Y N N N N 3065 38 IUGR Y N Y Y N N N Y 2525 41 POS. DATE Y Y Y N N Y DYST OCIA Y 3785 41 POS. DATE Y Y Y N N Y DYST OCIA Y 4346 41 POS. DATE Y Y Y N N Y FD Y 3828
40 CHOLESTASI Y N Y Y N N N N 3545 41 POS. DATE Y Y Y Y N N N Y 3610 41 PEE Y Y Y N N Y FD N 3510 40 PEE Y Y Y Y N N N N 3520 39 PEE Y Y Y N N Y MMI N 2615 39 PROM N N Y N N Y FD N 3380 37 PEE N Y Y Y N N N Y 3530 33 PROM N N Y Y N N N N 2250 40 OLIGOHYD Y Y Y N Y N N Y 3071 41 POS. DATE Y Y Y N N Y DYST OCIA N 4155 41 POS. DATE Y N Y N N Y FD Y 2830 37 GD/IUGR Y Y Y Y N N N Y 1970 40 OLIGOHYD Y Y Y Y N N N Y 3520 39 CHOLESTASI Y N Y Y N N N Y 3010 33 PEE Y Y Y N Y N N Y 1810 41 OLIGOHYD/POS.DATE N N Y N N Y FD N 3730 41 POS. DATE N Y Y N N Y DYST OCIA N 4070 40 HYPERTEN. N Y Y Y N N N N 3820 38 CHOLESTASI Y N Y Y N N N Y 3085 41 MACROSOMIA/GDM Y Y Y Y N N N Y 4425 40 CHOLESTASI Y Y Y Y N N N Y 3580 33 PEE N N Y N N Y MMI N 1600 23 HELLP Y N Y Y N N N Y 576 41 MACROSOMIA Y Y Y N N Y DYST OCIA Y 4635 40 CHOLESTASI N N Y N N Y MMI N 3380 41 POS. DATE Y N Y N N Y FD Y 3285 41 POS. DATE Y Y Y N N Y FD N 3500 39 PEE Y Y Y Y N N N Y 3180 41 POS. DATE Y Y Y Y N N N Y 3665 41 OLIGOHYD N N Y N N Y FD N 3440 37 PEE Y Y Y Y N N N Y 4080 41 GDM/PEE Y Y Y N N Y DYST OCIA N 4805 39 GDM Y Y Y Y N N N Y 3560 39 CHOLESTASI Y N Y N N Y DYST OCIA N 4495 41 POS.DATE Y Y Y N N Y FD N 4130 29 PROM N N Y Y N N N N 1257 39 GDM Y Y Y N N Y FD N 2970 41 POS. DATE Y N Y N N Y FD N 3070
39 IUGR N N Y Y N N N Y 2775 40 HT/POS.DATE Y N Y Y N N N N 3595 37 PEE N N Y Y N N N N 3225 38 IUGR Y Y Y Y N N N Y 2730 37 PEE Y N Y Y N N N Y 3000 41 CHOLESTASI Y N Y Y N N N Y 4005 39 IUGR Y N Y N N Y FD N 2580 41 OLIGOHYD. /POS.DATE Y N Y Y N N N N 3595 39 OLIGOHYD Y N Y Y N N N Y 3180 41 PROM N N Y Y N N N N 3520 39 CHOLESTASI Y N Y Y N N N Y 3225 39 IUGR Y Y Y Y N N N Y 2400 36 PROM N Y Y Y N N N N 2780 39 IUGR Y Y Y Y N N N Y 2575 41 PROM/POS. DATE Y N Y Y N N N N 4090 36 IUGR Y Y Y Y N N N N 2040 34 PEE Y Y Y Y N N N Y 2240 41 POS. DATE Y Y Y N N Y DYST OCIA Y 4260 39 IUGR Y Y Y Y N N N N 2960 39 CHOLESTASI Y Y Y N N Y DYST OCIA N 3440 38 GDM Y Y Y Y N N N N 3475 42 POS. DATE Y Y Y Y N N N Y 3145 35 PROM N Y Y Y N N N Y 2410 32 IUFD Y Y Y Y N N N N 1340
35 PEE N N Y N N Y
DYST
OCIA N 2395
35 PEE Y Y Y Y N N N Y 1905
41 POS. DATE N N Y N N Y FD N 3620
41 HT/POS. DATE Y Y Y Y N N N Y 3555
41 POS. DATE Y Y Y N N Y
DYST
OCIA Y 4170
37 PROM N Y Y N N Y
DYST
OCIA Y 2855
42 POS. DATE Y Y Y Y N N N Y 3855
39 OLIGOHYD Y Y Y Y N N N N 3605
38 PEE Y Y Y Y N N N Y 3810
40 OLIGOHYD Y Y Y Y N N N Y 3215
42 POS. DATE Y Y Y N N Y FD Y 3600
40
OLIGOHYD.
/POS.DATE Y Y Y Y N N N Y 3650
38 PEE N N Y N N Y MMI N 3250
39 PEE Y Y Y N N Y MMI Y 2760
39 PEE Y Y Y Y N N N N 3030
41
OLIGOHYD.
/POS.DATE Y N Y N N Y
DYST
OCIA Y 3545
XLSTAT 2016.06.36056 - Two-sample t-test and z-test Hypothesized difference (D): 0
