SOURCE OF DATA:

Pregnant women admitted as In-patients in Bokaro General Hospital, Bokaro Steel

City Jharkhand, Pin No-827004 over a period ranging for 16 months from November 2013 to
March 2015, were recruited for the study.
METHOD OF COLLECTION:
The study received approval from the institution and all participants gave written
informed consent. One hundred pregnant women were selected at random and were divided
into four equal groups:
1. Labour induced with oral prostaglandin (misoprostol) alone
2. Labour induced with vaginal prostaglandin (misoprostol) alone
3. Labour induced with cerviprime gel(PGE2-Dinoprostone gel)
4. Pregnant women in Active phase of spontaneous onset of labour.
All cases augmented with oxytocin drip depending on the Bishop score. On admission
to the labour room, the data was collected by an interview and clinical examination of the
patients based on a prepared questionnaire (as in proforma) which also included the plotting
of labour progression on a partogram.
Selection of candidates was made using inclusion and exclusion criteria as follows:
Inclusion criteria:
Primi & multi gravida with singleton vertex presenting pregnancy, either in active
phase of spontaneous labour or having an indication for induction of labour as laid down in
the ACOG practice bulletin 114, 2009.
Indications for induction of labour as per ACOG guidelines 20091 are:
1. Abruptio placenta
2. Chorioamnionitis
3. Fetal demise
4. Gestational hypertension
5. Preeclampsia, eclampsia
6. Premature rupture of membranes
7. Postterm pregnancy

8. Maternal medical conditions (e.g. diabetes mellitus, renal disease, chronic pulmonary
disease, chronic hypertension, antiphospholipid syndrome).
9. Fetal

compromise

(e.g.

severe

fetal

growth

restriction,

isoimmunization,

oligohydramnios).
10. Logistic reasons
a. Risk rapid labour
b. History rapid labour
c. Distance from the hospital
d. Psychosocial indication
Exclusion criteria:
Pregnant women having a contraindication for induction of labour as laid down in the
ACOG practice bulletin 114, 2009. Also excluded were those patients in whom there was a
medical contraindication for oxytocin or prostaglandins.

Contraindications for induction of labour as per ACOG guidelines 2009 are:

1. Placenta or vasa previa
2. Abnormal foetal lie
3. Cord presentation
4. Prior classical uterine incision
5. Prior myomectomy or uterine unification surgery entering the endometrial cavity.
6. Active genital herpes infection
7. Invasive cervical carcinoma

PROTOCOL FOR INDUCTION WITH CERVIPRIME GEL

Cerviprime gel is PGE2 gel has collagenolytic properties & sensitzes the
Myometrium to oxytocin. Applied intracervically as Dinoprostone gel(PGE2-0.5mg) gel is
gold standard for cervical ripening,repeat after 6hrs for up to 3-4 doses if required.

The women should be on bed for 30min some prefer 1hr following application of
gel& is monitored for uterine activity as well as for fetal heart rate.
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 was tried.
PROTOCOL OF INDUCTION WITH VAGINAL MISOPROSTOL :
Patients assigned to the intra-vaginal 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 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 and other methods was tried.
AUGMENTATION WITH OXYTOCIN :
Oxytocin was delivered in a high dose manner according to the arithmetic escalation
protocol given in the "Management of Labour" by Arulkumaran. The infusion rate was begun
at 5 milli units/minute and increased in 5 milli units/minute, increments every 30 minutes
depending on the frequency and strength of contractions. Maximum dose allowed was 40
milli units per minute.
Cervical examination was performed every two hours after starting induction and
whenever clinically indicated.
RECORDING OF PROGRESS IN LABOUR:
The name, age, parity and hospital identification data were entered.
In all patients, the cervical status is assessed by using Bishop's score prior to induction
and then after 6 hours of induction.

Burnetts modification of the Bishop score is as follows

Score
Factor

Dilatation

<1.5

1.5-3

>3

Station

-2/higher

-1

0 or lower

Position

Posterior

Mid

Anterior

Effacement

1.5 cm

Intermediate

<0.5

Consistency

Firm

Intermediate

Soft

Maximum score is 10.

A score of more than 6 is a favorable score with a predictable outcome.
Foetal heart rate is recoded half hourly. The basal foetal heart rate, that is the rate
between contractions is charted.
The state of membrane was "I" if membranes were intact, "C" if membranes were
ruptured and liquor clear, "M" if membranes were ruptured and liquor meconium stained.
Moulding of head at initial examination and subsequent vaginal examination was noted and
scoring was done as + or ++.
The most important measures of progress in labour, the rate of dilatation of the cervix
and the rate of descent of the foetal presenting part, are recorded by plotting the cervical
dilation on the vertical line on the left hand side of the graph in centimeters from 0 to 10
against the elapsed time which is plotted on the horizontal line in hours.
The admission time is taken as zero hours, and the dilatation at the initial examination
is plotted on the dilatation curve. The cervical dilatation should be measured by vaginal
examination four-hourly when the patient is in established labour and more frequently when
problem require an early decision.
The level of the head was measured by abdominal palpation as the number of fifths of
head above the pelvic brim. The head that is 5/5 above is entirely above the brim and the head
that is 4/5 above is just entering the brim; when the head js 3/5 above the hands on abdominal
palpation can still go partially round the head; when 2/5 above, the hands splay outwards
because more than half of the head has entered the brim. When 1/5 above, only the sinciput

can be tipped abdominally and no fifth represents a head entirely in the pelvis with no
sinciput or occiput palpable above the brim. The number of fifth was plotted on the
cervicograph with a '0' using the lines 0 to 5 on the left hand side.
The uterine contractions were plotted on the graph below the cervicograph. The
duration and frequency of contractions were recoded in one hour blocks beginning from 1
hour pre-dosing and then for each hour. The strength of contractions was assessed based on
perception of contraction intensity (none, mild moderate severe).
Episodes of uterine tachysystole defined as >5 contractions in 10 minutes or a single
contraction lasting more than 2 minutes and FHR abnormalities (variable decelerations and
bradycardia) were sought. The frequency was assessed by counting the number of
contractions occurring during of contraction was measured in seconds and the number of
blocks representing frequency were filled in by dots if the duration was less than 20 seconds,
cross-hatched if less than 40 seconds and blocked out if more than 40 seconds.
Below this uterine contraction, on the graph, mothers' temperature, pulse, BP were
recorded. Urine examination for glucose, albumin and acetone (if indicated and done) were
also recorded on the graph. The treatment given and the mode of delivery were illustrated on
the graph. Every participant was observed for any side effect during and after delivery.
Apgar scores of the baby were recorded at first and fifth minute. Any admission to
NICU was also noted.
The time of various stages, time from induction to delivery, route of delivery and
failed induction were also recorded.
The quantitative data, comparison was performed using chi-square test with Yates's
correction, students 't' test and analysis of variance. Group averages were reported as mean
standard deviation.