Telaah Jurnal

Defining failed 
induction of labor

Pembimbing Klinik:

DEPARTEMEN OBSTETRI DAN GINEKOLOGI dr. Ari Rinaldzy, Sp.OG

RUMAH SAKIT MUHAMMADIYAH PALEMBANG
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH PALEMBANG M. Padhalah Ramadhani,  S.Ked 
2018
71.2016.050
INTRODUCTION
           BACKGROUND
One approach to diagnosing
induction failure is based on
the duration of the latent
phase. However, the
standard for the minimum
duration that the latent
phase of labor induction
must continue, there is no
acute indication of mother
or fetus for cesarean.
Labor induction has become an
increasingly used obstetric
intervention.
Over the past 2 decades, its
use has more than doubled,
and currently, about 1 in 4
pregnant women
experience labor induction.
whether the benefits
outweigh the risks when a
woman stays in the latent
phase for a long period of
time.
The latent phase begins when oxytocin has
begun and membrane rupture (ROM) has
occurred, and ends at 4 cm dilatation and 90%
thinning or 5 cm dilatation apart from
thinning.
 Material and Methods
– From 2008 to 2011, researchers at Eunice Kennedy Shriver's National
Institute of Child Health and Human Development, the Mother-Fetal
Medical Network Unit conducted observational research (APEX study).

– In this study, the characteristics of nulliparous pregnancy patients; have

a single pregnancy, head presentation at ≥ 37 weeks; and undergo
labor induction. Randomly selected, representing one third of
deliveries over a 3-year period in 25 participating hospitals.
– Inclusion    nullipara;  single  pregnancy,  head 
presentation  at  ≥  37  weeks;  and  underwent  labor 
induction taken from 2008 to 2011 from 25 participating 
hospitals.

– Exclusion    time  taken  to  calculate  the  length  of  the 

latent  phase  (eg,  time  at  membrane  rupture,  time  at 
initiation of oxytocin, time at least 5 cm achieved) is not 
available in the graph and, thus, the length of the latent 
phase cannot be determined.
RESULT
 • A total of 10,677 women were available for analysis. In most
(96.4%) women, the active phase has been reached for 15
hours.

• The longer the duration of the latent phase of a woman, the greater
the chance to finally undergo caesarean delivery (P <0.001, for time
both as a continuous and categorical independent variable, even
though> 40% of women whose latent phase persisted ≥ 18 hours
still gave birth normally).

• Some maternal morbidity, such as postpartum

hemorrhage (P <.001) and chorioamnionitis (P
<.001), increase in frequency as the length of the
latent phase increases. Conversely, the worst
perinatal outcome frequency is statistically stable
over time.
DISKUSI
This study explains several aspects of the latent phase in the setting
of labor induction that can help when considering recommendations
regarding labor management.

 First, the majority of women (ie,> 96%) will enter the active phase
within 15 hours of completing cervical maturation (if needed),
oxytocin initiation, and membrane rupture. These patterns still
exist regardless of whether induction is without
 medical indication, after KPD, or after ripening of the cervix.

 There is no one time when sudden complications arise, although

there is a gradual increase in the frequency of some maternal
complications, and an NICU admission, over time.

 The latent phase that is displayed is associated with more frequent

maternal and neonatal complications, although this study is not
limited to labor induction or using a single "extending" consensus
definition.
Rouse et al. 3 conducted the first study using an approach similar to
the current analysis to try to determine the relationship between the
duration of the latent phase and obstetric complications in conditions
of labor induction. Their study involved 509 women with mixed
parity and showed that "continuous labor induction allows some
women to give birth normally," that chorioamnionitis increases with
a longer time than the latent phase, and that large maternal and
perinatal complications are rare.
Involve more nulliparous women with a latent phase duration of> 12
hours and conclude that even after 12 hours of the latent phase,
vaginal delivery occurs with a reasonable frequency and is rarely
accompanied by complications.
In a recent data analysis of 9763 nulliparous women in the
Consortium of Safe Labor study, where 6 cm was defined as late
latent labor, NICU care (but without mechanical ventilation or sepsis)
was statistically higher (8.7% at 12 hours vs. 6.7% at 9 hour) after 12
hours of latent phase.
CONCLUSION
Kesimpulan

Most women who undergo labor induction will enter the

15-hour active phase after oxytocin begins and membranes
rupture has occurred. Unwanted results for mothers are
more statistically more frequent in latent phases, although
absolute increases in frequency are relatively small.
Kesimpulan

These data indicate that caesarean delivery should not be carried out
during the latent phase before at least 15 hours after oxytocin and
membranes rupture has occurred. The decision to continue labor
outside this point must be individual, and can consider factors such
as other evidence of the progress of labor.
JOURNAL STUDY
 Review Journal Completeness
• Journal title: available

• Author and Institution: available

• Abstract: available

• ntroduction: available

• Method: available

• Result: available

• Discussion: available

• Conclusions and suggestions: : available

• References: : available

• Attachment: none
PICO
Population
– The population in this study was taken from 2008 to 2011,
researchers at Eunice Kennedy Shriver's National Institute of Child
Health and Human Development, the Maternal-Fetal Medical
Network Unit conducted observational research (i.e., the APEX
study).
Population
– In this study, the characteristics of patients included nulliparous,
intrapartum, head presentation at ≥37 weeks with fetuses living at
admission and maternity on a randomly selected day, representing
a third of deliveries over a 3-year period in 25 participating
hospitals.
 Indicator
Comparison

No intervention and comparison were carried out in this study

Outcome

– A total of 10,677 women met the inclusion criteria and were available for
analysis, 1725 (16.2%) of whom experienced induction because the KPD
and 5582 (52.3%) experienced ripening of the cervix.
Outcome

– For women who did not come with KPD, the median duration between oxytocin
initiation and membrane rupture was 215 minutes (interquartile range [IQR] 75-
418 minutes) for women undergoing cervical ripening and 180 minutes (IQR 65-
332 minutes) for women who did not undergoing cervical ripening..
Outcome
– The median duration of oxytocin use and membrane rupture (defined in this
analysis as the beginning of the latent phase) for active labor (or cesarean
delivery if active labor was not achieved) was 262 minutes (IQR 141-435
minutes). By 6 hours nearly two-thirds of women have developed from the start
of the latent phase to the active phase, and in most (96.4%) women, the active
phase has been reached in 15 hours.
Outcome
– 169 ruptures were detected intrapartum during emergency SC, and 
75 were detected postpartum at laparotomy after vaginal delivery.

– Mothers with rupture detected after labor have a higher percentage of 
maternal symptoms or signs than those detected by intrapartum. 
Middle time (median) from suspected rupture to labor is 20 minutes 
(Q1: 15 minutes, Q3: 30 minutes).
Outcome

– The longer the duration of the latent phase of a woman, the greater the chance
to finally give birth to a cesarean.
– However,> 40% of women whose latent phase survives ≥ 18 hours of vaginal
deliv
 Outcome
– Indications for cesarean delivery are grouped according to the phase and stage of
labor. As illustrated, the majority of cesareans at each interval time and especially
at the beginning of the interval time which is <15 hours - are not carried out in the
latent phase.
– Some maternal morbidity (eg chorioamnionitis, postpartum haemorrhage and
bleeding transfusion) also increases in frequency as the latent phase increases.
VIA
Validity

– Research question
Is the data collected in accordance with the purpose of the research?
– Yes. Data taken is in accordance with the research objectives. This study was based on data from an
obstetric cohort of women who gave birth in 25 US hospitals from 2008 to 2011. nulliparous women
who had a single pregnancy in head presentation were eligible for this analysis if they underwent
labor induction.
– Are the inclusion and exclusion criteria in this research clearly defined?
– yes. The inclusion criteria in this study were nulliparous pregnant women; have
a single pregnancy, head presentation at ≥ 37 weeks; and underwent labor
induction taken from 2008 to 2011 from 25 participating hospitals.
– While the exclusionary criteria are the time taken to calculate the latent phase
length (for example, the time at which membrane rupture, the time at oxytocin
initiation, the time at least 5 cm is reached) is not available in the graph and,
thus, the latent phase cannot be determined.
– Are the research subjects explained in detail?
Yes. Subjects in this study were nulliparous, intrapartum women, head
presentations at ≥37 weeks with fetuses living at admission and maternity on a
randomly selected day, representing a third of deliveries over a 3 year period in
25 participating hospitals. The research subjects will be included in the group
according to the inclusion criteria.
Randomization
– Was the randomization list concealed from patients, clinicians, and researchers?

Yes. In this study both patients, researchers and health workers did not know the prescribed
treatment group.

Interventions and co-interventions

– Were the perfomed interventions described in sufficent detail to be followed by other?

In this study the research subject was not intervened.

Importancy 
– Is this study is important?
Yes, this research is important because the results of this study can assess how long the latent
phase can affect induction.
Applicability

– Is your environment so different from the one in study that the methods could not be use there?
– The environment in this study is different from the environment in Indonesia. However, the same
method can still be used in research conducted in Indonesia.
Conclusion

Based  on  the  journal  review    valid,  important,  and 

applicable  can be used as a reference.
42

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