Anam Riaz, Alia Bano, Samina Saleem Dojki
Department of Gynaecology and Obstetrics, Patel Hospital Karachi, Pakistan
Email
: khadijahabid@gmail.com , ORCID: 0000-0002-8532-5714
https://doi.org/10.36570/jduhs.2020.1.948
Objective: To assess the delivery outcome in
nulliparous women at term and to compare the outcomes among induced versus
spontaneous labor.
Methods: A descriptive study was conducted at
Obstetrics and Gynecology department of Patel Hospital, Karachi from April to
October 2019.All women with age between 20-40 years, gestational age between
37-42 weeks, and singleton pregnancy were consecutively included. Mode of
delivery and Apgar score at 5 minutes were noted.
Results: Of 172 women, the mean age of the women
was 29.9+-4.64. Vaginal delivery was reported in 102 (59.3%) and cesarean
section in 70 (40.7%) women. Cesarean delivery was found to be significantly
higher among women with >29 years of age (p-value 0.006), >38 weeks of
gestational age (p-value <0.001), obesity (p-value <0.001), and induction
of labor (p-value 0.020). Mean APGAR score at 1 min was 7.45 +- 0.69 and APGAR score at 5min was 8.84 +-0.41. Mean APGAR
score at 5 minutes was significantly higher in women vaginal delivery than that
of women with cesarean delivery (p-value 0.034).
Conclusion: The frequency of vaginal delivery was
found higher in nulliparous women presenting at term. Moreover, APGAR score at
5 minutes was found to be significantly different in both groups.
Keywords: Caesarean delivery, Induction of
labor, maternal outcome, Induced labor, Spontaneous labor, Nulliparous women.
INTRODUCTION
One of the most common procedures for obstetrics is the
induction of labor.It is reported that one fifth of all pregnanciesrequire
induction procedure.1,2Some studies suggest that induction of
pregnancy increases the risk of complications due to uterine overactivity or
atony.3,4
Various
studies have reported that in women with induced labor, caesarean sections were
considerably higher than in women with spontaneous labor. Mean Apgar score, however,
was better than spontaneous labor in induced labor.5-7Induced labor
was proposed to increase the chances of caesarean section and have no adverse
impact on the neonatal outcome. Therefore, induced labor is recommended to be a
safe procedure for nulliparous women if labor is controlled in a partographic
way.7, 8
Previous
literature showed varied results and found that induced labor is associated
with complications and caesarean section as compared to spontaneous labor.7-10
Moreover, a though literature search has revealed dearth of local studies on
this topic particular from private sector hospitals. Therefore, we planned this
study to evaluate the rate of induced labor in nulliparous women and to compare
delivery outcome between induced and spontaneous labor at term.
METHODS
Thisdescriptive
study was carried out at Obstetrics and Gynaecology department, Patel Hospital,
Karachi from April to October 2019. All women of age between 20-40 years
presenting at gestational age between 37-42 weeks assessed on dating scan with
singleton pregnancy confirmed on ultrasound, gestational hypertension
(BP>140/90 mmHg), gestational diabetes (BSR>140 mgdl), intact membranes
on examination, and active phase of labor with cervical dilation at least 4cm
were consecutively enrolled. Whereas patients with non-cephalic presentation
(on USG), previous scar, anemia (Hb<10g/dl), eclampsia (BP≥140/90mmHg
with convulsions), placenta previa, cephalopelvic disproportion, multiple
pregnancy (with 1stnoncephalic twin), have previous uterine surgery
on history and were confirmed through discharge card, multiple gestation on
ultrasound, gestational age less than 28 weeks, caesarean Section done for
reasons like placenta previa, primi breach presentation (diagnosed by
ultrasonography), and fetal distress in first stage of labor (diagnosed by
strict fetal monitoring by fetoscope during labor) were excluded.
A
sample of 172women was estimated with 95% confidence level,reported percentage
of caesarean section with induced labor i.e. 20% at margin of error 6%.6All
females underwent induced labor with 3mg dinoprostone vaginally. Dose were
repeated after sixhours. Maximum allowable up to two doses (6 microgram of the
drug). While females underwent spontaneous initiation of labor,all were followed-up
till delivery. Regarding delivery outcomes,mode of delivery and Apgar score at
5-minutes were noted. Nulliparous was defined as if female has never given
birth to a viable child before current pregnancy. Apgar score were measured in
term of mean and standard deviation recorded after 1 minute and 5 min of birth.
This information of outcome variable and demographics like age, gestational
age, and obesity were noted.
Statistical
analysis was done using SPSS version 20. Mean +-SD for quantitative while frequencies
and percentages for quantitative variables were computed.Inferential statistics
were calculated using chi-square test and independent sample t-test. P-value≤0.05
was taken as significant.
RESULTS
The
average age of the women was 29.9+-4.64 (ranging: 10+20 years). Spontaneous
induction of labor was observed in 118 (69%) women. Most of the women found
obese i.e. 115 (67%) who had body mass index more than 30 kg/m2.
Gestational age of 148 women (86%) was more than 38 weeks while 24(14%) was
observed less than 38 weeks. A total of 102 (59.3%) women delivered through
vaginal and 70 (40.7%) women delivered by cesarean section. (Table 1)
Cesarean
delivery was found to be significantly higher among women with >29 years of
age (p-value: 0.006), >38 weeks of gestational age (p-value:<0.001),
obesity (p-value:<0.001), and induction of labor (p-value: 0.020). (Table 2)
Mean
APGAR score at 1-minute was 7.45 +-0.69 and APGAR
score at 5-minutes was 8.84 +-0.41. Mean APGAR score at 5-minutes was
significantly higher in women vaginal delivery than that of women with cesarean
delivery (p-value: 0.034). (Table 3)
DISCUSSION
Labor
induction is one of the main procedures in obstetrics, and is not risk-free.11,12
In many circumstances, induction of labor may either result in an increase or a
decrease in maternal or perinatal morbidity.13-15
The successful vaginal delivery rate in those induced was 22.7%
compared to36.6% in those with spontaneous labor. This difference was
statistically significant, which is in agreement with those documented in the
literature.16-18
Comparatively, the study s successful induction rate was lower
than previous study reported.19Our successful induction rate was,
however, similar to that reported in the large Latin American Study.20
Orji et al.21 achieved successful labor
induction in 64.7% nulliparous cases following use of vaginal misoprostol
compared to 72.1% in women with spontaneous labor.21
In
this study, induced labor was associated with a higher caesarean rate (32.3%)
compared to 16.4% in those who had spontaneous onset labor. This finding is
consistent with other studies.21-23
Caesarean
section rate in this study was observed to be higher in nulliparous women in
both the induced and spontaneous labor groups. This was similar to findings of
Orji et al.21
Regarding
mode of delivery, spontaneous onset of labor had more vaginal deliveries as
compared to induced labor group while vice versa for caesarean section. Our
results were comparable to a study in which they found that a larger proportion
of spontaneous group females had vaginal deliveriescompared to induced group
and also a smaller proportion of spontaneous group ends up on caesarean
section.24
Women
with nulliparous statusare suspected as an independent detrimental factor for
elective induction, which is contrary to some studies and found it to be a
protective effect.25-27
The findings of this study have certain limitation.
Firstly, the study was a descriptive study. Further exploratory research is
recommended to explore the outcome of this study. Secondly, this study has
reported findings from a single center. Despite of these limitations, the
current study was conducted on an ample number of cases from a private sector
hospital of metropolitan city Karachi.
CONCLUSION
In nulliparous women presenting at term, the frequency of
vaginal delivery was found to be higher. In addition, it was found that APGAR
performance at 5 minutes is significantly different in both classes. The
findings of this study have indicated that a decline in cesarean birth in
nulliparous women is correlated with the elective induction of labor at more
than 38 weeks gestation.
|
Table
1: Descriptive statistics of the patients (n=172) |
||
|
Descriptive Statistics |
Mean +-SD |
Range (Max-Min) |
|
Age |
29.9+-4.64 |
22(42-20) |
|
Height |
1.6+-0.06 |
0.49(1.73-1.24) |
|
Weight |
76.17+-9.94 |
50(108-58) |
|
BMI |
30.83+-3.35 |
18(42-24) |
|
Gestational
Age |
38.37+-1.93 |
10(42-32) |
|
|
n |
% |
|
Classification of labor |
||
|
Spontaneous |
118 |
69 |
|
Induced |
54 |
31 |
|
Obesity |
||
|
Yes |
115 |
67 |
|
No |
57 |
33 |
|
Mode of delivery |
||
|
Vaginal |
102 |
59.3 |
|
Cesarean Section |
70 |
40.7 |
|
SD: Standard deviation, Max: Maximum, Min: Minimum n: number |
||
|
Table
2: Comparison of mode of delivery with general characteristics of the
patients (n=172) |
||||
|
Variables |
Mode of delivery |
P-value |
||
|
Vaginal Delivery |
Caesarean Section |
Total |
||
|
Age |
||||
|
≤29 Years |
58(33.7%) |
25(14.5%) |
83(48.3%) |
0.006* |
|
>29 Years |
44(25.6%) |
45(26.2%) |
89(51.7%) |
|
|
Gestational
age |
||||
|
≤38 Weeks |
2(1.2%) |
22(12.8%) |
24(14%) |
<0.001 |
|
>38 Weeks |
100(58.1%) |
48(27.9%) |
148(86%) |
|
|
Obesity |
||||
|
Yes |
56(32.6%) |
59(34.3%) |
115(66.9%) |
<0.001 |
|
No |
46(26.7%) |
11(6.4%) |
57(33.1%) |
|
|
Type of
Labor |
||||
|
Induced |
39(22.7%) |
15(8.7%) |
54(31.4%) |
0.020 |
|
Spontaneous |
63(36.6%) |
55(32%) |
118(68.6%) |
|
|
Chi-square
test applied, p-value <0.05 taken as significant |
||||
|
Table 3: Mean difference of APGAR at 1 and 5 minutes
with respect to mode of delivery (n=172) |
||||
|
APGAR Score |
Mode of delivery |
p-value |
||
|
Vaginal Delivery |
Caesarean Section |
Total |
||
|
Mean APGAR at 1 minute |
7.51+-0.69 |
7.39+-0.71 |
7.46+-0.7 |
0.251 |
|
Mean APGAR at 5 minutes |
8.9+-0.33 |
8.76+-0.49 |
8.84+-0.41 |
0.034* |
|
Independent t-test applied, p-value <0.05 taken as
significant |
||||
REFERENCES
2.
ACOG committee on practice bulletins no 107: induction of
labor. Obstet Gynecol 2009; 114:386-97.
3.
Bukola F, Idi N, M Mimunya M, Jean-Jose W-M, Kidza M, Isilda
N, et al. Unmet need for induction of labor in Africa: secondary analysis from
the 2004-2005 WHO Global Maternal and Perinatal Health Survey (A cross-sectional
survey). BMC Public Health 2012; 12:722.
11.
Ryan R, McCarthy F. Induction of labour. Obstet Gynaecol
Reprod Med 2016; 26:304-10.
12.
Tsakiridis I, Mamopoulos A, Athanasiadis A, Dagklis T.
Induction of Labor: An Overview of Guidelines. Obstet Gynecol Surv 2020;
75:61-72.
13.
Chouhan YS, Sharma A, Agrawal M. A randomized comparative
study of progress of labour and fetal outcome of delivery amongst spontaneous
versus induced labour in term pregnancy primi gravida of using modified who
partograph in the department of obstetrics and gynecology SMS Medical Colleg.
Int J Med Biomed Studies 2019; 3.
14.
Saccone G, Della CL, Maruotti GM, Quist‐Nelson J,
Raffone A, De Vivo V, et al. Induction of labor at full‐term in pregnant
women with uncomplicated singleton pregnancy: A systematic review and meta‐analysis
of randomized trials. Acta Obstet Gynecol Scand 2019; 98:958-66.
15.
Sinkey RG, Lacevic J, Reljic T, Hozo I, Gibson KS, Odibo AO,
et al. Elective induction of labor at 39 weeks among nulliparous women: The
impact on maternal and neonatal risk. PLoS One 2018; 13:e0193169.
19.
Ekele BA, Oyetunji JA. Induction of labour at Usmanu Danfodiyo
University Teaching Hospital, Sokoto. Trop J Obstet Gynaecol 2002; 19:74-7.
22.
Abisowo OY, Oyinyechi AJ, Olusegun FA, Oyedokun OY,
Motunrayo AF, Abimbola OT. Feto‑maternal outcome of induced versus spontaneous labour in a
Nigerian Tertiary Maternity Unit. Niger J Obstet Gynaecol 2017; 34:21-7.
23.
Kwawukume EY, Ayertey R. The use of misoprostol for
induction of labour in a low-resource setting. Trop J Obstet Gynaecol 2002;
19:78-81.
24.
Suzuki S. The effect of time of day on unscheduled cesarean
delivery and perinatal outcome. Int J Gynaecol Obstet 2012; 116:177-8.
1.
Rayburn WF, Zhang J. Rising rates of labor induction:
present concerns and future strategies. Obstet Gynecol 2002; 100:164-7.
2.
Muto H, Ishii K, Nakano T, Hayashi S, Okamoto Y, Mitsuda N.
Rate of intrapartum cesarean section and related factors in older nulliparous
women at term. J Obstet Gynaecol Res 2018; 44:217-22.
3.
Penfield CA, Wing DA. Labor induction techniques: which is
the best?. Obstet Gynecol Clin North Am 2017; 44:567-82. doi:
10.1016/j.ogc.2017.08.011.