In current obstetric practice, induction of labour is often carried out for various maternal and/or fetal reasons
Macer JA et al in their study, found that all babies were born alive and there were no neonatal death in the induction group. Neonatal intensive care unit admission was only in 0.8% babies 30
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- GENERAL OBJECTIVE: To study the relationship of pre-induction Bishop score with the outcome of induction of labour. Specific Objectives
- Study design Type of Study
- Time of study
- Inclusion criteria
- Induction procedure
- DATA MANAGEMENT
- Ethical Consideration
- TABLE I : PATIENTS CHARACTERISTICS
Macer JA et al in their study, found that all babies were born alive and there were no neonatal death in the induction group. Neonatal intensive care unit admission was only in 0.8% babies 30In a study of 125 primigravidae, one-minute Apgar score <5 was found in 23% and 6% of patients with cervical score of 0-3 and 4-7 groups respectively.9 Misra M et al in a study of induced labour in women with a modified BS of less than 3, found a five minutes Apgar score of 4-6 in 2.8% primigravidae and 7-10 in 97% of primigravidae and 100% of multigravidae.22 In a study of induced labour, neonatal complications included neonatal sepsis (1.5%), 5-minutes Apgar score <7 (2%) and few neonatal deaths mainly in extremely premature babies. 24 Women with poor cervical score had a poor neonatal outcome in a Singaporean study in which the neonatal condition assessed by one-minute and five-minutes Apgar score, it was slightly but not significantly lower in those with poor cervical scores, especially in multigravidae.10 Among the neonates, 6.3% had one-minute Apgar score of 6 or less and 93.7% had above 6. Similarly 1.5% had one minute Apgar score of 6 or less and 98.5% had above 6.10 Only 4.7% neonates were admitted to the SCBU. GENERAL OBJECTIVE: To study the relationship of pre-induction Bishop score with the outcome of induction of labour. Specific Objectives: To find out the Bishop scores and indications in cases of induction of labour. To measure the induction delivery interval. To study the mode of delivery To observe the maternal complications. To study the fetal outcome. Study design Type of Study: This study was a hospital based prospective analytical study. Place of study: It was conducted in Paropakar Shree Panch Indra Rajya Laxmi Devi Prasuti Griha located in Thapathali, Kathmandu (Nepal). This hospital was established in 1959 AD with 40 obstetric beds. Now it has 302 beds, where total number of delivery is around 14000 each year and a CS rate of 9.6% 36, 37 It is a central referral level maternity hospital in Nepal. Time of study: The duration of the study was two and a half months, starting from 31 July, 1998 to 15 Sept. 1998 and 16 May 1999 to 15 June 1999. Sample and Sampling Technique: A census of obstetrics patients admitted in the hospital was taken during the study period. From these, only those who underwent induction of labour (IOL) were picked up for the study. Within the time frame, a sample of 103 patients undergoing IOL was included for the study. This study population was representative of our general induction population. Pregnant women satisfying the following inclusion criteria were included in the study. Inclusion criteria: All parity (except grand multipara > 4 viable deliveries). Alive singleton pregnancy with cephalic presentation. Gestational age of 28 or more weeks. Exclusion criteria: Pre-labour rupture of membranes. (PROM) Previous CS Not sure of date/No dating scan. Questionnaires were pre-tested before the study and necessary changes were made. The questionnaires were administered to the study cases. The basic data and clinical information were recorded in the questionnaire. General, physical and obstetrical examination of the patient were done. The pre-induction BS using the scoring system of Bishop was assessed by the investigator every day in the morning usually between 0600 to 1000 hours on the day of induction in the antenatal ward (ANC-B). These patients were categorized by Bishop scores at the beginning of induction for comparison of success of induction, mode of delivery, induction delivery interval, maternal complications and fetal outcome in terms of standard Apgar score at birth. Women undergoing induction with low Bishop scores (0-4) were grouped in one study group, and those with high Bishop scores (5-8) into another. Induction procedure : All the patients were induced by oxytocin infusion according to the Maternity hospital protocol.37 None of our subjects received prostaglandin gel to ripen the cervix and none were given epidural analgesia during labour. In the present study the traditional protocol of high dose oxytocin infusion by titration method was utilized by using a standard administration-set, 15 drops per minute equals a rate of 1 ml. per minute. Synthetic oxytocin (Syntocinon) was administered intravenously as 2.5 units in 540 ml. 5% dextrose with gravity-fed method (counting and adjusting the drip rate manually) at 10 drops/minute (3.0 mU per minute), increased by 5 drops per minute every 15 minutes until an adequate pattern of uterine contractions ( 3 contractions in 10 minutes lasting > 40 seconds) was obtained, to a maximum of 60 drops per minute. Whenever second pint (next 540 ml. 5% Dextrose) was needed, 5 units of Syntocinon was added to it and infused at half of the rate of running drip and increased upto 40 drops per minute. Once labour was established the rate was not increased further. Once oxytocin was started continuous nursing care and fetal heart sound monitoring, in the form of intermittent auscultation at every 15-30 minutes interval, were provided. None were monitored by CTG and fetal blood sampling (FBS). Maternal vital signs were monitored regularly and liquid diet was allowed to all the patients. Uterine contractions were also palpated and recorded every 30 minutes. Progress of labour was monitored by noting the descent of the head and assessing the cervical status. Vaginal examinations were usually performed four-hourly. If membranes had not ruptured spontaneously, artificial rupture of membrane was generally performed when the cervix was 3-4 cm dilated in established active labour. Intake output chart was maintained and monitoring of the patients was individualised according to the indication for induction. In case of HDP, urine albumin was tested regularly. Infusions were discontinued if there was fetal tachycardia, bradycardia or persistent abnormal FHS and managed appropriately. The infusion was discountinued also in case of failed induction. Patients, who did not go into active labour following the 12 hour of Syntocinon infusion, were managed at the discretion of their attending obstetricians. The decision to discontinue the labour and deliver by LSCS was made by the duty registrar or consultants if fetal distress supervened or delayed progress occurred. At delivery, condition of the babies were assessed in terms of Apgar score at one and five-minutes, birth weights were taken and immediate neonatal nursing care provided. After delivery the infusion was continued for one hour as prophylaxis against PPH. The mothers and their babies were followed-up till their discharge from the hospital. Premature babies, low birth-weight babies and babies with hypoxic ischaemic encephalopathy (HIE) were admitted in the SCBU. Perinatal morbidity was measured in terms of admissions to Special Care Baby Unit (SCBU). DATA MANAGEMENT After primary data collection and recording details of obstetric history, examination, age, parity, gestational age assessment, cervical score (BS), indication of induction, fetal condition in labour, induction delivery interval, mode of delivery, indication for operative delivery, maternal complications and neonatal outcome, data entry into the master chart was done. The data were then presented in diagrams, charts and tables. Data analysis was done manually and tests of significance were performed by using EPI-INFO softwares with the help of a statistician. Interim analysis was done monthly and final analysis was done after completion of data collection. Statistical analysis of categoric or non-continuous variables (i.e. CS, Apgar Score etc.) was done using the X2 test. Comparison of continuous variables (i.e. maternal age, gestational age, IDI) was done with the Student t test. A two tailed P value less than 0.05 was considered to indicate a significant difference.38 Ethical Consideration Informed consent was obtained from all the subjects prior to induction of labour. Permission was taken from the hospital authority to conduct the study in the hospital. Secrecy and confidentiality were maintained. Over the two and a half months' study period, 120 women (out of 3238 obstetric admissions) underwent induction of labour. The induction rate was 3.7%. Out of these inductions 103 fulfilled the study criteria and thus entered into the study, 72 (70%) were nulliparas and 31 (30%) were multiparas. The patients were stratified by Bishop score at entry for further analysis. Fourty-eight (46.6%) women had low BS (0-4), whereas fifty-five (53.4%) had high BS (5-8). The mean BS in low BS group and high BS group was 3.72 and 6.01 respectively. TABLE I : PATIENTS CHARACTERISTICS
Numbers in parentheses indicate numerator and denominator of percent. NS : Not Significant S : Significant As summerized in Table I, there were no differences between the two study groups with regards to maternal age, gestational age at induction, antenatal attendance and socio-economic status. 
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