Misoprostol for induction of labour at term

ORIGINAL ARTICLE
Misoprostol for induction of labour at term
53
Arshia Javed, Haleema A Hashmi
Abstract:
Objectives: The purpose of this study is to assess the effectiveness of 50mg vaginal Misoprostol
for induction of labour at term.
Design: Retrospective observational study.
Setting: Department of Obstetrics &Gynaecology, Liaquat National Hospital, Karachi, Pakistan
from 1st January 2008 to December 2009.
Methods: Two hundred and twenty one patients were analyzed; who were induced at 37
weeks gestation and onwards by using 50mg vaginal misoprostol repeated every 6 hourly for a
maximum of 3 doses or initiation of active labour, to assess the efficacy of the drug.
Results: The results were analyzed by using SPSS version 13.0. Among 221 patients 161
(73%) delivered by vaginal route & 60 (27.1%) patient had caesarean deliveries. Out of these
91 (57%) patient, delivered within 8 – 12 hours. 22 (9.95%) patients had Meconium stained
liquor. No case of uterine hyperstimulation and perinatal mortality observed.
Conclusion: Vaginal Misoprostol was found to be safe and effective drug to use for induction
of labour with least complications.
Keywords: Misoprostol, Induction of Labour, Term
Department of
Obstetrics &
Gynaecology,
Liaquat National
Hospital,
Stadium Road
Karachi
A Javed
HA Hashmi
Correspondence:
Dr. Arshia Javed
Senior Registrar
Department of Obstetrics
&Gynaecology
Liaquat National Hospital
National Stadium Road
Karachi – PAKISTAN
Cell # 0300-2119180
Pak J Surg 2012; 28(1):53-56
Introduction:
The induction of labour (IOL) is an important
part of modern obstetric practice that occurs in
15% of all pregnancies. 1 Nearly 27% of pregnant
women had their labour induced. 2
There are many situations in obstetrics when
there is need for labour induction. Generally
induction is indicated when the benefits to either
the mother or the fetus out weight those
of continuing the pregnancies. 3 IOL in women
with unripe cervices are frequently prolonged
and very often unsuccessful, resulting in caesarean
delivery. 4 Studies have established that prelabour
cervical status highly correlates with the
inducibility of labour and that cervical ripening
improves the success of labour induction. 5
Misoprostol has become an important drug in
obstetric and gynaecological practice because of
it’suterotonic and cervical ripening activity and
good safety profile compared to other prostaglandin
preparation, misoprostol is inexpensive.
It does not require parenteral administration or
refrigeration and has few systemic side effects.
It can help save maternal life by preventing or
treating postpartum haemorrhage where other
safe alternative do not exists. 6
Cochrane pregnancy and childbirth group analyzed
48 randomized trials including > 5400
women have found vaginal misoprostol to be
more effective than oxytocin or vaginal prostaglandin
E2 for effective delivery with in 24
hours. 6,7
The aim of this study is to assess the effectiveness
of 50mg vaginal misoprostol for induction
of labour at term with respect to vaginal delivery
within 24 hours, mode of delivery, fetal outcome
and maternal side effects also studied.

54 A Javed, HA Hashmi
Material and Methods:
This is a retrospective observational study conducted
at the department of obstetrics &gynaecology,
LiaquatNationalHospital, Karachi,
Pakistan over a period of 2 years from 1st January,
2008 to 31st December, 2009. 221 patient,
were included in the study, who were induced at
37 weeks of gestation & onwards by using 50mg
vaginal misoprostol to assess the efficacy of the
drug.
Inclusion Criteria:
• Singleton viable pregnancy
• Cephalic presentation
• Duration of gestation > 37 weeks
• Reactive CTG
Exclusion Criteria:
• Any contraindication to vaginal birth
• Previous caesarean section
• Placenta previa
• Moderate to severe abruptio
Women were induced with 50mg misoprostol
placed in the posterior vaginal fornix every 6
hours till 3 doses. Women were monitored with
intermittent Cardiotocography and partogram
was plotted. More than 4 uterine contractions of
40 seconds in 10 minutes were taken as hyperstimulation.
Results:
The results were analyzed by using SPSS Version
13. The data represent as percentage as
well as mean, mode and standard deviation as
being appropriate. Two hundreds and twentyone
patients were induced with different indications
of IOL most common indication was post
dates (28%). Age range of women were 18 – 38
years with mean Age of 27.8, 131 patients were
of parity between P0-2 (58.82%) as shown in
Table 1. Vaginal delivery occurred in 161 (73%)
patient’s & 60 (27%) ended up in caesarean section,
Meconium stained liquor was found in 22
patietns (9.95%) & 20 patients had abnormal
CTG (9.04%) as shown in Table 2.
When low apgar score was analyzed 28 (12.6%)
babies had apgar score less than 7 in 1 min & 4
had less than 7 in 5 min (1.8%) Table 3.
No case of uterine hyperstimulation and perinatal
mortality observed.
Discussion:
Induction of labour is a common procedure in
the labour ward. it is performed for several fetal
& maternal indications. with an unripe cervix
IOL may be difficult and unsuccessful. IOL before
the cervix is ripe often results in prolonged
labour or failed induction with increased risk of
operative delivery & morbidity. 8,9
The use of agents to ripen the cervix prior to conventional
methods of induction is the standard
practice. Vaginal prostaglandin preparation have
proved to be beneficial and are now the most
widely used agents in developed countries. 10
Misoprostol is a synthetic analogue of naturally
occurring prostaglandin E1& it is an effective
drug for cervical ripening & labor induction.
Although it is not approved by FDA for this
indication, the AmericanCollege of Obstetrics
&Gynaecologist advocates misoprostol & it is
on WHO essential drug list for labour induction.
It is now licensed for labour induction in
Egypt&Brazil, & a licensed induction product
was expected in UK some time in 2008. 11
Misoprostol has been safe in IOL in resource
constrained hospital settings in developing
countries like ours, using basic clinical tools for
monitoring. 12-14
In this study 221 patients were induced with
50mg vaginal misoprostol. The most common
indication of IOL was postdate 28%. Majority
of the patient 161 (73%) delivered by vaginal
route. The results are comparable to the study
conducted by Aqeela et al. 15 in which 77% patients
delivered by vaginal route. A study conducted
by Z. Tabasi et al. 16 also supported the
result in which 72.7% patients delivered by vaginal
route. Similar results were seen in study by
Shetty et al. 17 .
Caesarean Section rate was found to be 27%
which is comparable to the study by Z. Tasasiet
al. 16 in which 27.3% delivered by caesarean section.
Pak J Surg 2012; 28(1):53-56

Misoprostol for induction of labour at term
Table 1: Demographic Data of Women
Maternal Age (Mean + SD) 27.8 + 97.29
Parity: (Mean + SD) 1.8 + 154.99
P0-2 130
P2-4 70
P4-6 21
Table 2: Maternal Outcome
Mode of Delivery
All Vaginal Deliveries 161 73%
Spontancous 124 77%
Assisted 37 23%
Caesarean Section 60 27%
Meconium Stained Liquor 22 9.95%
Abnormal CTG 20 9.04%
Uterine Hyperstimulation Nil Nil
Induction to delivery interval (Mean+SD) 12.45 ± 105.64
Table 3: Fetal Outcome
Apgar Score
< 7 in 1 min 28 12.6%
< 7 in 5 min 4 1.8%
Perinatal Mortality Nil Nil
The patients delivered within 6 – 8 hours were
9% & 57% were within 8 – 12 hours with mean
induction to delivery interval was 12.45. Many
studies have been found same results Z. Tabasiet
al. 16 , Ferzuson et al. 18 , Sahin et al. 19 , Ramsey et
al. 21
Meconium Stained Liquor (MSL) was observed
in 9.95% of patients & 9.04 % patients had abnormal
Cardiotocography. The other studies
supported the results were of Majid N et al
2009 22 in which 12% patients had MSL.
Most of the babies born with good Apgar score
85%, only 13% baby had Apgar score

56 A Javed, HA Hashmi
20. Ramsey, P. S, L. Meyer, B. A. Walkes, D. Harrus, P. L. Jr. Ogburn,
R. H. Heise and K. D Ramin, 2005 Cardiotocographic
abnormalities associated with dinoprostone and Misoprostol
cervical ripening. Obstet .Gynaecol; 105: 85 - 90.
21. Zeteroglu S, G. H. Sahin and H. A Sahin, 2006. Indution of
labour with Misoprostol in pregnancies with advanced maternal
age. Eur. J. Obstet. Gynaecol. Reprod. Biol; Jan. 4. (In
press).
22. Majid N, Nasir F, Akhter T, Fatima H. Misoprostol: An effective
agent for labour induction in full term parous women.
Medical channel. 2009; 15(2): 51 - 54.
Sheikher C, Suri N, Kohli U. Comparative evaluation of oral
23.
Misoprostol, vaginal Misoprostol and intra cervical foley’s
catheter for induction of labour at term. JK Science. 2009;
11(2): 75 - 77.
Abbasi N, Danish N, Shakoor F, Perveen Z, Bilal S A. Effective-
24.
ness and safety of vaginal Misoprostol for induction of labour
in un favourable cervix in 3rd trimester. J Ayub Med Coll Abbotabad.2008;
20(3): 33 - 5.
Pak J Surg 2012; 28(1):53-56