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\title{A Study of Maternal and Foetal Outcomes in Cases of Induction of Labour in a Tertiary Care Centre}
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             \author[1]{Dr. Priyanka  Phunde}

             \author[2]{Dr. Tushar  Palve}

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\date{\small \em Received: 15 December 2019 Accepted: 2 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


The aim of the present study was to assess indications for induction, various methods of induction used, the mode of delivery and study of the maternal and foetal outcome. Inclusion criteria were singleton pregnancies with cephalic presentation. Multifetal pregnancies, pregnancies, previous caesarean sections were excluded. Indications, pre-induction Bishop scores, mode of delivery and adverse maternal and foetal outcomes were registered. Most common indications were post datism (57.78 %), premature rupture of membranes (22.22 %), oligohydramnios (13.33 %), Non reassuring foetal heart status (4.44 %), & PIH (2.22%). About 84 % of inductions were done at gestational age 37 weeks and more. Induction of labour resulted in normal vaginal delivery in 60% of cases.

\end{abstract}


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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
nduction of labour implies stimulation of contraction before the spontaneous onset of labour, with or without ruptured membranes \hyperref[b0]{[1]}. The goal of induction is to achieve successful vaginal delivery as natural as possible. Induction of labour is considered when the expected benefits of shortening the duration of pregnancy outweigh the potential harms from continuation of pregnancy with no contraindications for vaginal delivery. \hyperref[b1]{[2,}\hyperref[b2]{3]} The rate of induction of labour is increasing. In United states, the incidence of labour induction increased 2.5 folds from 9.5 percent in 1991 to 23.8 percent in 2015 . \hyperref[b0]{[1]} Indications for induction include post term pregnancy, premature rupture of membranes, gestational hypertension, oligohydramnios, abruption, non-reassuring foetal surveillance, significant foetal growth restriction, intrauterine death, maternal medical conditions like chronic hypertension, type I diabetes, renal disorders, significant pulmonary disease (ACOG2016 ). \hyperref[b3]{[4,}\hyperref[b4]{5,}\hyperref[b5]{6]} Induction of labour in post term pregnancy has reduced likelihood of perinatal death \hyperref[b6]{[7,}\hyperref[b7]{8]}. Elective induction of labour is defined as induction without any medical indication in healthy pregnant women. \hyperref[b9]{[9,}\hyperref[b10]{10,}\hyperref[b11]{11]} Some experts term it as non-medically indicated induction of labour . \hyperref[b12]{[12]} The American College of Obstetricians and Gynaecologists suggests that labour may be induced for logistic reasons including risk of rapid labour, distance from hospital and psychosocial reasons but not before 39 weeks of gestation.\par
Potential risks associated with induction of labour are increased rate of operative vaginal delivery, caesarean birth, uterine hyperstimulation, non-reactive NST, uterine rupture, mistaken dates leading to preterm deliveries, risk of cord prolapse with artificial rupture of membrane, maternal water intoxication syndrome . \hyperref[b13]{[13]}. Cervical favourability is the most important factor determining the success of induction. The aim of the study was to assess and evaluate the indications for induction, method of induction used, success rate, maternal and foetal outcome in cases with induction of labour. 
\section[{II.}]{II.} 
\section[{Aims and Objectives}]{Aims and Objectives}\par
Aim of this study is to assess the clinical profile of patients admitted for induction of labour, indications and different methods of induction used success rates among different methods used, maternal and foetal outcome and complications if any. 
\section[{III.}]{III.} 
\section[{Material and Method}]{Material and Method}\par
It is a retrospective study conducted over a period of 3 months from January 2020 to March 2020 in Department of Obstetrics and Gynaecology, at a tertiary care centre in Mumbai. We studied the clinical profile of the patients, indications for induction, different methods used, the success rates, mode of delivery, the maternal and foetal outcome in cases of induction, complications. Singleton pregnancies with cephalic presentation at or near term were included in this study. Multifetal pregnancies, malpresentations, transverse lie, previous caesarean sections were excluded. Indication for induction, contraindications, gestational age, cervical favourability (Bishop's score assessment), assessment of the pelvis, foetal size, presentation, membrane status (intact or ruptured) and foetal wellbeing, documentation of discussion of indication of induction and disclosure of risk factors were taken into consideration prior to induction.\par
In our study majority of cases of induction of labour were of 20 -25 years of age (51.11\%) followed by 25-30 years (35.56\%) and 13.33 \% cases between 30-35 years of age.\par
In this study 60 \% of inductions were done in primigravida, followed by 20 \% in third gravida, 15.56 \% in 2 nd gravida and 4.44 \% in 4 th gravida. 
\section[{Graph 3: Methods of induction used}]{Graph 3: Methods of induction used}\par
In our study 51.11 \% inductions were done using transcervical insertion Foley's catheter followed by dinoprostone gel, while 40 \% inductions were done using dinoprostone gel alone and remaining 8.89\% cases were induced with Intracervical insertion of Foley's catheter.  In our study, majority of inductions were done at gestational age > 40 weeks (48.89\%) with cause of induction being post-dated pregnancy, PIH, oligo another 44.44 \% cases were induced at gestational age of 37 to 40 weeks and 6.67 \% cases were induced at < 37 weeks. Thus almost 93.33 \% cases were induced at full term gestation. 
\section[{Graph 7: Birth weight}]{Graph 7: Birth weight}\par
In our study, out of 45,25 babies had birth weight between 2.5 to 3 kg, followed by 13 babies had birth weight between 3 to 3.5 kg,3 babies had birth weight 2 to 2.5 kg another 3 had birth weight 1.5 to 2 kg only 0.22 \% had birth weight < 1.5 kg. 
\section[{Graph 8: NICU admission}]{Graph 8: NICU admission}\par
In our study only 4 babies (8.89\%) required NICU admission, 3 babies in view of PROM and 1 in view of MSAF with respiratory distress. Rest 41 babies did not require NICU admission. In our study only one patient had postpartum haemorrhage. no maternal complication was seen in remaining 44 cases. 
\section[{IV.}]{IV.} 
\section[{Discussion}]{Discussion}\par
Most common indication for induction of labour in present study were post-dated pregnancy (57.78 \%) Similar findings were observed i.e. 44.5 \% in a study 'Outcome of Induction of Labour: A Prospective Study' in Nepal and 45.8\% in a study "Outcome and significance of labour induction in a health resource poor setting" in Nigeria. In the present study, premature rupture of membrane (PROM) is the second most common indication of induction (22.22 \%), followed by oligohydramnios (13.33).\par
In our study 51.11 \% inductions were done using transcervical insertion Foley's catheter followed by dinoprostone gel, while 40 \% inductions were done using dinoprostone gel alone and remaining 8.89\% cases were induced with Intracervical insertion of Foley's catheter.\par
In our study 60 \% cases delivered vaginally and rest 40 \% required caesarean section. Lamichhane et al in their study observed that 67.7\% patients delivered vaginally and 32.3\% underwent caesarean section. They found that most common indication for caesarean section was for failure of induction 44\% followed by foetal distress 29\% and meconium stained liquor in early stage of labour which was about 17\% , least common being arrest of descent and dilatation in active stage of labour around 8.7\% . In that study out of 67.7 \% vaginal delivery, 4.86\% had instrumental vaginal deliveries. Patterson J et al in Australia reported that 30.4\% nulliparous women delivered by caesarean in his study. In a study, Throsell M et al showed that among induced women, 42\% nulliparous and 14\% multiparous women delivered by caesarean section.\par
In our study, it was observed that the success rate of induction of labour in the form of vaginal delivery was maximum with transcervical Dinoprostone (PGE2) gel instillation (72.22 \%). Transcervical Foley's catheter insertion followed by dinoprostone gel instillation resulted in normal vaginal delivery in 52.17 \% cases. Whereas 50\% cases induced with transcervical Foley's catheter insertion resulted in normal vaginal delivery.\par
In our study majority of cases of induction of labour were of 20 -25 years of age (51.11 \%) followed by 25-30 years (35.56\%) and 13.33 \% cases between 30-35 years of age. Lamicchane et al in their study observed that the maximum patients belonged to 20 -30 years of age.\par
In this study 60 \% of inductions were done in primigravida, followed by 20 \% in third gravida, 15.56 \% in 2 nd gravida and 4.44 \% in 4 th gravida. Similar findings were observed in a study by Patil et al prolonged pregnancy occurred more frequently in primigravida than in multigravida. About 69\% cases belonged to primigravida and 31\% cases belonged to multigravida.\par
In our study, majority of inductions were done at gestational age > 40 weeks (48.89\%) with another 44.44 \% cases were induced at gestational age of 37 to 40 weeks and 6.67 \% cases were induced at < 37 weeks. Thus almost 93.33 \% cases were induced at full term gestation.\par
In our study, out of 45, 25 babies (55.55) had birth weight between 2.5 to 3 kg, followed by 13 babies (28.89\%) had birth weight between 3 to 3.5 kg, 3 babies (6.66\%) had birth weight 2 to 2.5 kg another 3 (6.66\%) had birth weight 1.5 to 2 kg only 0.22 \% had birth weight < 1.5 kg. In a similar study by Lamichanne et al it was found that 88.76\% of babies birth weight was in between 2.5 -3.5kg. In the same way 4.6\% of babies weighed less than 2.5 kg and 26\% of babies weighed more than 3.5kg, which showed that there is less chances of  
\section[{Rates of admissions to a neonatal}]{Rates of admissions to a neonatal}\par
In our study only one patient had postpartum haemorrhage. no maternal complication was seen in remaining 44 cases. Patil et al in their study of maternal and perinatal outcome in induction of labour at 40 weeks and 41 weeks of gestation observed that maternal morbidity like increased rate of caesarean section, PPH, perineal tear, sepsis and cervical tear are more common in 41-week group in compare to 40-week group.\par
V. 
\section[{Conclusion}]{Conclusion}\par
In our study, it was observed that the success rate of induction of labour in the form of vaginal delivery was maximum with transcervical dinoprostone (PGE2) gel instillation (72.22 \%). Transcervical foley's catheter insertion followed by dinoprostone gel was successful in 52.17 \% cases. 50\% cases induced with transcervical Foley's catheter insertion resulted in normal vaginal delivery. So induction of labour with dinoprostone gel used alone or with foleys catheter resulted in successful delivery. There was no significant increase in the cesarian section rates with any of the methods. And overall maternal and perinatal mortality and morbidity was reduced with timely induction for indicated cases.\par
Labour induction should be done if the benefits of termination of pregnancy overweighs that of continuation of pregnancy. Pregnancy and labour is a natural process and we should allow its natural course until and unless the indication for induction is justified.\begin{figure}[htbp]
\noindent\textbf{5}\includegraphics[]{image-2.png}
\caption{\label{fig_0}AGraph 5 :}\end{figure}
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\noindent\textbf{9}\includegraphics[]{image-3.png}
\caption{\label{fig_1}AGraph 9 :A}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
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\tabcellsep \multicolumn{4}{l}{Graph 4: Method of induction v/s success rate}\tabcellsep \tabcellsep \\
\multicolumn{3}{l}{In our study, it was observed that the success}\tabcellsep \multicolumn{4}{l}{instillation resulted in normal vaginal delivery in 52.17 \%}\\
\multicolumn{3}{l}{rate of induction of labour in the form of vaginal delivery}\tabcellsep \multicolumn{4}{l}{cases. Whereas 50\% cases induced with transcervical}\\
\multicolumn{3}{l}{was maximum with intracervical dinoprostone gel}\tabcellsep \multicolumn{4}{l}{Foley's catheter insertion resulted in normal vaginal}\\
\multicolumn{3}{l}{(PGE2) gel instillation (72.22 \%). Transcervical Foley's}\tabcellsep delivery.\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{3}{l}{catheter insertion followed by dinoprostone gel}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
> 40 WEEKS\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
37-40 WEEKS\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
< 37 WEEKS\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
0\tabcellsep 10\tabcellsep 20\tabcellsep 30\tabcellsep 40\tabcellsep 50\tabcellsep 60\\
\tabcellsep Column1\tabcellsep \multicolumn{2}{l}{PERCENTAGE}\tabcellsep NO OF CASES\tabcellsep \tabcellsep \end{longtable} \par
  {\small\itshape [Note: Graph 6: Gestational age at the time of induction]} 
\caption{\label{tab_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
Volume XX Issue V Version I\\
D D D D ) E\\
(\\
Medical Research\\
Global Journal of\\
© 2020 Global Journals\end{longtable} \par
  {\small\itshape [Note: A]} 
\caption{\label{tab_1}}\end{figure}
 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\bibitem[Society Of Obstetricians and Gynaecologists Of (2001)]{b14}\label{b14} 	 		\textit{Induction of Labour. Clinical Practice Guidelines for Obstetrics},  		 			Society Of Obstetricians 		,  		 			Canada Gynaecologists Of 		.  		2001. August. p. .  	 
\bibitem[Leduc et al. ()]{b1}\label{b1} 	 		‘Induction of labour: review. SOGC clinical practice guidelines’.  		 			D Leduc 		,  		 			A Biringer 		,  		 			L Lee 		,  		 			Jessida Dy 		.  	 	 		\textit{J Obstet Gynecol}  		2015. 37  (4)  p. .  	 
\bibitem[Crowley]{b7}\label{b7} 	 		\textit{Interventions for preventing or improving the outcome of delivery at or beyond term},  		 			P Crowley 		.  		 	 
\bibitem[Tenore ()]{b2}\label{b2} 	 		‘Methods of cervical ripening and induction of labour’.  		 			J L Tenore 		.  	 	 		\textit{American family physician}  		2003. 67  (10)  p. .  	 
\bibitem[Nonmedically indicated early -term deliveries ()]{b12}\label{b12} 	 	 	 		\textit{Nonmedically indicated early -term deliveries},  				2013. 121 p. .  	 	 (ObstetGynecol) 
\bibitem[Tan and Hannah ()]{b4}\label{b4} 	 		\textit{Oxytocin for pre labour rupture of membranes at or near term (Cochrane Review). The Cochrane Library},  		 			B P Tan 		,  		 			M E Hannah 		.  		2000. Oxford U K.  	 
\bibitem[Tan and Hannah ()]{b5}\label{b5} 	 		\textit{Prostaglandins for pre labour rupture of membranes at or near term (Cochrane Review). The Cochrane Library},  		 			B P Tan 		,  		 			M E Hannah 		.  		2000. Oxford U K. 3.  	 
\bibitem[Williams obstetrics 25 th edition, Induction and Augmentation of Labour]{b0}\label{b0} 	 		\textit{Williams obstetrics 25 th edition, Induction and Augmentation of Labour},  		 	 
\end{bibitemlist}
 			 		 	 
\end{document}