- Received December 28, 2024
- Accepted January 24, 2025
- Publication February 15, 2025
- Visibility 4 Views
- Downloads 0 Downloads
- DOI 10.18231/j.ijogr.2025.026
-
CrossMark
- Citation
Efficacy and safety of labor induction by oral versus vaginal misoprostol–study of 200 cases in private setup
- Author Details:
-
Manish R Pandya *
-
Kishan S Adroja
-
Viashvi C Patel
-
Jaini Girishkumar Pandya
-
Lipi Kartik Modha
Manish R Pandya *
Introduction
In today’s modern obstetrics practice, induction of labour is one of the most key procedures.[1] This procedure is widely performed when continuation of pregnancy is hazardous to the mother and fetus or there is need to cut shorten the labour time. It is the artificial induction of uterine contraction before its spontaneous onset for purpose of delivery of the fetoplacental unit. The success of labour induction largely depends on the cervical factor, maternal health or bishop’s score at the time of induction of labour.[2] A successful induction of labour refers to the vaginal delivery of the healthy baby, in desirable time with minimum maternal side effect or truma.
Misoprostol drug is a prostaglandin E1 analogue molecule. It is a new agent for induction and cervical ripening and uterotonic properties.[3] It is less expensive, stable at room temperature with very less side effects and can be easily administered through oral, vaginal, route.[4] Most clinical trials have used 25 microgram every six hours vaginally and orally.[5]
Bishop score
Bishop scoring system is based on digital cervical examination of the patient with a zero (0) point which is minimum and 13 point which is maximum. This system uses cervical dilation, its position, effacement, consistency, and fetal station. Cervical dilation, effacement, and station are given 0 to 3 points, while cervical position and consistency are given o to 2 points.[6], [7] Bishop score of 8 or greater is considered to be favourable for induction, or chances of vaginal delivery with induction is similar to spontaneous labour. A score 6 or less is considered to be unfavourable if an induction is indicated cervical ripening agents may be taken in use.[8]
|
Score |
Dilation (cm) |
Position of cervix |
Effacement (%) |
Station (-3 to +3) |
Cervical consistency |
|
0 |
Closed |
Posterior |
0-30 |
-3 |
Firm |
|
1 |
1-2 |
Mid posterior |
40-50 |
-2 |
Medium |
|
2 |
3-4 |
Anterior |
60-70 |
-1,0 |
Soft |
|
3 |
5-6 |
- |
80 |
+1,+2 |
- |
Materials and Methods
This was prospective comparative study conducted in Scientific Research Institute, Surendranagar, Gujarat from October 2023 to September 2024. Study population comprised of 200 subsequent pregnant women.
25 microgram misoprostol vaginally and orally in alternative manner used every 6 hourly for maximum of five doses.
Inclusion criteria
Singleton intrauterine pregnancy
Full term pregnancy
Adequate pelvis size
Bishop score more than 6
No uterine contraction
Reactive non stress test
Previous LSCS
Multiparity (first baby vertex presentation)
Exclusion criteria
Malpresentation of fetus
Previous more than 1 caesarean section
Cephalopelvic disproportion of pelvic
Non- reactive non stress test
Placenta previa
Abruptio placenta
Vaginal delivery: any contraindicated
Step by step detailed history of all the patient is taken, followed by general physical examination of all the patients was done. Obstetrical examination included lie of baby, presentation of fetus, fundal height, fetal heart sound, per vaginal examination for assessing bishop’s score and pelvis type. Antenatal ultrasound and required blood investigations were done to ensure correct gestational age and anaemia status of mother respectively. Duration, intensity and frequency of uterine contraction were observed and plotted on partograph. Study population was examined and vaginal 25 microgram misoprostol was placed in posterior fornix after moistening with normal saline. Similarly in every alternative patient tablet of 25 microgram misoprostol is given orally. Per vaginal examination done every 6 hourly to note the changes in the cervical dilatation and effacement status. To minimize the infection unnecessarily, per vaginal examination is avoided. Before each successive dose of 25 microgram misoprostol fetal heart monitoring was done and induction continued only if there is no fetal distress. Progress of labour charted on partograph. Induction was stopped when the adequate uterine contraction of at least 3 contraction/10 min each of 40sec duration is achieved. All patients were augmented with 2.5 Unit of Oxytocin in second stage of labour, another 2.5 unit of oxytocin was given in third stage for easy progression of labour. A further induction was withhold in cases of tachysystole, hyper tonus or hyper stimulation of uterus or non-reactive CTG not corrected by primary measures. If the patient did not enter active labour six hour after last dose the induction was considered to have failed and caesarean section was performed to avoid further maternal or fetal complications.
|
Characteristics |
Group (n=200) |
|
Maternal age |
years 20-30 years |
|
Parity |
|
|
a) Primipara |
128 (64%) |
|
b) Multipara |
72 (36%) |
|
Mode of delivery |
Oral route |
Vaginal route |
|
Vaginal delivery |
55 (67%) |
81 (68%) |
|
LSCS |
10 (12%) |
14 (11%) |
|
Instrumental delivery (vacuum/ forceps) |
17 (21%) |
23 (21%) |
|
Induction to delivery interval |
||
|
Vaginal delivery within 24 hours |
(70%) |
(85%) |
|
Other parameters |
||
|
Uterine hyper stimulation |
5% (5/100) |
10% (10/100) |
|
Haemorrhage |
2% (2/100) |
1% (1/100) |
|
No. of doses |
Vaginal delivery after oral route |
Vaginal delivery after vaginal route |
|
1 |
5 (9%) |
8 (9%) |
|
2 |
8 (14%) |
18 (22%) |
|
>2 |
42 (77%) |
55 (69%) |
|
Indications for NICU admission |
With oral route |
With vaginal route |
|
|
Meconium stained liquor |
5 (5%) |
3 (3%) |
8 (4%) |
|
Delayed cry |
5 (5%) |
3 (3%) |
8 (4%) |
|
Fetal distress |
6 (6%) |
7 (7%) |
13 (13%) |
|
Total |
16 (16%) |
13 (13%) |
29 (21%) |
Result
Our study shows that the use of vaginal misoprostol results in more effective cervical ripening and induction of labour and to reduce rate of caesarean section and increasing rate of vaginal delivery compared to orally given misoprostol. [Table 2] shows the of the study group with regards to maternal age and parity. In our study we included 200 pregnant women group in which 100 (50%) women were 25 micrograms of misoprostol tablet given vaginally and 100(50%) were given same dose orally. All patients were among age group of 20-30 years. [Table 3] shows comparison of primary outcomes, spontaneous vaginal delivery with oral misoprostol (67%) and with vaginal misoprostol (68%) and instrumental vaginal delivery with oral misoprostol (21%) and with vaginal misoprostol (21%). Both with vaginal and oral route in sum spontaneous (normal) vaginal delivery rate is higher (68%) than caesarean section (12%). There was less induction to delivery interval in vaginal group compared to caesarean section, and among the vaginal delivery group, comparison done according to interval within 12 hours and within 24 hours vaginal delivery after induction. The secondary outcomes are given in [Table 4]. 42 patients among orally proffered group require more than 2 doses of misoprostol to effect delivery and 55 patients among vaginally proffered group require more than 2 doses of misoprostol to effect delivery. Very less side events were encountered during our study.
Discussion
Misoprostol 25 microgram for induction of labour has been very promising. Misoprostol administered vaginally is slightly more effective as conventional methods then orally for induction of labour at term or near term. Distribution according to demographic characteristic in our study population was almost similar to various studies.[9], [10], [11], [12] This study shows that women who receive misoprostol vaginally experience slightly faster induction to delivery then orally given misoprostol.[13] Time taken for induction to vaginal delivery was significantly less in vaginal group as demonstrated by various studies, because vaginal misoprostol is absorbed quickly and removed slowly from body which makes it available to act for a longer time as compared to oral resulting in rapid progression of labor.[13] There is wide clinical experience with this agent and a large number of published reports supporting its safety and efficacy when used appropriately and in proper dose. Vaginal misoprostol significantly reduces the time interval from induction to delivery and increases chances of eventless vaginal delivery.[14]
|
Outcome |
Route |
Rehman et al[10] (50mcg PO vs. 25mcg PV) |
J Anice et al[9] (50mcg PO vs. PV) |
Jindal et al[15] (50mcg PO vs. PV) |
Pandya et al[12] (25 mcg PO vs. PV) |
Present study (25 mcg PV) |
|
Vaginal delivery |
Oral |
58% |
83.3% |
74.5% |
- |
67% |
|
|
Vaginal |
64% |
76.8% |
90.38% |
68% |
68% |
|
Vaginal instrumental |
Vaginal |
- |
- |
- |
20% |
21% |
|
|
Oral |
30% |
16% |
25.49% |
- |
21% |
|
Caesarean section |
Vaginal |
29% |
19% |
9.62% |
12% |
21% |
|
|
Oral |
21.22+2.4 |
27.3(18.8) |
16.47% |
- |
11% |
|
Induction to vaginal delivery interval |
Vaginal |
20.15+3.1 |
19.0(11.9) |
9.79% |
36% |
85% |
|
|
Oral |
27.27% |
78% |
- |
- |
70% |
|
Oxytocin administration |
Vaginal |
23.6% |
50% |
- |
- |
- |
|
|
IV |
- |
- |
- |
- |
- |
Conclusion
As per 2013 SOCG guidelines which says that misoprostol is safe and effective agent for induction in labour with intact membrane for impatient. This is somewhat confirmed with our study with more recent data, as analysed we concluded that vaginal misoprostol appears to be slightly more efficacious and safe for cervical ripening and labour induction then oral misoprostol. Vaginal misoprostol tablet is most effective in achieving vaginal births relatively rapidly then oral route. Misoprostol is considered as a safe agent for labour induction by world health organization (WHO). As per 2011 WHO guidelines WHO recommended misoprostol for induction of labour except in those with previous 2 LSCS (lower segment caesarean section). We have to assess patient’s safety data and monitoring requirements, to ensure safe and better outcomes for pregnant women fetuses and neonates with use of misoprostol in induction of labour.
Source of Funding
None.
Conflict of Interest
None.
References
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