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INDUCTION OF LABOUR WITH FOLEY’S CATHETER VERSUS VAGINAL MISOPROSTOL AT TERM 1 2 3 4 5 Venkata Ramana Kodali , Padma Leela Kotipalli , Madhuri Ampilli , Naga Lalitha Kokkiligadda , Mitra Vinda Vayilapalli , Mounica Kollabathula6

1Assistant Professor, Department of Obstetrics and Gynaecology, Andhra Medical College, Visakhapatnam, Andhra Pradesh. 2Professor, Department of Obstetrics and Gynaecology, Andhra Medical College, Visakhapatnam, Andhra Pradesh. 3Postgraduate, Department of Obstetrics and Gynaecology, Andhra Medical College, Visakhapatnam, Andhra Pradesh. 4Postgraduate, Department of Obstetrics and Gynaecology, Andhra Medical College, Visakhapatnam, Andhra Pradesh. 5Postgraduate, Department of Obstetrics and Gynaecology, Andhra Medical College, Visakhapatnam, Andhra Pradesh. 6Postgraduate, Department of Community Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

ABSTRACT BACKGROUND The incidence of induction of labour is raising worldwide with a rate of 20% to 30% in developed countries. At present, each method of induction of labour has its own merits and demerits. We studied the safety and efficacy of Foley’s catheter in induction of labour at term and compared its safety and efficacy with that of vaginal misoprostol.

MATERIALS AND METHODS This is a case-control study conducted on 100 pregnant women planned for induction of labour at term with a Bishop’s score of ≤6. Women were randomly divided into two groups of 50 patients in each group. In group A, labour was induced with trans cervical Foley’s catheter and in women in group B labour was induced with 25 micrograms of intravaginal misoprostol 4th hourly up to maximum of 6 doses. Induction delivery intervals and fetomaternal outcomes were noted.

RESULTS In group A (Foley’s catheter group) only 50% of women delivered before 24 hours whereas 94% of group B (Misoprostol group) delivered before 24 hrs. The induction to delivery interval in group B is significantly shorter compared to group A. The rate of vaginal delivery was 76% in group A versus 82% in group B. The rate of caesarean section due to failed induction was 58.4% in group A compared to 22% in group B. There were higher rates of APGAR ≤6, Meconium stained liquor and NICU admissions in group B compared to group A.

CONCLUSION Intravaginal Misoprostol is associated with shorter induction to delivery interval compared to Foley’s catheter and higher rate of vaginal delivery in case of unripe cervix. Whereas trans-cervical Foley’s catheter is associated with lower incidence of hyperstimulation and may be a reasonable alternative for patients who are at increased risk of uterine rupture during labour.

KEYWORDS Bishop’s Score, Prostaglandins, Induction of Labour, Foley’s Catheter, Misoprostol. HOW TO CITE THIS ARTICLE: Kodali VR, Kotipalli PL, Ampilli M, et al. Induction of labour with foley’s catheter versus vaginal misoprostol at term. J. Evid. Based Med. Healthc. 2019; 6(11), 886-892. DOI: 10.18410/jebmh/2019/187

BACKGROUND Induction of labour should be performed only when In developed countries, up to 25% of all deliveries at term there is a clear medical indication for it and the expected are involved with induction of labour. Induction of labour is benefits outweigh its potential harms. The most effective defined by the World Health Organization as initiation of method for inducing labour has not been established in labour by artificial means prior to its spontaneous onset at a medical literature. The ideal induction agent would result in viable gestational age with the aim of achieving vaginal a short induction to delivery without risk to fetus and with delivery in a pregnant woman. low rates of emergency caesarean section. The common indications for induction of labour are Financial or Other, Competing Interest: None. Postdated pregnancy, Pre labour rupture of membranes, Submission 23-02-2019, Peer Review 28-02-2019, Hypertensive disorders, Maternal medical complications like Acceptance 08-03-2019, Published 15-03-2019. Corresponding Author: Preeclampsia, Gestational diabetes mellitus, Fetal growth Dr. K. Padma Leela, restriction, Fetal demise, Oligohydramnios etc. The role of Department of Obstetrics and Gynaecology, cervical ripening in success of induction of labour is well King George Hospital, Andhra Medical College, Maharanipeta, Visakhapatnam- 530002, established. A score of 6 or less indicates an unfavourable Andhra Pradesh. cervix and may be an indication for cervical ripening to E-mail: [email protected] initiate labour. DOI: 10.18410/jebmh/2019/187 Various methods available for cervical ripening and induction of labour are Sweeping of membranes, intravenous

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Oxytocin, intracervical application of Prostaglandins like Andhra Pradesh between February 2016 to October 2017. PGE2 Dinoprostone gel or PGE1 Tablet Misoprostol, 100 pregnant women during this period who presented with Mechanical methods like introduction of Transcervical Foley’s various indications for induction of labour, who were willing catheter. However, induction of labour itself, especially to participate in the study. applied at an inappropriate time, may increase the risk of perinatal morbidity and /or caesarean delivery. Inclusion Criteria One systematic review and network meta-analysis was All the pregnant woman, more than 18 years of age, with conducted to compare the use of Foley’s catheter, various indications for induction of labour. Furthermore, only misoprostol and dinoprostone for cervical ripening in labour singleton gestation with cephalic presentation with intact induction and the results showed that no method of labour membranes, a reassuring feral heart rate on induction revealed overall superiority when all outcomes cardiotocography and those with Modified Bishop’s Score of were considered.1 Vaginal misoprostol was considered the 6 or less were included in the study. most effective method of induction of labour, but was associated with high rate of hyperstimulation and fetal heart Exclusion Criteria rate changes and not recommended for women with Women with previous caesarean section or other uterine previous caesarean section. surgery, contracted pelvis, Multiple pregnancies, Parity of 4 Prostaglandin E2 gel, intracervical and intravaginal are or more, Placenta Previa, antepartum hemorrhage, recommended but expensive and not a priority for premature rupture of membranes, fetal malpresentation and implementation in low- and middle-income group countries. estimated foetal weight more than 4000 grams or less than Prostaglandins, cyclopentane derivatives of arachidonic acid, 2000 grams were excluded from the study. stimulate remodeling of cervical collagen and act within the uterine myocytes, increasing contractility of uterus. Women with inclusion criteria were randomly divided Misoprostol is expensive, stable at room temperature into two groups of 50 each. The selected women’s baseline and may also be used in the treatment of postpartum demographic data, clinical history was obtained. A clinical haemorrhage, hence, partially useful in poor resource examination was done. Necessary investigations were done. settings. In fact, misoprostol has been recommended to be Modified Bishop’s score was analyzed and fetal used for induction of labour by the World Health cardiotocography was done. In the first group, that is Group Organization and the American College of Obstetricians and A, under aseptic conditions, a sterile vaginal speculum was Gynecologists but, still misoprostol remains unapproved for placed and Foley’s catheter number 16F was inserted induction of labour. through the external os and once when the tip of the Foley’s balloon catheter was associated with lower risk catheter was beyond the internal os in the extra amniotic of uterine hyperstimulation. Hence may be preferred in space, the balloon was filled with 30 cc of normal saline. women with scarred uterus. The mechanism of Foley’s Gentle traction was given, and the catheter was taped to the catheter consists of direct mechanical stretching of cervix thigh. If catheter was expelled within 6 hours after insertion, and lower uterine segment and stimulation of endogenous another Foley’s was inserted under aseptic conditions. In the prostaglandin release following separation of chorionic absence of uterine contractions even after 24 hours, labour membrane and decidua. Use of balloon catheter for cervical induction was done with oxytocin drip. Initially the oxytocin ripening is supported by the WHO, ACOG, SOGC and NICE drip was started at a dose of 1 mu/min and the rate of flow guidelines and there is no increase in maternal or neonatal was enhanced every 20 minutes by 1mu/min in order to infectious morbidity with Foley’s catheter cervical ripening. achieve effective uterine contractions and women went into The advantages of Foley’s catheter are low cost, easy established labour. If at the end of 48 hours, if there was no reversibility, feasibility, less need for continuous fetal improvement in Bishop’s score or there was no onset of monitoring during cervical ripening, safe in a scarred uterus, active phase of labour, it was considered as Failed induction and can be used on outpatient treatment basis. and caesarean section was performed for the patient. The present study aims at comparing the efficacy, safety For the second group of pregnant women, that is, in and fetomaternal outcome of transcervical Foley’s catheter Group B, under aseptic conditions, 25 mcg misoprostol was as cervical ripening and labour inducing agent versus placed in the posterior fornix of vagina and repeated every intravaginal misoprostol. 4th hourly till the onset of effective uterine contractions initiating labour up to a maximum of 6 doses. If effective Aim of The Study uterine contractions did not begin 6 hours after the last dose, To study the safety and efficacy of Foley’s catheter in oxytocin infusion was used. Throughout the induction, induction of labour at term and comparing with vaginal uterine action and fetal heart rate was monitored misoprostol in pregnant women who are planned for continuously using partogram. If there was no improvement induction of labour. in Bishop’s score or there was no onset of active phase of labour, in spite of oxytocin drip, labour was terminated by MATERIALS AND METHODS caesarean section considering it as Failed induction. This case-control study was carried out at Government Victoria Hospital, Andhra Medical College, Visakhapatnam,

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The primary outcome, that is, the measure of efficacy IUGR 5.10% 4.8% was the induction to delivery interval. Secondary outcome IUD 1.2% 1.2% measures were mode of delivery, total dose of inducing Total 50 50 agents required for delivery. The measures of safety included Table 2. Indications for Induction of Labour the uterine tachysystole, uterine hyper stimulation, abnormal fetal heart rate tracings, incidence of meconium stained Majority of the cases in group A that is 72% and 70% liquor and neonatal outcome. cases in group B were induced for postdated pregnancy. 8% in group A and 12% in group B were induced for Data Analysis Preeclampsia. In both groups, IUD contributed to 2% of Data were analyzed by using SPSS version 24 and MS EXCEL inductions. The indications for induction of labour was 2013. All the qualitative variables were expressed as comparable in both groups. numbers and percentage. Quantitative variables were No. of expressed as means. Associations were tested using Chi- No. of times Sl. pregnant Percentage square test and Fischer’s exact test. Level of significance was Foley’s catheter No. women (%) considered as p< 0.05. inserted NA=50 1. Once 36 72% Ethical Consideration 2. Twice 14 28% The study was approved by the Institutional Ethics Table 3. Number of Times Foley’s Committee, Andhra Medical College, Visakhapatnam. Written Catheter Inserted in Group A informed consent was taken from each participant. In our study in 72% of women single Foley’s catheter RESULTS insertion initiated labour and in 28% of women Foley’s In this study, one hundred pregnant women were included. catheter was inserted twice for initiation of labour They were randomly divided into two groups. In group A 50 No. of women were induced with trans cervical Foley’s catheter and Total No. of tab. Sl. Pregnant Percentage in group B, 50 women were induced with intravaginal 25 mcg Misoprostol 25 No. Women (%) misoprostol. mcg Doses Used (NB=50) The demographic data of women in both groups is 1. ≤2 Doses 6 12% shown in Table 1. 2. 3-4 Doses 24 48% 3. 5-6 Doses 20 40% Group A Group B Table 4. Number of Doses of Misoprostol 25 (Foley’s (Misoprostol Micrograms Used in Group B Sl. No. Parameter Catheter Group) Group) (N =50) In our study majority of women that is 60% needed 4 (N =50) B A doses of misoprostol for initiation of labour. 1. Mean Age 24.7±3.53 22.46±2.9 Parity (%) Group A Group B (Foley’s 2. Primigravida 44% 56% (Misoprostol p- Parameter Catheter Group) Value Multigravida 62% 38% Group) (N =50) (N =50) B Mean A < 12 Hours 2 (4%) 7 (14%) 3. Gestational 37.4±0.5 38.2±0.4 13 -18 Hours 5 (10%) 17 (34%) <0.001 Age 19- 24 Hours 18 (36%) 23 (46%) Table 1. Maternal Demographic Data 24- 48 Hours 25 (50%) 3 (6%) Mean induction To delivery 22.06±12.1 19±4.6 The Demographic Data regarding Age, Parity, Interval Gestational Age was almost comparable in both groups as Table 5. Induction to Delivery Interval mentioned in Table 1.

Group A Group B As shown in the table above, in group A, that is Foley’s (Foley’s (Misoprostol catheter group, only 50% of the women delivered before 24 Parameter Catheter Group) Group) hours, whereas 94% of the women in group B that is (NA= 50) (NB=50) N (%) N (%) misoprostol group delivered within 24 hrs. 50% of the Postdated women in study group i.e., Foley’s catheter group delivered 36.72% 35.70% Pregnancy between 24 to 48 hours whereas only 6% of the women in Pre-Eclampsia 4.8% 6.12% control group i.e., misoprostol group delivered between 24 GDM 1.2% 2.4% to 48 hrs. The induction to delivery interval was significantly Oligohydramnios 3.6% 2.4% shorter in group B that is misoprostol group than in group A

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Jebmh.com Original Research Article that is Foley’s catheter group. As the p value <0.001, this is the control group (group B). With regards to Augmentation statistically significant. The mean interval from induction to of labour, table 6 shows the methods used. delivery in the study group (group A) is 22.06 hours (SD=12.1) as compared to 19 hours (SD=4.6) seen among

Group A Group B Method of Augmentation (Foley’s Catheter Group) % (Misoprostol Group) % p-Value of Labour (NA=50) (NB=50) Oxytocin Drip 19 38% 12 24% ARM + Oxytocin drip 16 32% 14 28% 0.15 ARM 15 30% 24 48% Total 50 50 Table 6. Methods of Augmentation in Labour

After induction of labour, 38% women in group A and 24% women in group B, needed augmentation of labour with oxytocin drip. In group A, 32% and 28% in group B needed artificial rupture of membranes with oxytocin drip, whereas the use of ARM for labour augmentation was done in 30% of women in group A and 48% in group B. Thus more no. of women that is 70% of women in group A (Foley’s catheter group) needed augmentation of labour either by oxytocin drip or combined ARM with oxytocin drip as compared to 52% of women in group B(misoprostol group). However, this difference is not statistically significant (p=0.15).

Group A Group B Mode of (Foleys Catheter Group) % (Misoprostol Group) % p-Value Delivery (NA=50) (NB=50) Vaginal Delivery 36 72% 38 76% Forceps Delivery 2 4% 3 6% 0.75 LSCS 12 24% 9 18% Total 50 50 Table 7. Mode of Delivery

The rate of vaginal delivery was 76% in group A (Foley’s catheter group) as compared to 82% in group B (Misoprostol group) as shown in Table 7. The rate of caesarean section was 24% and 18% in group A and group B respectively. 4% in group A had forceps delivery whereas 6% in group B had forceps delivery. Thus, the rate of vaginal delivery was higher in group B (misoprostol group) compared to group A (Foley’s catheter group). The rate of forceps delivery was higher in group B (Misoprostol group) compared to group A (Foley’s catheter group) and the indication was fetal distress in majority of cases. However, this difference is not statistically significant (p=0.75).

Group A (Foley’s Catheter Group) Group B (Misoprostol Group) Indications % % (NA=50) (NB=50) Fetal Distress 3 25% 5 56% Thick Meconium 1 8.3% 2 22% Stained Liquor Failed Induction 7 58.4% 2 22% Arrest of Labour 1 8.3% 0 0 Total 12 9 Table 8. Indications for LSCS

As depicted in Table 8, group B (Misoprostol group) had higher no. of caesarean sections that is 56% due to fetal distress as compared to 25% in group A (Foley’s group). In 22% of women in group B (Misoprostol group) the indication was meconium stained liquor versus 8.3% in group A (Foley’s group). Group A (Foley’s catheter group) had higher rate of failed induction as an indication for LSCS that is 58% compared to 22% in group B (Misoprostol group).

Complications Group A (Foley’s) (NA=50) Group B (Misoprostol) (NB=50) Hyperstimulation 0 1 2% Tachysystole 0 1 2% Total 0 2 4% Table 9. Complications Due to Induction of Labour

In group B (Misoprostol group), 2% had hyperstimulation and another 2% of women had tachysystole. Whereas no case of hyperstimulation or tachysystole was reported in group A (Foley’s catheter group).

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Group A (Foley’s Catheter Group) Group B (Misoprostol Group) Neonatal Outcome p-Value (NA=50) n(%) (NA=50)%

APGAR Score 7-10 49 (98) 48 (96) 1 at 5 Minutes ≤6 1 (2) 2(4) Meconium Yes 2(4) 4 (8) 0.67 Stained Liquor No 48 (96) 46 (92) Yes 3 (6) 5 (10) NICU Admission 0.71 No 47 (94) 45 (90) Table 10. Neonatal Outcome

98% of babies born in group A (Foley’s catheter group) in group A (Foley’s catheter group) and 70% in group B had an APGAR of 7-10 as compared to 96% in group B (Misoprostol group). (Misoprostol group) whereas 2% of newborn in group A There was no significant difference in demographic (Foley’s catheter group) had an APGAR ≤ 6 compared to 4% profile like age of patient, parity and gestational age and of newborn in group B (Misoprostol group). However, this indications for induction of labour in both groups in the difference was found to be not statistically significant (p=1) present study. 4% of newborn in group A (Foley’s catheter group) had In our study, 94% of women in group B (Misoprostol meconium stained liquor versus 8%. In group B (Misoprostol group) delivered before 24 hours compared to only 50% in group). There were 6% of NICU admissions in group A group A (Foleys’ catheter group). Hence the induction to (Foley’s catheter group) as compared to 10% of NICU delivery interval was significantly shorter in Misoprostol admissions in group B (Misoprostol group). Thus, there were group (19±4.6 hours) compared to Foley’s catheter group higher rates of APGAR ≤ 6, meconium stained liquor and (22.06±12.1 hours). This finding was similar to J. Promila et NICU admissions in group B (Misoprostol group) compared al6 11.58 hours versus 19.54 hours in Misoprostol group than to group A (Foley’s catheter group). However, this difference that in Foley’s catheter group. This finding was also similar was found to be not statistically significant. to the study by Bhatiyani BR et al,7 who noted that the mean induction delivery interval was shorter in Misoprostol group DISCUSSION by a mean of 3 hours when compared with those induced The ultimate outcome of good obstetric care is the delivery with Foley’s bulb 8.15 ± 3.23, 10.75 ± 3.82 hours of a healthy baby with a healthy mother. This can be respectively. Our study is comparable to the study by Noor achieved only after meticulous planning of antenatal care et al5 who reported induction to delivery interval in and delivery. There are times when the benefits of delivery Misoprostol group significantly shorter than that in Foley’s outweigh the continuation of pregnancy and the need for catheter group 14.03 ± 7.61 hours versus 18.40 ± 8.02 induction of labour arises. This process of induction of labour hours respectively. requires a comprehensive assessment of the indication, This finding in our study is not similar to the study of appropriate choice of the method and skillful execution to Sujata et al4 who reported shorter induction delivery interval attain the final goal of obstetrics.2 with the Foley’s catheter than with intravaginal misoprostol When embarking on induction of labour, it is essential and PGE2 gel 19.18 ± 2.12 hours, 21.04 ± 2.32 hours; 20.12 to review the indication carefully to avoid fetal or neonatal ± 1.21 hours respectively which was statistically significant. compromise as well as maternal morbidity, especially Greybush et al8 documented that a supracervical Foley caesarean delivery due to failed induction of labour.3 catheter had similar efficacy in cervical ripening to Labour is commonly induced in response to a number of intravaginal misoprostol. fetal and maternal situations including postdated pregnancy, Rachel et al9 reported in their study that PGE1 and EASI preeclampsia and rupture of membranes etc. without the have similar efficacy in induction of labour, but in onset of spontaneous contractions.4 unfavourable cervices, Foley’s catheter with EASI is better Induction rates between 10% and 25% are common in than other methods of induction especially in areas with industrialized countries. Different methods are used for limited resources. labour induction but none of the available methods of In the present study, 70% of women in group A (Foley’s induction of labour is free of associated medical risks.5 catheter group) needed augmentation of labour either by Ripening of cervix may be achieved by both pharmacological oxytocin drip or combined ARM with oxytocin drip as and non–pharmacological (mechanical methods) methods. compared to 52% of women in group B(Misoprostol group). In our study, the efficacy and safety of trans cervical Foley’s Use of oxytocin for labour augmentation was significantly catheter was compared with Misoprostol (PGE1) for pre higher in women induced with Foley’s catheter as compared induction cervical ripening and maternal and perinatal to women induced with intravaginal misoprostol. This finding outcome was analyzed. is similar to the study by Noor et al5 who reported 77.2% in In our study, postdated pregnancy was the predominant Foley’s group versus 48.3% in Misoprostol group with regard indication for induction of labour in both groups, that is 72% to use of oxytocin for labour augmentation. Combined use of

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Jebmh.com Original Research Article oxytocin and ARM was 41.7% and 77.2% in misoprostol and CONCLUSION Foley’s catheter group respectively, and statistically it was The demographic profile was similar between the two very highly significant. Our findings are also similar to the groups, Group A (Foley’s catheter group) and Group B study by Rachel et al9 who reported 38.55% of oxytocin use (misoprostol group). The indication for induction of labour in Misoprostol (PGE1) group as compared to 86.79% in was comparable in both groups. The induction to delivery Foley’s catheter with Extra Amniotic Saline Infusion group in interval was significantly shorter in group B that is unfavourable cervix. misoprostol group than in group A that is Foley’s catheter This finding is also similar to the study by Sujata et al4 group. p value <0.001, which is statistically significant. There who reported that all women in Foley’s group required was higher rate of need for augmentation of labour either by augmentation in which 30% required oxytocin drip, 36% oxytocin drip or combined ARM with oxytocin drip in group A required ARM + oxytocin both, whereas in misoprostol (Foley’s group) that is (70%) compared to Group B (52%) group, 15 women had spontaneous rupture of membranes that is misoprostol group. while 39 women required augmentation and maximum no.of The rate of vaginal delivery was higher in group B women (35.19%) required ARM. (misoprostol group) that is 82% as compared to 76% in In our study, the rate of vaginal delivery was 76% in group A (Foley’s catheter group). The rate of forceps delivery group A (Foley’s catheter group) as compared to 82% in was higher in group B (Misoprostol group), 6% versus 4% in group B (Misoprostol group) and the rate of caesarean group A (Foley’s group) and indication was fetal distress in section was 24% and 18% in group A and group B majority of cases. respectively; thus higher rate of vaginal delivery was seen in There were higher rates of APGAR≤6, meconium misoprostol group. Our results are similar to Sujata et al4 stained liquor and NICU admissions in group B (Misoprostol who reported that maximum no. of women delivered group) compared to group A (Foley’s catheter group). vaginally. The rate of vaginal delivery was 76.7% versus However, this difference was found to be not statistically 56.8% in misoprostol and trans cervical Foley’s catheter significant (p-value >0.05). group, respectively as reported by Noor et al5 which was The group B (Misoprostol group) had higher number of similar to our study. caesarean sections that is 56% due to fetal distress as Rachel et al9 reported 81.56% of spontaneous delivery compared to 25% in group A (Foley’s group). In 22% of in misoprostol group compared to 62.26% in EASI group, women in group B (Misoprostol group) the indication for whereas 12.85% in misoprostol group and 30.19% in EASI LSCS was meconium stained liquor versus 8.3% in group A group underwent caesarean section, is also comparable to (Foley’s group). Group A (Foley’s group) had higher rate of our study. Orji et al10 reported that successful induction failed induction as an indication for LSCS that is 58% occurred in 95% of misoprostol group compared to 75% in compared to 22% in group B (Misoprostol group). catheter/ oxytocin group, which is similar to the present Thus, we conclude that intravaginal misoprostol is study. associated with shorter induction to delivery interval when NS Fox et al,11 reported that there was no significant compared to Foley’s catheter insertion and increases the rate difference in the rate of caesarean delivery between women of vaginal delivery in cases of unripe cervix, which is who received misoprostol compared with trans cervical statistically significant. Trans cervical Foley’s catheter is Foley’s catheter (RR 0.991; 95% CI 0.7683, 1.278). associated with a lower incidence of hyperstimulation in With regards to neonatal outcome in the present study, addition to other advantages like low cost, easy reversibility, 98% of newborn in group A (Foley’s catheter) had an APGAR feasibility, less need for continuous fetal monitoring during of 7-10 as compared to 96% in group B (misoprostol group). cervical ripening and can be used on outpatient treatment The incidence of babies born with APGAR ≤6 was 2% in basis. group A (Foley’s catheter group) was lesser compared to The findings that trans cervical Foley’s catheter is group B (misoprostol group) which was 4%. In our study the associated with no risk of hyperstimulation may be rate of meconium stained liquor was 4% in group A infants particularly useful when inducing labour in women with compared to 8% infants in group B and higher rate of NICU previous caesarean section who are at increased risk of admissions was observed in group B (misoprostol group) uterine rupture.5 compared to group A (Foley’s catheter group). These findings were not comparable to study by Noor et al5 and REFERENCES Rachel et al.9 In the study by Noor et al,5 meconium amniotic [1] Wang KC, Lee WL, Wang PH. Is it safe to use fluid was seen in 8.3% women induced with misoprostol and pharmacological agents for induction of labor? J 9.1% in women induced with Foley’s catheter groups. Rachel Chin Med Assoc 2017;80(3):123-124. et al9 reported that the babies born in PGE1 (misoprostol) [2] Kumari SS. Induction of labour – good clinical group had a higher APGAR score of (7-10), 2.24% babies in practice recommendations. 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