A Dissertation on COMPARISON of MIFEPRISTONE with FOLEY's CATHETER for INDUCTION of LABOUR in POST DATED PREGNANCY

A Dissertation on COMPARISON OF MIFEPRISTONE WITH FOLEY'S CATHETER FOR INDUCTION OF LABOUR IN POST DATED PREGNANCY

Dissertation submitted to THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY CHENNAI-600032 With partial fulfillment of the requirements for the award of M.S.DEGREE IN OBSTETRICS AND GYNAECOLOGY (BRANCH VI) Reg No:221716303

COIMBATORE MEDICAL COLLEGE, COIMBATORE MAY 2020

DECLARATION

I Dr. DHIVYA.M. solemnly declare that the dissertation

entitled “ COMPARISON OF MIFEPRISTONE WITH

FOLEY'S CATHETER FOR INDUCTION OF LABOUR IN

POST DATED PREGNANCY” is a bonafide work done by me

at Coimbatore Medical College Hospital during the year Jan 2018

to Dec 2018 under the supervision of Dr.RMANONMANI,

M.D,D.G.O, Professor& Head of Department, Department of

Obstetrics and Gynaecology, Coimbatore Medical College &

Hospital. The dissertation is submitted to Dr.MGR Medical

University towards partial fulfillment of requirement for the award

of MS degree Obstetrics and Gynaecology.

PLACE: Dr. DHIVYA.M

DATE:

CERTIFICATE

This is to certify that the dissertation entitled “COMPARISON OF MIFEPRISTONE WITH FOLEY'S CATHETER FOR INDUCTION OF LABOUR IN POST DATED PREGNANCY”is a bonafide original work done by Dr.DHIVYA.M.Post graduate student in the Department of OBSTETRICS AND GYNAECOLOGY , Coimbatore Medical College Hospital, Coimbatore under the guidance of Dr.R.MANONMANI (M.D,D.G.O), Professor and HOD of Department, Department of OBSTETRICS AND GYNAECOLOGY, Coimbatore Medical College Hospital, Coimbatore in partial fulfillment of the regulations for the Tamilnadu DR.M.G.R Medical University, Chennai towards the award of M.S., degree (Branch VI) in Obstetrics and Gynaecology.

Date : GUIDE Dr.N.GEETHA, M.D.OG, Professor, Department of Obstetrics and Gynaecology, Coimbatore Medical College & Hospital.

Date : Dr.R.MANONMANI, M.D,D.G.O, Professor & HOD, Department of Obsterics and Gynaecology, Coimbatore Medical College & Hospital.

Date : Dr.B.ASOKAN, M.S., Mch., Dean, Coimbatore Medical College & Hospital, Coimbatore.

Declaration by the Candidate

I hereby declare that The Tamilnadu DR.M.G.R Medical University,

Chennai shall have the rights to preserve, use and disseminate this dissertation/thesis in print or electronic format for academic/research purpose.

PLACE: COIMBATORE Dr. DHIVYA.M DATE:

PLAGIARISM CERTIFICATE

This is to certify that this dissertation work titled "COMPARISON OF

MIFEPRISTONE WITH FOLEY’S CATHETER FOR INDUCTION OF

LABOUR IN POST DATED PREGNANCY" of the candidate

Dr.DHIVYA.M with registration number for the award of M.S.OBSTETRICS

AND GYNAECOLOGY IN THE BRANCH VI. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and results shows 6 percentage of plagiarism in the dissertation.

Signature of the Guide

ACKNOWLEDGEMENT

I solicit my humble thanks to the Dean Dr.B.Asokan, M.S.,

Mch.,Coimbatore Medical College Hospital, for allowing me to conduct the study in this hospital.

I would like to express my gratitude and indebtness to our Prof and HOD,

Dr.R.MANONMANI,M.D,D.G.O, Department of Obstertrics and Gynaecology for her motivation and support.

I am also immensely thankful to my guide Prof.

Dr.N.GEETHA,M.D,OG. Professor, Department of Obstetrics and

Gynaecology for her invaluable guidance, motivation and help throughout the study.

I express my earnest gratitude to all Professors, Department of Obstetrics and Gynaecology Dr. K.Murugalakshmi, M.D,D.G.O, Dr.Mohanasundari

M.D,OG,Dr.P.Thilagavathy M.D,OG, without their help and guidance this work would not have been possible.

I thank all my Assistant professors who helped me to accomplish my study.

I owe a lot to my parents, my spouse Dr. D.Senthil kumar and other family members who have always been my pillar of support in all stages of my life.

I thank my seniors and my fellow post graduate colleagues who have been of immense help throughout the study period.

I am very grateful to all patients for their co-operation and participation in the study.

CONTENTS

SL.NO TITLES PAGE NO

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 3

3 4 REVIEW OF LITERATURE 4 THEORETICAL BACKGROUND 8

5 MATERIALS AND METHODS 63

6 OBSERVATION AND RESULTS 66

7 DISCUSSION 79

8 SUMMARY 81

9 CONCLUSION 83

10 BIBLIOGRAPHY 84

ANNEXURES 11 98

LIST OF TABLES

SL.NO TABLES PAGE NO

1 Modified Bishop’s score 33

2 Distribution of Study Participants 66

3 Mean Age of the study group 68

4 Association of Parity with type of induction 69

Association between mode of delivery and 5 71 type of induction

Association between induction –delivery 6 73 interval and type of induction

Association between the neonatal outcome and 7 75 type of income

Association between induction type and 8 77 incidence of PPH

LIST OF CHARTS

SL.No CHARTS PAGE No

1 Flow chart for management of post dated pregnancy 31

2 Distribution of study participants 67

3 Distribution of mean age of the study group 68

4 Association between parity and type of induction 70

Association between mode of delivery and type of 5 72 induction

Association between duration of delivery and 6 74 induction type

Association between neonatal outcome and induction 7 76 type

Association between induction type and incidence of 8 78 PPH

LIST OF FIGURES

SL.NO FIGURE PAGE NO Formation Of Physiological And Pathological 1 12 Retraction Ring

2 Image showing Mechanism of Labour 14

3 FRIEDMAN’S curve for labour monitoring 16

4 Image showing Bag of membranes formation 17

5 Bearing down efforts and fetal expulsion 20

6 Placental seperation 22

7 Sweeping of membranes 35

8 Amniotomy 37

9 Synthesis of Prostaglandins 41

10 Mechanism of action of PGE2 43

11 Intracervical application of PGE2 44

12 Chemical structure of Mifepristone 46

13 Three dimensional image of Mifepristone 47

Mechanism of action of Mifepristone 48 14 15 Image of Foley’s catheter 52

Image showing cervical dilatation and 16 55 effacement

17 Image of a double balloon catheter 57

18 Insertion of double balloon catheter 58

19 Picture of Laminaria tent 59

20 Insertion of Laminaria tent 61

LIST OF ABBREVIATIONS

ACOG American College of Obstetrics and Gynaecology

ANC Antenatal clinic

ARM Artificial rupture of membranes

BMI Body Mass Index

C/S Caeserean section

CPD Cephalo-pelvic disproportion

FIGO International Federation of Obstetrics and Gynaecology

PGs Prostaglandins

PGE1 Misoprostol

PGE2 Dinoprostone

RU 486 Mifepristone

RCOG Royal College of Obstetricians and Gynaecologists

WHO World Health Organization

MLCK Myosin Light Chain Kinase

LIST OF NOMENCLATURE

Expected date of delivery(EDD)- 280 days or 40 completed weeks from the last menstrual period.

Post-maturity: Post-maturity or Post-maturity Syndrome (PMS) can only be diagnosed after delivery and is defined as a post-dated pregnancy accompanied with any combination of the following newborn assessments a. No Lanugo ( fine body hair ) b. Long Nails c. Abundant Hair On Head d. Calcified Fetal Skull e. Hanging Or Wrinkled Skin, With The Appearance Of Weight Loss f. Dehydrated g. Alert Face h. Peeling Skin i. Little or No Vernix j. Oligohydramnios k. Meconium or bile staining of skin and long, thin growth retarded body

with long thin limbs. Induction of labor: Artificial initiation of contractions in a pregnant woman who is not in labor to help her achieve a vaginal birth within 24 to 48 hours.

Successful induction: A vaginal delivery within 24 to 48 hours of induction of labor.

Elective induction: Induction of labor in the absence of acceptable fetal or maternal indications.

Cervical ripening: Use of pharmacological or other methods to soften, efface, or dilate the cervix to increase the likelihood of a vaginal delivery.

Tachysystole: More than 5 uterine contractions in 10 minute period averaged over 30 minutes. This is further subdivided into two categories, one with and one without fetal heart rate changes.

Hypertonus: Excessive uterine contractions lasting more than 120 seconds without fetal heart rate changes.

Hyperstimulation: Excessive uterine contractions (tachysystole or hypertonus) as a result of induction of labor with nonreassuring fetal heart rate changes

Amniotomy: Artificial rupture of the membranes to initiate or speed up labor.

Failed induction: Failure to achieve regular uterine contractions (every 3 minutes) after one cycle of completion of cervical ripening consisting of a) Insertion of three intracervical PGE2 gel (3gm) at 6-hourly intervals, and 12-24 hours of oxytocin administration after rupture of membranes, if feasible, or

b) One PGE2 pessary (10 mg) within 24 hours.

ABSTRACT TITLE:

COMPARISON OF MIFEPRISTONE WITH FOLEY’S

CATHETER FOR INDUCTION OF LABOR IN POST DATED

PREGNANCY.

BACKGROUND AND OBJECTIVES:

Induction of labor is artificial initiation of uterine contractions before spontaneous onset of labor or after the period of viability of the fetus. Induction of labour is indicated when complications of pregnancy may have a negative impact on the health of the mother, fetus, or both. Induction of labour is therapeutic option when the benefits of the delivery outweigh the risks of continuing the pregnancy. Routine antenatal ultrasound for confirmation of EDD has been shown to reduce induction rates for post dated pregnancies after correction of dates. Prolonged pregnancy is known to be associated with significantly increased risks of perinatal and maternal complications. . Induction of labour is planned for many indications.In this study induction of labour done for post dated pregnancies was taken into account.The purpose of this study is to compare the efficacy of mifepristone with foley’s catheter for induction of labour in post dated pregnancies.The drug have been chosen for the above study based on cost factor,safety profile and the results shown by previous studies.This will be of very use in future management of post dated pregnant woman planned for induction of labor.

METHODOLOGY:

This is a randomized comparative study conducted from Jan 2018 to Dec

2018 in Department of Obstetrics and Gynaecology,Coimbatore Medical

College Hospital.Two hundred post dated pregnant mothers were enrolled in the study based on inclusion and exclusion criteria.

All patients were explained about the study and informed written consent was obtained from them in the language of their convenience.A thorough history regarding the regularity of menstrual cycle,LMP,dating scan,risk factors of post dated pregnancy,past obstetric history were obtained and recorded.Complete systemic and obstetric examination were done in all patients.Complete blood count,blood sugar, renal function test, ultrasound obstetrics were done in all patients.

Per vaginal examination done to assess adequacy of pelvis,the bishop’s score of the patients included in the study.The results obtained by considering the following parameters,

Changes in the bishop’s score,

Induction delivery interval,

Mode of delivery,

Neonatal outcome,

Incidence of PPH. Patients were randomised into two groups. One group were treated with Tab.

Mifepristone and another group were treated with Foley’s catheter. After 24 hours, the treatment results were noted by change in the Bishop's score, need for further induction with prostaglandins or augmentation with ARM or oxytocin, fetal heart rate monitoring to rule out fetal distress, mode of delivery, induction delivery interval, incidence of PPH.

Thus the efficacy of Mifepristone with Foley’s catheter for induction of labor in post dated pregnancies were studied and compared.

RESULTS:

Our study included 200 patients out of which 100 were treated with

Mifepristone,100 were treated with Foley’s catheter. Among the study group,

135 women are Primigravida and 65 women are multigravida.

The mean age for the women in the study group were in between 24 -25 yrs.The mode of delivery in the women who were enrolled in the study was found to be significant as 84% of patient in mifepristone group delivered vaginally compared to 64% in foley’s induction group.16% patients were undergone caesarean section in mifepristone group as compared to 33% in the foley’s induction group.The mean duration of induction –delivery interval was found to be 26 hours in mifepristone group compared to 36 hours in foley’s group.The incidence of respiratory distress in mifepristone group was found to be 3% compared to 12% in foley’s group.The incidence of PPH observed in the study was found to be insignificant. CONCLUSION:

Thus, based on the results observed in our study, Tab.Mifepristone can be considered as effective in induction of labour in post dated pregnancy.

Keywords : Induction of labor,Postdated, pregnancy,Mifepristone,Foley's catheter,induction-delivery interval,neonatal outcome. INTRODUCTION

Induction of labour is defined as the stimulation of uterine contractions to bring about the delivery before the onset of spontaneous labour or after the period of viability.

Induction of labour is indicated when complications of pregnancy may have a negative impact on the health of the mother, fetus, or both. Induction of labour is therapeutic option when the benefits of the delivery outweigh the risks of continuing the pregnancy.

There are many methods for induction of labour. In this study one group was induced with Tab.Mifepristone another group was induced with foley’s catheter.

Induction of labour is planned for many indications.In this study induction of labour done for post dated pregnancies was taken into account.

Routine antenatal ultrasound for confirmation of EDD has been shown to reduce induction rates for post dated pregnancies after correction of dates[1,2]

This study is done in a developing country like India at

Coimbatore medical college hospital to find the efficacy of mifepristone and foley’s catheter for induction of labour in post dated pregnancy as a part of routine elective induction in inpatients admitted for safe confinement.

AIMS AND OBJECTIVES

To compare the safety and efficacy of mifepristone and foley’s catheter for induction of labour in post dated pregnancies

REVIEW OF LITERATURE

Lata G et al study showed in term pregnancy and in patients with unripe cervix mifepristone was effective in cervical ripening and inducing labour. In this study 80% of patients in study group showed improvement in cervical ripening compared to 50% patients in control group. 70% patients in study group delivered within 48 hours as compared to 38% patients in control group[3]

In a study conducted by RUTUJA ATHAWALE, the inducing agent Mifepristone acts by increasing uterine contractility and uterine sensitivity to the actions of prostaglandin. In this study, the women showed drastic improvement in cervical score within 24-48 hours after induced with oral mifepristone and the cesarean rate was decreased and amount of dose requirement for augmentation of labour with

Misoprostol or Oxytocin, lesser NICU admission and maternal complication in the study group as compared to placebo group.[4]

Kanan yelikar studied the efficacy of mifepristone in cervical ripening and induction of labour in prolonged pregnancy .In this study there was 100 subjects, out of which 50 received mifepristone and 50 received placebo. Mean induction to delivery interval ,mean Bishop score was analysed after 24 hours. 16 % women in Study Group and 4 % women in Control Group delivered vaginally within 24 h without any

4 need of augmentation. There was 12 % caesareans and 4 % instrumental deliveries in Study Group as compared to 16 % and 10 % respectively in the Control Group. In both groups no statistically significant difference in perinatal outcomes. Mifepristone has modest effect on cervical ripening and reduces need for misoprostol compared with placebo.[5]

In a study Byrne demonstrated that after exposure to mifepristone venous blood samples were taken to measure serum cortisol, CRH,

ACTH at 0,3,6 hours then every 6 hours till delivery.in study group there was no significant elevation in ACTH and CRH levels rather than there is significant elevation in cortisol levels was observed within 18 h of exposure to mifepristone as a matter of response to stress(progress of labour).[6]

In a study conducted by Wing DA, among 180 subjects 97 were given mifepristone and 83 were given placebo. Out of which 87.5% in mifepristone group delivered vaginally after 48 hrs of treatment compared to 46% in placebo groups. variations in fetal heart rate pattern and changes in uterine contractilities were noted in mifepristone groups.

The neonatal outcome was found to be same in both groups.[7]

Hapangama et al compared the usage of mifepristone in third trimester cervical ripening and labour induction with placebo. The results are mifepristone treated groups entered into labour and bishop score

5 improvement within 48 hours and this effect persisted for 96 hours. There is insufficient information regarding uterine rupture and dehiscence in cases of previous caesarean deliveries[8].

Atawale et al.[9] and Fathima et al. [10] also noted the significant change in Bishop score with the use of oral mifepristone after 24 hours of administration.

In a study conducted by Dr gautham aher the effect of mifepristone on cervical score by comparing the pre and post induction bishop’s score. There was a significant improvement in bishop’s score noted in mifepristone group than placebo group.[11]

Dharani H reported that mifepristone-treated women were less likely to undergo C/S due to failure of induction and the need of augmentation with oxytocin is reduced when compared to placebo.[12]

In a study conducted by Baburam dixit two groups are there one is induced with foley’s catheter another is induced with misoprostol, the results are in foley’s induction group,80 went into normal labour,16 had caesarean deliveries,1 had vaccum delivery,9 patients delivered with meconium stained liquor,1 still birth,no hyper stimulation was noted.[13]

W Chen studied the effects of foley’s catheter, oral misoprostol and dinoprostone for cervical ripening in induction of labour. The results

6 showed that vaginal misoprostol was most effective in achieving vaginal delivery within 24 hours with high incidence of uterine hyperstimulation. lower incidence of hyperstimulation was noted with foley’s catheter.C/S rates were lower with oral misoprostol.[14]

In a study done by Mieke L and tenEikelder foley’s catheter showed better safety profile in women with unripe cervix at term as compared to misoprostol.in this study there was lesser incidence of hyperstimulation, fewer instrumental deliveries, lesser caesarean deliveries than misoprostol[15]

THEORETICAL BACKGROUND

Labor is a process by which the fetus after the period of viability, is expelled from the genital tract.

According to WHO Normal labor is defined as

Onset is spontaneous

Term gestation {37-42 weeks}

Vertex presentation

Uncomplicated

Natural expulsive forces

Vaginal delivery

Preterm labor is onset of labor before 37 weeks of geststion.

PHYSIOLOGY OF ONSET OF LABOR

The basis of uterine contractility is the interaction between actin and myosin in myometrial smooth muscle cells. This is brought by calcium through Ca2+–calmodulin‐dependent myosin light chain kinase

(MLCK) activity. The calcium sensitisation in smooth muscle occurs through activation of Rho kinase, a calcium‐independent pathway that promotes contractility by inhibiting myosin phosphatase and probably by

8 phosphorylating myosin on the same site as MLCK. Uterine activity can be modulated by many G‐protein coupled receptors (GPCRs )

1.Receptors coupled to Gαq (oxytocin‐, prostanoid FP and TP, endothelin‐receptors) stimulate contractility by activating the phospholipase C/Ca2+ pathway

2.Receptors coupled to Gαs (β2‐adrenoceptors, prostanoid EP2 and

IP, some 5‐hydroxytryptamine receptors e.g. 5‐HT7) relax the uterus by increasing myometrial cyclic AMP levels

3.Receptors coupled to Gαi (α2‐adrenoceptors, muscarinic,

5‐HT1) potentiate contractility, probably by inhibiting cAMP production.

Recent evidence showed that fetal adrenal cortisol induces prostaglandin synthase type 2 in placental trophoblast and that the resulting increase in prostaglandin E2 participates in the activation of the

P450 cascade The endocrine imbalance promotes increased intrauterine production of prostaglandins, cervical softening and the onset of myometrial contractions [17]

The progress of normal labor depends upon interaction between the 3 P’s

Passage

Passenger

Power

PASSAGE

The passage consists of both bony pelvis and soft tissues. Shapes and diameters of the true pelvis assessed by clinical pelvimetry.

The soft tissues (cervix and pelvic muscles) undergo some changes during labor that favors descent of the fetus through the pelvis.

PASSENGER

Fetal factors leading to successful vaginal delivery are

Vertex presentation

Longitudinal lie

Average weight

Well flexed attitude

Left occipito anterior position.

Factors leading to poor prognosis to successful vaginal delivery

Fetal weight >4 kg

Deflexed head

Occipito posterior position

Malpresentations such as breech ,brow and face.

POWER

Uterine contractions play a major role in the process of labor.as the labor goes on ,interval between the contractions gradually decreases and it’s intensity increases.5 contractions in ten minutes is considered normal.

Intra amniotic pressure as measured by intrauterine pressure catheter is measured 20-40 mmHg. The strength of the contractions is expressed in Montevideo units.

As the uterus contracts there is formation of upper and lower uterine segment, physiologic retraction ring formation, increase in hydrostatic pressure dilates the cervical canal hence bag of membranes is formed.

IMAGE 1

FORMATION OF PHYSIOLOGICAL AND PATHOLOGICAL

RETRACTION RING

MECHANISM OF NORMAL LABOUR

It is defined as the process by which the fetus adjust it’s position throughout the labor so as to accommodate the pelvic canal and favors the delivery of the fetus.

To understand the mechanism and management of labour we should first know the

Physiological mechanisms of labour[16,17]

The cardinal movements of labor are,

1. Engagement

2.Descent

3.Flexion

4.Internal rotation

5.Extension

6.Restitution

7.External rotation

8.Expulsion.

The most important movements among these is internal rotation which occurs at the level of ischial spines bringing the occiput anterior thereby extension occurs and delivery of the fetus.

IMAGE 2

MECHANISM OF LABOUR

A-engagement& descent, B-flexion, C-internal rotation, D-extension,

E-restitution, F-external rotation.

Labor is a continuous process. It is divided into three stages.

1.First stage : Stage of dilatation

2.Second stage : Stage of expulsion of fetus

3.Third stage : Placental expulsion

PRELABOUR OR PREPARATORY STAGE OF LABOR

The preparatory changes like cervical changes, engagement of the fetal head, takes place few weeks prior to onset of labor.

FOURTH STAGE OF LABOR

In this stage contraction and retraction of the uterus and arrest of bleeding occurs. The duration is 1-2 hours after delivery. PPH due to atony can occur close monitoring is needed.

FIRST STAGE

Starts from onset of true labor pains to full dilatation of cervix

Events :

1 . Regular and painful uterine contractions which progressively

increases in intensity ,duration ,frequency.

2 . Show

3 . Effacement and dilatation of cervix. Cervical dilatation is divided

into two phases,

a) latent phase

b) active phase- acceleration phase,

phase of maximum slope,

deceleration phase,

IMAGE 3

FRIEDMAN’S CURVE FOR LABOUR MONITORING

4 .Lower uterine segment formation

5 .Descent of presenting part

6 .Bag of membranes formation.

Duration of first stage of labor

Nullipara-6-8 hours

Multipara-4-6 hours

Rate of cervical dilatation

Nullipara-1.2 cm/hr

Multipara-1.5cm/hr

Minimum-1 cm/hr

IMAGE 4

BAG OF MEMBRANES FORMATION

SECOND STAGE

Starts from full dilatation of cervix to delivery of fetus.

1. It consists of two phases,

a. Pelvic phase or phase of descent-full dilatation to the time when head reaches the pelvic floor which is identified by the bearing down efforts.

b. Perineal phase or phase of expulsion-starting of bearing down efforts to delivery of fetus.

2. Uterine contractions increase in frequency and duration.

3. Bearing down efforts

4. Crowning

5. Expulsion of fetus.

IMAGE 5

BEARING DOWN EFFORTS AND EXPULSION OF FETUS

THIRD STAGE

Stage of placental expulsion

Placental separation consists of 4 phases

1. Latent phase-placenta free wall of the uterus contracts

2. Contraction phase-uterine wall at the placental site contracts

3. Detachment phase- placenta seperates from the uterine wall

4. Expulsion phase-placenta expelled from the uterine cavity

SIGNS OF PLACENTAL SEPERATION

Well contracted uterus

Gush of blood coming from vagina indicating complete or partial separation

Lengthening of the cord

Placenta descends

Uterus becomes hard, round and mobile.

PLACENTAL SEPERATION METHODS

There are two methods,

1. Schultze-centre of the placenta seperates first and comes out as an

inverted umbrella.

2. Duncan method-margins of the placenta seperates first followed by

the central part.

IMAGE 6

METHOD OF PLACENTAL SEPARATION

A-Schultze method

B-Duncan method

After confirming the placental separation by per vaginal examination, placenta was delivered by controlled cord traction method.(Brandt

Andrew method)[18]

Induction of labour is the iatrogenic stimulation of uterine contractions before the onset of spontaneous labour, to accomplish vaginal delivery. It is performed when the benefits of expeditious delivery to either mother or fetus outweigh the risk of continuing the pregnancy.

Labour may be induced because of maternal or fetal indications

MATERNAL INDICATIONS

Post dated or post term pregnancy

Preterm, prelabour rupture of membranes(PPROM)

Prelabour rupture of membranes(PROM)

Placental abruption

Hypertensive disorders

Gestational hypertension

Pre eclampsia

Eclampsia

Chronic hypertension

Diabetes mellitus(GDM)

Anti phospholipid antibody syndrome(APLA)

Intrauterine fetal demise(IUFD)

FETAL INDICATIONS

Fetal growth restriction(FGR)

Oligohydramnios

Rh alloimmunisation

Non reassuring fetal heart rate pattern

Induction of labour is a relatively common procedure. The rate of induction of labour may differ depending on the availability of resources and population. Worldwide, the prevalence of labour induction varies greatly between countries and even between different regions of the same country. In general, however, it is higher in developed countries (at around 20%) than in developing countries [19].

In the Western world, frequency of labour induction has been increasing, with reasons including the availability of better cervical ripening agents, patient and clinicians desire to arrange a convenient time of delivery, and more relaxed attitudes toward marginal indications for induction [19]. Patient or provider concerns about the risk of fetal demise with expectant management of post-term pregnancies have also

24 contributed to the increased rate of induction[19,20]]. In the United

Kingdom according to the National Health Survey (NHS), one in every five live births is induced half of which are due to post-term pregnancies

[21,22].In another study in Sweden, the rate of induction in nulliparous women was as high as 40% with post-dates being the major indication.

[23]

From observational studies it has been found that nulliparous women have a higher failure rate than multiparas and also induction has been known to fail when the bishop score is five or less.[24]. However no such study has been carried out specifically for post-term pregnancies and the rate of successful induction of prolonged pregnancies with such factors world-wide is not known.

Prerequisites for induction of labour

1.Indication for induction of labour.

2.Cervix must be assessed for Bishop’s score

3.pelvis to be assessed for CPD/FPD

4.Estimated weight of the baby

5.Fetal presentation

6.Fetal well being

Predictors of successful induction

1.Gestational age

2.Pelvic configuration

3.Multiparity

4.EFW<3.5 kg

5.Normal BMI

6.Favourable Bishop’s score

7.Tall stature

The etiology of post term gestation is not clearly understood.

Some of the risk factors for post term pregnancy are

1. Previous post term pregnancy,

2. Nulliparity,

3. Maternal age > 30 years,

4. Obesity[25,26]

In certain rare conditions genetic predisposition to postterm pregnancy

has been reported[27,28,29] .In 49% woman who was born postterm has

26 increased risk of giving birth to a child beyond 42 weeks' gestation; the risk is 23% if the father of the child was born postterm[28].Some of the rare causes are Fetal anencephaly and placental surfactant deficiency[30].

Sometimes inappropriate clinical dating may lead to the misdiagnosis of late-term or postterm pregnancy.[30,31] EDD calculation using the last menstrual period, which assumes accurate recall and ovulation at day 14, can overestimate gestational age.[32] Early USG can reduce this miscalculation and thereby decreasing inductions for miscalculated late-term and postterm pregnancies.

Although first-trimester measurement of crown-rump length is the most accurate dating method and is often performed[30]

The American College of Obstetricians and Gynecologists states that the estimated date of delivery can be calculated from the last menstrual period if the patient has regular, normal menstrual cycles and has not taken oral contraceptives in the three months before the last menstrual period[30] However, first-trimester ultrasonography is recommended for accurate dating based on the last LMP. A post-term or prolonged pregnancy according to World Health Organization (WHO) is one that has exceeded 294 days from the last normal menstrual period.

A prolonged pregnancy can lead to post-maturity of the fetus posing a great threat to its further survival in-utero and multiple complications

27 including neonatal mortality post delivery. World-wide 5-10% of all pregnancies are prolonged with 20% of post-term fetuses having dysmaturity syndrome. The incidence of induction is on the rise, half of which are due to post-dates. At Kenyatta National Hospital the rate of induction of labour due to prolonged pregnancies stands at 50 % of all inductions. The failure of induction world-wide has been increasing and it is therefore important to determine some of the predictors of successful induction. Several studies have been done world-wide to predict factors influencing failed induction but there has been none specifically for predictors of successful induction in post-dates.

Post-term or prolonged pregnancy is when the pregnancy has exceeded the expected date of delivery by 2 weeks or more [33]. World- wide about 5-10% of pregnancies are prolonged [34]. Such pregnancies are at an increased risk of utero-placental insufficiency and macrosomia of the fetus which may lead to other fetal and maternal complications [35] and thus the need to deliver them.

In this study induction of post-dated pregnancies is done at 41 weeks as per the national guidelines, the WHO, American College of

Obstetrics and Gynaecology (ACOG) and the Royal College of

Obstetricians and Gynaecologists(RCOG) guidelines [33, 36,37,38]. The policy of inducing labour at 41 weeks (288 days of gestation) in

28 uncomplicated pregnancies is justified because when the gestational age is more than 41 weeks, the incidence of meconium staining of amniotic fluid and evidence of utero-placental insufficiency increases significantly

[39,40]. In addition, labour induction at 41 weeks’ gestation for otherwise uncomplicated singleton pregnancies reduces caesarean delivery rates without compromising perinatal outcomes [39,41] A number of key morbidities are greater in infants born to pregnancies that progress to and beyond 41 weeks gestation including meconium aspiration, neonatal academia, low Apgar scores, macrosomia, and, in turn, birth injury[42,43]. Such complications associated with fetal macrosomia include prolonged labor, cephalo-pelvic disproportion, and shoulder dystocia with resultant risks of orthopaedic or neurologic injury [42].

Approximately 20% of post-term fetuses have fetal dysmaturity

(post-maturity) syndrome, which describes infants with characteristics of chronic intrauterine growth restriction from utero-placental insufficiency

[44,45]. These pregnancies are at increased risk of umbilical cord compression from oligohydramnios, non-reassuring fetal status

(antepartum or intrapartum), intrauterine passage of meconium, and short-term neonatal complications such as hypoglycaemia, seizures, and respiratory insufficiency.[44,45]

Post-term pregnancy is also an independent risk factor for neonatal encephalopathy and for death in the first year of life [46]. Perinatal mortality (defined as stillbirths plus early neonatal deaths) at 42 weeks of gestation is twice that at 40 weeks (4-7 vs. 2-3 per 1,000 deliveries, respectively) and increases 4-fold at 43 weeks and 5- to 7-fold at 44 weeks [46,47]

Prolonged pregnancy is known to be associated with significantly increased risks of perinatal and maternal complications [48]

CHART 1 - FLOW CHART FOR MANAGEMENT OF POST

DATED PREGNANCY

The pre-induction cervical status is known to be the most effective of all parameters in accounting for successful induction [49,50]. Bishop established the relationship between cervical ripeness and entering spontaneous labour about fifty years ago [50].

The modified Bishop score is now being used to assess the cervix.

This system tabulates a score based upon the station of the presenting part and four characteristics of the cervix: dilatation, cervical length (instead of effacement in the original scoring system by Bishop), consistency, and position. A score that exceeds 8 describes the patient most likely to achieve a successful vaginal birth without cervical ripening [51]. Bishop scores of less than 6 usually require that a cervical ripening method be used before other methods [51]

TABLE 1 - MODIFIED BISHOP’S SCORE

Score <6 –unfavourable, Score >6 - favourable

The relationship between a low Bishop score and failed induction, prolonged labour, and a high caesarean birth rate was first described prior to widespread use of cervical ripening agents [52].

If the cervix is unfavourable cervical ripening should be done for successful induction

Cervical ripening is a complex process that results in physical softening and distensibility of the cervix, leading to cervical effacement and dilatation. Remodelling of the cervix involves enzymatic dissolution.

METHODS USED FOR CERVICAL RIPENING

There are 3 methods used for pre induction cervical ripening

They are

1. Surgical methods

-sweeping/stripping of membranes

-amniotomy or artificial rupture of membranes(ARM)

2. Pharmacological methods

3. Mechanical methods

SWEEPING OF THE MEMBRANES

It can be done as an outpatient procedure

Procedure -finger is inserted in between the membrane and cervix, then fingers swept in 360 degree causes release of prostaglandins(PGF2 alpha) which causes cervix to dilate most effective in multigravida

IMAGE :7 – SWEEPING OF MEMBRANE

The main aim is to initiate labour and improve the favourability of cervix by increasing the local production of prostaglandins.[53]

It is an effective mean of induction in uncomplicated term pregnancy, but less efficient than other methods such as the use of oxytocin, prostaglandins and amniotomy [54,55]. This procedure is a conservative and a non invasive approach, which could be performed in the situations where the indication to induce labor is not immediate or urgent for intervention. Therefore, membrane sweeping may hasten the

35 onset of labor and reduces the number of pregnant women continuing beyond 41 weeks and the need for formal labor induction.

Contraindications:

They are 1.Multiple gestation,

2. Placenta previa,

3. Placental abruption,

4. History of preterm delivery,

5. Vasa previa,

6. Active cervical infection,

7. Mullerian anomalies,

8.severe fetal anomalies and active herpes infection.

A recent Cochrane review showed that routine use of membrane sweeping from 38 weeks onwards does not found to have clinically important benefits [56]. The efficacy of membrane sweeping is found to be low at an earlier gestational age, and the major concern are pregnancies that extending beyond 41 weeks of gestation with unfavorable cervix [56,58]; de Miranda et al [57] noted that the Cochrane

36 review included studies with relatively small sizes, and heterogeneity between the trial results outcome.

AMNIOTOMY

It is a procedure done to release fluid from the amniotic sac to induce labor during childbirth. It is usually performed in a labor or delivery room wherein the obstetrician punctures the amniotic membrane using special instrument.

IMAGE :8 - AMNIOTOMY

INDICATIONS

Induction of labour

For monitoring the health status of fetus(fetal distress) during labour /childbirth

Augmentation of labour

CONTRAINDICATIONS

Placenta praevia[59]

Cephalopelvic disproportion

Abnormal position of the fetus

Active genital herpes infection

Previous classical caesarean section

PROCEDURE

1. First to determine the position and presentation of the fetus

2. Patient should be put on electronic fetal monitoring

3. For this procedure to be effective fetal head should apply sufficient pressure on the cervix.

4. Ask the patient to lie down in dorsal position in labour room, insert a vaginal speculum, amniotomy was done by using amniotomy hook or amni hook in between the uterine contractions

5. After the rupture one hand is placed in the vagina to let the fluid come out in a controlled manner thereby preventing cord prolapse.

Colour and consistency of the liquor was noted.

6. Check the fetal heart rate for one full minute before and after procedure to rule out any fetal distress.

COMPLICATIONS

Cord prolapse

Ruptured vasa praevia

Cord compression

Fetal scalp injury with blood loss

Infection

Chorioamnionitis

After the procedure got over labour can be augmented with oxytocin depends upon the progress of labour.[59,60]

PHARMACOLOGIGAL METHODS

The drugs used for cervical ripening and induction are

1. Prostaglandins – most commonly used

2. Mifepristone- now under many trials

3. Oxytocin –was used for ripening of cervix in the past, nowadays its usage for augmentation is increased rather than ripening.

4. Relaxin

5. Hyaluronidase

6. Nitric oxide donors

- Glyceryl trinitrite

- Isosorbide mononitrate

PROSTAGLANDINS

Prostaglandins are most commonly used for cervical ripening in an unscarred uterus. Prostaglandins not only improve the cervical score but also cause ripening and initiate labour. Thus the need for oxytocin to induce or augment labor is reduced.

The commonly used prostaglandins are

1.PROSTAGLANDIN E1(MISOPROSTOL)

SYNTHESIS OF PROSTAGLANDINS:

They are mainly synthesized from phospholipids by the enzyme phospholipase A2.The flow chart was shown below

IMAGE 9

SYNTHESIS OF PROSTAGLANDINS

It was first discovered by SEARL in 1973 for treating peptic ulcer patients and its effect on pregnant uterus was a major side effect. As time goes on it’s effect on termination of pregnancy and induction of labour has overcome it’s therapeutic value.

DOSAGE:

Vaginal route: 25 microgram of misoprostol in the posterior fornix-repeated every 3-6 hours until adequate uterine contractions

[61,62]

Oral route: 50 microgram once in every 3-6 hours Interval of about

4 hours should be there after the last dose before oxytocin is started.

The side effects are

Nausea

Vomitting

Diarrhoea

Tachysystole

Hyperstimulation.

2.PROSTAGLANDIN E2 (DINOPROSTONE)

It induces cervical ripening.

Reduces failed induction rate and the need for oxytocin.

Shortens the induction –delivery interval.

IMAGE 10

MECHANISM OF ACTION OF PG E2

ROUTE OF ADMINISTRATION

Intracervical –is in the form of preloaded syringe(2.5 ml) with plastic insertor which contains 0.5 mg of PG E2-cervical insertion every 6 hrs maximum of 3 doses in 24 hours interval.[63]

Intravaginal- is in the form of vaginal insert contains 10 mg of

PGE2-easily removed in cases of tachysystole/hyperstimulation.

IMAGE 11

INTRACERVICAL APPLICATION OF PG E2 GEL

In a study comparing group A having prostaglandin E1 with group B having prostaglandin E2 with oxytocin showed the mean induction delivery interval was reduced in group A than group B. A group showed higher number of successful vaginal deliveries(82%) than

B(77%).Tachysystole was more common in A group (20%) than

B(5%)[64].

MIFEPRISTONE{RU 486}

The use of Mifepristone provides an interesting new alternative to classic uterotonic agents for induction of labour. The potential advantages of Mifepristone over prostaglandins or oxytocin requires further evaluation.

Mifepristone is classified as an anti progestin and binds to the progestin receptor without activating it.[65].It is structurally similar to norethindrone(progestin),it binds to the progesterone receptor with affinity equal to or greater than progesterone[66].

Synonym: RU-486; RU-38486; ZK-98296

IMAGE 12

STRUCTURAL FORMULA OF MIFEPRISTONE

11β-[p-(Dimethyla; mino)phenyl]-17α-(1-propynyl)estra-4,9- dien-

17β-ol-3-one dien-17β-ol-3-one

IMAGE 13

THREE DIMENSIONAL STRUCTURE OF MIFEPRISTONE

Pregnancy category: X

Route of administration: oral

Drug class: anti progestogen,anti-glucocorticoid.

PHARMACOKINETICS

Bio availability:69%

Protein binding:98%

Metabolism:Liver catalysed by CYP3A4 enzyme

Excretion:feces and urine

IMAGE 14

MECHANISM OF ACTION OF MIFEPRISTONE

INDICATIONS

1. First and second trimester abortion

2. For emergency contraception at low doses

3. Fibroid uterus-in relief from bleeding and improving quality

of life.

4. Cervical ripening and induction of labour-many trials

supporting the evidence for its use.

5. For treating hyperglycemia secondary to cushing’s

syndrome.

DRUG INTERACTIONS:

Enzyme inhibitors:increases the drug level

Itraconazole/ketoconazole

Erythromycin macrolide

Grapefruit juice

Enzyme inducers:decreases drug level

Carbamazepine/phenytoin/phenobarbitone

Rifampin

Dexamethasone

Aspirin-increases risk of bleeding.

Mifepristone may inhibits the liver enzymes thereby enhancing the drugs which are going to be excreted through liver.

SIDE EFFECTS

Nausea

Vomiting

Diarrhea

Dizziness

Headache

Arthralgia

Back pain

Hypokalemia

Thyroid profile abnormality

Endometrial hypertrophy

Hypoglycemia

Insomnia

Chest pain

Vaginal bleeding or spotting

Fever,chills,weakness

Allergic reactions: hives, dyspnoea, swelling of face, lips,tongue,throat.

Adrenal insufficiency (4%)

MECHANICAL METHOD

They are used for cervical ripening in cases with unfavourable cervix.

1. Transcervial foley’s catheter/double balloon catheter

2. Extra amniotic saline infusion..[EASI]

3. Laminaria tents..

A Foley bulb induction is a method for inducing labor. It involves inserting a Foley catheter into the cervix to help it dilate so that the baby can pass through the birth canal.

A Foley catheter is a long, rubber tube with an inflatable balloon

on one end that a doctor can fill with air or sterile water.

When the balloon inflates inside the cervix, it puts pressure on the cervical cells, helping it dilate and increasing the tissue's response to oxytocin and prostaglandins. Oxytocin and prostaglandins are hormones that help to promote labor.

IMAGE 15

FOLEY’S CATHETER

A Foley bulb induction is a safe procedure. There is no evidence of increased risks for infection. Serious complications for the woman and baby are also rare.

There are advantages and disadvantages to this approach, so people should thoroughly discuss the decision to have a Foley bulb induction with their doctor.

The benefits of using a Foley bulb induction include that it is: low-cost low-risk in most people simple to use

widely available

Side effects:

Pain

Discomfort

Prelabour of membranes

Vaginal bleeding

Infection rarely.

Procedure

The typical Foley bulb induction procedure includes the following steps:

A doctor will monitor the baby's heart rate for at least 20 minutes.

They will confirm that the baby is in a head-down (vertex) position.

The medical team will help the woman move into the lithotomy position,

53 which involves her lying on her back with her legs in special stirrups.

The doctor will clean the perineal area using a medical solution.

Using forceps, they will move the tip of the Foley catheter through the opening in the cervix. The balloon will be just beyond the cervix, but outside the amniotic sac.

They will fill the Foley balloon with about 30 milliliters of sterile water.Doctors may tape the Foley catheter to the woman's thigh to create dragging tension.

The doctor may put more sterile water into the Foley balloon to help the cervix dilate further as time goes on.The Foley balloon will usually fall out when the cervix has dilated 3 centimeters

IMAGE 16

CERVICAL EFFACEMENT AND DILATATION

Nasreen nor et al compared the foley’s catheter with misoprostol for labour induction .the induction to delivery interval was shortened in misoprostol induction group when compared to foley’s group and also

55 increased vaginal delivery in unripe cervix at term. With foley’s catheter incidence of uterine hyperstimulation during labour was decreased.

COOK’S DOUBLE BALLOON TRANSCERVICAL CATHETER

The Cook Cervical Ripening Balloon catheter is comprised of two silicone balloons and uniquely engineered to allow the cervix to naturally and gradually dilate prior to the induction of labor. The first of two balloons is inflated on the uterine side of the cervix; the second is then inflated in the vaginal side of the cervix.

The two balloons adapt to the contour of the cervical canal minimizing discomfort for the patient. When the catheter is removed, cervical conditions should have improved to a favorable state to allow for induction of labor and active labor management.

IMAGE 17

DOUBLE BALLOON CERVICAL CATHETER

IMAGE 18

INSERTION OF DOUBLE BALLOON CATHETER

3.LAMINARIA TENTS

It is a type of osmotic dilator used to dilate the cervix by swelling as they absorbs fluid from the surrounding tissue.[67].A laminaria tent or stick is a thin rod made of the stems of dried laminaria plant[68]

IMAGE 19

IMAGE OF A LAMINARIA TENTS

PROCEDURE

A speculum is placed in the vagina to allow visualization uterine cervix. Anterior lip of the cervix is grasped by a vulsellum to straighten the cervical canal and steady the cervix. It is performed by giving paracervical block. The dilator is then grasped with a ring forceps and is placed into the cervix spanning both the internal and external cervical os.

After sometime, the dilator absorbs fluid and swells 3 to 4 times the initial diameter.[69] this increase in size occurs within 6 hours after the dilator are placed in the cervix, then expansion will continue over 12–24 hours.[70] Depends upon the degree of cervical dilation more than one dilator can be inserted . This may be affected by the gestational age of the pregnancy and history of prior vaginal deliveries. The number of dilators increases with advancing gestational age. Laminaria tents are usually left in place overnight.[71][72]

IMAGE 20

INSERTION OF LAMINARIA TENT

MECHANISM OF ACTION

It acts by absorbing fluid from the surrounding tissue and expanding. Thus exerts radial pressure on the cervix. They also cause the release of prostaglandins.[73]

REMOVAL

After they have started the process of dilating the cervix it was removed prior to initiating the D&E by grasping the strings of the dilator and applying gentle traction. The cervix may be dilated further using rigid cervical dilators [74]

INDICATION

1.surgical abortion prior to D&E

2.cervical ripening in late pregnancy

3.gynecological procedures like hysteroscopy in non pregnant uterus

COMPLICATIONS

1. Pain during insertion

2. Rupture of membranes

3. Cervical /uterine perforation, infection due to its retention

MATERIALS AND METHODS

Study design - Randomised control study

Study place - Department of obstetrics and gynaecology,

Coimbatore medical college hospital

Study duration - Jan 2018 to Dec 2018

Inclusion criteria

• Post dated pregnant women

• Singleton pregnancy

• Cephalic presentation

Exclusion criteria

• Hypertension

• Diabetes mellitus

• Multiple pregnancy

• Renal disease

• Heart disease complicating pregnancy

• Oligohydramnios

• FGR

• Big baby

• Contracted pelvis

Sample size

200

Study design

During the period from Jan 2018 to Dec 2018,patients coming to

Obstetrics and Gynaecology department in Coimbatore medical college hospital based on the inclusion and exclusion criteria were enrolled in the study.

All patients were explained about the study and informed written consent was obtained from them in the language of convenience.

A detailed history including patient’s age, parity, socioeconomic status, menstrual, medical history, obstetric history, past history noted.

General examination, systemic and obstetric examination done.

Routine investigations like complete blood count, urine routine, blood grouping,,HIV, HbsAg, VDRL, Blood sugar and Ultrasound was done.

Study population were randomized into two groups. One group of patients were treated with Tab. Mifepristone 200 mg orally. Another group treated with foley’s catheter for induction of labor.

The following results were observed after 24 hours

1.change in the bishop’s score

2.mode of delivery

3.induction delivery interval

4.neonatal outcome

5.incidence of PPH

Based upon the results, need for further augmentation by either prostaglandin gel induction or amniotomy or oxytocin acceleration was taken into consideration for safe delivery.

OBSERVATION AND RESULTS

The following pages are the tables and graphs which gives us the descriptive analysis of 200 patients in the study according to the distribution, age, parity, mode of delivery, induction -delivery interval, neonatal outcome, amount of blood loss.

TABLE 2

DISTRIBUTION OF STUDY PARTICIPANTS

Induction types Frequency Percentage (%)

MIFEPRISTONE 100 50.0

FOLEY 100 50.0

Total 200 100.0

In this study,100 patients were induced with mifepristone, another

100 patients were induced with foley’s catheter

CHART 2

DISTRIBUTION OF STUDY PARTICIPANTS

Distribution of study participants

MIFEPRISTONE 50% 50% FOLEY

TABLE 3

MEAN AGE OF THE STUDY GROUP

Induction types N Mean SD P value

MIFEPRISTONE 100 24.54 3.940 AGE .356

FOLEY 100 25.01 3.211

A total of 200 patients were included in the study.The mean age of the patients taking part in this study was around 24-25 years.

CHART 3

MEAN AGE OF THE STUDY GROUP

Mean age

25.01 25.1

24.9

24.8

24.7 24.54

24.6

24.5

24.4

24.3 MIFEPRISTONE FOLEY

TABLE 4

ASSOCIATION OF PARITY WITH TYPE OF INDUCTION

PARITY INDUCTION

P value MIFEPRISTONE FOLEY

Primi gravida 63(46.7%) 72(53.3%) .174 Multi gravida 37(56.9%) 28(43.1%)

In this study out of 200 patients,100 patients were induced with

tab.mifepristone and 100 patients were induced wth foley’s catheter.

In mifepristone group out of 100, 46.7% was primigravida and

56.9% was multigravida.

In foley’s catheter group,out of 100,53.3% was primigravida and

43.1% was multigravida

CHART 4

ASSOCIATION OF PARITY WITH TYPE OF INDUCTION

Association of Parity with type of Induction

80 72 70 63 60 50 37 MIFEPRISTONE 40 28 FOLEY 30 20 10 0 Primi gravida Multi gravida

TABLE 5

ASSOCIATION OF MODE OF DELIVERY WITH TYPE OF INDUCTION

TYPE OF MODE OF DELIVERY

INDUCTION P value LABOUR LSCS NATURAL

MIFEPRISTONE 84(84.0%) 16(16.0%) .005* FOLEY 67(67.0%) 33(33.0%)

*-P is <0.05 and found to be Statistically Significant

In this study ,association of mode of delivery with the type of induction was studied.In mifepristone group,84 % of patients deliver by labour natural compared to 67% in foley catheter group. The rate of caesarean section rate was only 16% in mifepristone group than compared to foley group which was 33%.This reduction in the rate of caesarean section among the two groups were found to be significant(p value<0.05).

CHART 5

ASSOCIATION OF MODE OF DELIVERY WITH TYPE OF INDUCTION

Association of Mode of delivery with Type of Induction

84 90 80 67 70 60 Labour natural 50 LSCS 40 33 30 16 20 10 0 MIFEPRISTONE FOLEY

TABLE 6

ASSOCIATION OF DURATION OF DELIVERY WITH TYPE OF INDUCTION

INDUCTION N MEAN SD TYPES P value

100 26.85 8.169 INDUCTION MIFEPRISTONE .000* -DELIVERY INTERVAL IN HRS 100 36.01 6.118 FOLEY

*-P is <0.05 and found to be Statistically Significant

This study showed that there was a significant reduction in induction – delivery interval in mifepristone group compared to foley’s catheter group.The mean induction to delivery interval was 26 hours as compared to 36 hours in foley’s induction group. This decrease in interval between the two groups was found to be significant(p value :

<0.05)

CHART 6

ASSOCIATION OF DURATION OF DELIVERY WITH TYPE OF INDUCTION

Association of duration of delivery with Type of Induction

36.01 40 35 26.85 30 25 20 15 10 5 0 MIFEPRISTONE FOLEY

TABLE 7 ASSOCIATION OF NEONATAL OUTCOME WITH TYPE OF INDUCTION

NEONATAL OUTCOME

INDUCTION TYPES WELL MSAF/VIGOROUS RDS BABY P value

MIFEPRISTONE 9(9.0%) 3(16.0%) 88(88.0%) .028* FOLEY 13(13.0%) 12(12.0%) 75(75.0%)

*-P is <0.05 and found to be Statistically Significant

This study compared the incidence of meconium stained liquor and respiratory distress in newborn born in the study group.

The incidence of meconium stained liquor was 9% in mifepristone group when compared to 13% in the foley’s group. All the babies born with meconium stained liquor are vigorous only.

This decline in the incidence of respiratory distress in newborn was found to be statistically significant (p value: < 0.05%)

CHART 7

ASSOCIATION OF NEONATAL OUTCOME WITH TYPE OF INDUCTION

Association of Neonatal outcome with type of Induction

88 90 75 80

50 MIFEPRISTONE

40 FOLEY

20 13 12 9 10 3

0 MSAF/VIGOROUS RDS WELL BABY

TABLE 8

ASSOCIATION OF BLOOD LOSS WITH TYPE OF INDUCTION

INDUCTION MODE OF DELIVERY TYPES P value Nil Yes

MIFEPRISTONE 0(0.0%) 100(100.0%) .316 FOLEY 1(1.0%) 99(99.0%)

In this study the incidence of PPH was compared between the two groups which was found to be insignificant as the P value >0.05.

CHART 8

ASSOCIATION OF BLOOD LOSS WITH TYPE OF INDUCTION

Association of Blood loss with type of Induction

100 99 100

60 Yes 50 No

10 0 1 0 MIFEPRISTONE FOLEY

DISCUSSION

This observational randomized study was conducted in the

Coimbatore medical college hospital among 200 post dated pregnant mothers planning for induction of labour. There are various methods used for induction of labor. In this study we compare the efficacy of

Tab,Mifepristone with Foley’s catheter for induction of labor. Response to the induction were observed by using various parameters.

Among the 200 patients in the study,100 women were induced with Tab. Mifepristone and another 100 women were treated with Foley’s catheter. In the study group, 135 women are Primigravida and 65 women are multigravida.

The mean age for the women in the study group were in between

24 -25 yrs. There was significant improvement in bishop’s score in the study groups which showed similarities with the studies conducted by

Atawale et al, Fathima et al and Dr.Gautam Aher

The mode of delivery in the women who were enrolled in the study was found to be significant as 84% of patient in mifepristone group delivered vaginally compared to 64% in foley’s induction group.16% patients were undergone caesarean section in mifepristone group as compared to 33% in the foley’s induction group. Similar results were

79 observed in studies conducted by Lata G et al, Rutuja at hawale, Wing

DA.

The mean duration of induction –delivery interval was found to be

26 hours in mifepristone group compared to 36 hours in foley’s group.This was in accordance with study conducted by Kannan Yelikar.

The incidence of respiratory distress in mifepristone group was found to be 3% compared to 12% in foley’s group. There was no significant changes in perinatal outcome as observed in studies conducted by Hapangama and Byrne et al. The incidence of PPH observed in the study was found to be insignificant.

The use of Mifepristone in induction of labor in post dated pregnancy have shown significant reduction in caesarean section rates, shortens the induction –delivery interval, reduction in the incidence of respiratory distress.

SUMMARY

A comparative study to assess the efficacy of Mifepristone with

Foley’s catheter for induction of labor in post dated pregnancies was done in patients admitted in Department of Obstetrics and Gynaecology of a tertiary care centre from Jan 2018 to Dec 2019.A thorough history,LMP, systemic and obstetric examination and basic blood investigations and ultrasound was done. Patients were randomly allocated into two groups.

One treated with Oral Mifepristone 200 mg and another group with

Foley’s catheter. Various parameters were observed after 24 hours of induction.

 Our study included 200 patients out of which 100 were given

mifepristone and another 100 were given foley’s catheter.

 135 women are primigravida and 65 women were multigravida.

 The mean group of the patients in this study were in the range of

24-25 years.

 84% of patient in mifepristone group delivered vaginally

compared to 64% in foley’s induction group.16% patients were

undergone caesarean section in mifepristone group as compared to

33% in the foley’s induction group.

 The mean induction –delivery interval was found to be 26 hours

in mifepristone group compared to 36 hours in foley’s group.

 The incidence of respiratory distress in mifepristone group was

found to be 3% compared to 12% in foley’s group. Majority of

studies showed that there was no significant perinatal morbidity

and mortality in using this drug.

CONCLUSION

Based on the observations made in our study we recommend the following:

• Mifepristone can be used as an inducing agent in post dated

pregnancy due to it’s effect on induction –delivery interval,

mode of delivery, neonatal outcome.

• No significant results were observed in incidence of PPH in

both groups.

• The incidence of meconium stained liquor with fetal distress

needs further follow up with the study.

• Further trials for the use of Mifepristone in inducing labor in

post dated pregnancy and it’s effect in causing tachysystole

and hyperstimulation during induction.

Limitations of the study:

1. The study period and sample size was limited and thus the

results obtained may lack precision.

2. No control group were included in the study.

BIBLIOGRAPHY

1. Delaney M, Roggensack A, Leduc DC, et al. Clinical Practice

Obstetrics Committee; Maternal Fetal Medicine Committee.

Guidelines for the management of pregnancy at 41+0 to 42+0

weeks. J Obstet Gynaecol Can. 2008;30(9):800–823.

2.. Nielson JP. Ultrasound for fetal assessment in early pregnancy

Neilson 2000. Neilson JP. Mifepristone for induction of labour.

Cochrane Database of Systematic Reviews. 2000;(4) DOI:

10.1002/14651858.CD002865. [PubMed] [Google Scholar]

3. Lata G.*, Rana N., Mittal R., Kumar S.mifepristone for cervical

ripening and induction of labour Int J Reprod contracept obstet

gynecol 2018;7:5041-4.

4. Rutuja Athawale, Neema Acharya, S. Samal, C. Hariharan Effect

of mifepristone in cervical ripening for induction of labour Int JRC

OG Home.vol 2 no 1(2013)

5. Kanan Yelikar, Son. Yelikar, S. Deshpande, R. Deshpande,

D. LoneSafety and efficacy of oral mifepristone in pre-induction

cervical ripening and induction of labour in prolonged pregnancyJ

Obstet Gynaecol India, 65 (July (4)) (2015), pp. 221-225

CrossRefView Record in ScopusGoogle Scholar

6. James D. Byrne, term pregnancy. J Perinatol. 2004;24:416–420.

doi: 10.1038/sj.jp.7211127. [PubMed] [CrossRef] [Google

Scholar]

7. Wing DA1, Fassett MJ, Mishell DR. . Mifepristone for

preinduction cervical ripening beyond 41 weeks’ gestation: a

randomized controlled trial. Obstet Obstet Gynecol. 2000;96:543–

548. doi: 10.1016/S0029-7844(00)00947-9. [PubMed]

[CrossRef] [Google Scholar]

8. D. Hapangama, J.P. NeilsonMifepristone for induction of labour

Cochrane Database Syst Rev (3) (2009),

10.1002/14651858.CD002865.pub2 Art. No.: CD002865 Google

Scholar

9. Athawale R, Acharya N, Samal S, et al. Effect of mifepristone in

cervical ripening for induction of labour. Int J Reprod Contracept

Obstet Gynecol. 2013;2(1):35–38. doi: 10.5455/2320-

1770.ijrcog20130206. [CrossRef] [Google Scholar]

10. Fathima S, Nayak SR, Rao B, et al. Mifepristone in induction of

labour at term. Int J of Pham Biomed Res. 2013;4(3):164–

166. [Google Scholar]

11. Dr.Purva Reelkar1, Dr. Anita Solunke2, Dr.Gautam Aher3*, Dr.

Mrs. Urmila Shinde4 Study of Use of Single Dose of Oral

Mifepristone in Induction of LabourPublished: 30.04.2018 DOI:

10.21276/sjams.2018.6.4.85 Sch. J. App. Med. Sci. ISSN 2347-

954X

12. Dharani H, James PN. Mifepristone for induction of

labour(review). Chochrane Database Syst Rev. 2009; 3, Art. No.

CD002865. [PMC free article] [PubMed].

13. Dixit, B., Manandhar, T., Sitaula, S., & Basnet, T. (2018).

Induction of Labor in Post Dated Pregnancy with Intra-cervical

Foley Catheter in Antenatal Ward. Birat Journal of Health

Sciences, 3(1), 338-341. https://doi.org/10.3126/bjhs.v3i1.19737

14. W Chen J Xue MK Peprah SW Wen M Walker Y Gao Y Tang.

A systematic review and network meta‐analysis comparing the use

of Foley catheters, misoprostol, and dinoprostone for cervical

ripening in the induction of labour . BJOG: An International

Journal of Obstetrics & GynaecologyVolume 123.

First published: 05 November 2015

https://doi.org/10.1111/1471-0528.13456

15. Mieke L. ten Eikelder;Kelly Mast;Annemarie van der Velden;Kitty

W. Bloemenkamp;Ben Mol; Induction of Labor Using a Foley

Catheter or Misoprostol: A Systematic Review and Meta-analysis

Obstetrical & Gynecological Survey.

10.1097/OGX.0000000000000361 , 71(10):620–630,( 2016)

16. panel W.L.Martin a f 1S.P.Hutchon. Mechanism and management

of normal labour Current obstetrics and gynecology vol

11,Issue5,2001 https://doi.org/10.1054/cuog.2001.0194

17. Andrés López Bernal Mechanisms of labour—biochemical aspects

BJOG: An International Journal of Obstetrics &

GynaecologyVolume 110, Issue s20 , 22 December

2003,https://doi.org/10.1046/j.1471-0528.2003.00023.x

18. Norman Kimbell Brandt-Andrews Technique of Delivery of the

Placenta r Med J. 1958 Jan 25; 1(5064): 203–204.

doi: 10.1136/bmj.1.5064.203.

19. Lydon-Rochelle, M. T., Cardenas, V., Nelson, J. C., Holt, V. L.,

Gardella, C. and Easterling, T. R. Induction of labor in the absence

of standard medical indications: incidence and correlates. Med

Care 2007; 45:505-512

20. Rayburn, W. F. and Zhang, J. Rising rates of labor induction:

present concerns and future strategies. Obstet Gynecol 2002;

100:164-167.

21. Mealing NM, Roberts CL, Ford JB, Simpson JM, Morris JM.

Trends in induction of labour, 1998-2007: a population-based

study. Aust N Z J Obstet Gynaecol2009;49:599-605

22. BMJ 2012;344:e2838 Outcomes of elective induction of labour

compared with expectant management: population based study

23. Yeast, J. D., Jones, A., & Poskin, M. (1999). Induction of labor and

the relationship to cesarean delivery: a review of 7001 consecutive

inductions. American Journal of Obstetrics and Gynecology,

180(3),

24. Vrouenraets, F. P., Roumen, F. J., Dehing, C. J., van den Akker, E.

S., Aarts, M. J., & Scheve, E. J. (2005). Bishop score and risk of

cesarean delivery after induction of labor in nulliparous women.

Obstetrics & Gynecology, 105(4), 690-697

25. Roos N, Sahlin L, Ekman-Ordeberg G, Kieler H, Stephansson O.

Maternal risk factors for postterm pregnancy and cesarean delivery

following labor induction. Acta Obstet Gynecol Scand.

2010;89(8):1003–1010

.26. Arrowsmith S, Wray S, Quenby S. Maternal obesity and labour

complications following induction of labour in prolonged

pregnancy. BJOG. 2011;118(5):578–588 al in Ile-lfe, Nigeria. J

Obstet Gynaecol. 2002;22(3):283-286. doi pubmed

27 e. Olesen AW, Basso O, Olsen J. Risk of recurrence of prolonged

pregnancy. BMJ. 2003;326(7387):476.

28. Morken NH, Melve KK, Skjaerven R. Recurrence of prolonged

and post-term gestational age across generations: maternal and

paternal contribution. BJOG. 2011;118(13):1630–1635.

29. Oberg AS, Frisell T, Svensson AC, Iliadou AN. Maternal and fetal

genetic contributions to postterm birth: familial clustering in a

population-based sample of 475,429 Swedish births. Am J

Epidemiol. 2013;177(6):531–537

30. ACOG Committee on Practice Bulletins–Obstetrics. ACOG

practice bulletin. Clinical management guidelines for obstetricians-

gynecologists. Number 55, September 2004 (replaces practice

pattern number 6, October 1997). Management of postterm

pregnancy. Obstet Gynecol. 2004;104(3):639–646.

31. Baskett T. F., Nagele F. (2000). Naegele's rule: A reappraisal.

BJOG: An International Journal of Obstetrics & Gynaecology,

107(11), 1433-1435. doi:10.1111/j.1471-0528.2000.tb11661.x

[Context Link]

32. American College of Obstetricians and Gynecologists, American

Institute of Ultrasound Medicine, & Society for Maternal-Fetal

Medicine. (2014). Method for estimating due date (ACOG

Committee Opinion No. 611). Obstetrics and Gynecology, 124(4),

863-866. doi:10.1097/01.AOG.0000454932.15177.be [Context

Link]

33. WHO recommendations for induction of labour, World Health

Organization 2011O ISBN 978 92 4 150115 6

34. Zeitlin J, Blondel B, Alexander S, Breart G. Variation in rates of

post term birth in Europe: reality or artifact? BJOG. 2007;

114:1097–103.

35. Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy:

evaluating gestation-specific risks of fetal and infant mortality.Br J

Obstet Gynaecol. 1998; 105:169–73.

36. Clinical Guidelines for Diagnosis and Treatment of Common

Conditions in Kenya. October, 2002 Nairobi, Kenya. ON-LINE

ACCESS:

http://collections.infocollections.org/whocountry/en/d/Jh4329e/

(Accessed on 14/12/13)

37. ACOG Guidelines on Management of Post-term Pregnancy :2004

Dec 1;70(11):2221-2225. ON-LINE ACCESS

www.aafp.org/afp/2004/1201/p2221.html (Accessed on

14/12/2013)

38. NICE clinical guideline 70 : Induction of labour JULY 2008. ON-

LINE ACCESS

www.nice.org.uk/nicemedia/live/12012/41256/41256.pdf

(Accessed on 14/12/13)

39. Anne Biringer, Lily Lee, Jessica Dy, Dean Leduc, Induction of

labour, SOGC CLINICAL PRACTICE GUIDELINES-S No. 296,

September 2013

40. Olesen AW, Westergaard JC, Olesen J. Perinatal and maternal

complications related to pos-term delivery: a national register-

based study, 1978-1993. Am J Obstet Gynecol, 2003; 189:222-7

41. Sanchez-Ramos, L., Olivier, F., Delke, I., & Kaunitz, A. M.

(2003). Labor induction versus expectant management for post

term pregnancies: a systematic review with meta-analysis.

Obstetrics & Gynecology, 101(6), 1312-1318

42. Caughey AB, Stotland NE, Washington AE, et al. Maternal and

obstetric complications of pregnancy associated with increasing

gestational age at term. Am J Obs/ Gyn 2007; 196:155-155?

43. Arias, F. (1987). Predictability of complications associated with

prolongation of pregnancy. Obstetrics and gynecology, 70(1), 101

44. Vorherr, H. (1975). Placental insufficiency in relation to postterm

pregnancy and fetal postmaturity. Evaluation of fetoplacental

function; management of the post term gravida. American journal

of obstetrics and gynecology, 123(1), 67.

45. Clifford, S. H. (1954). Post maturity—with placental dysfunction:

Clinical syndrome and pathologic findings. The Journal of

pediatrics, 44(1), 1-13

46. Divon, M. Y., Haglund, B., Nisell, H., Otterblad, P. O., &

Westgren, M. (1998). Fetal and neonatal mortality in the post term

pregnancy: the impact of gestational age and fetal growth

restriction. American journal of obstetrics and gynecology, 178(4),

726-731.

47. Yudkin PL, Wood L, Redman CWG. Risk of unexplained stillbirth

at different gestational ages. Lancet 1987; 1: 1192–1194.

48. T.A. Bruckner, Y.W. Cheng, A.B. CaugheyIncreased neonatal

mortality among normal-weight births beyond 41 weeks of

gestation in California Am J Obstet Gynecol, 199 (October

(4)) (2008), pp. 421-427

49. Gonen, R., Degani, S., & Ron, A. (1998). Prediction of successful

induction of labor: comparison of transvaginal ultrasonography and

the Bishop score. European Journal of Ultrasound, 7(3), 183-187.

50. Bishop, E. H. Pelvic Scoring for Elective Induction. Obstet

Gynecol 1964; 24:266-268 32.

51. American College of Obstetricians and Gynecologists. Induction of

labor. Practice bulletin no. 10. Washington, D.C.: ACOG, 1999;

.www.ohsu.edu//obgyn//ACOG (Accessed on 9/12/13)

52. Arulkumaran, S., Gibb, D. M., TambyRaja, R. L., Heng, S. H. and

Ratnam, S. S. Failed induction of labour. Aust N Z J Obstet

Gynaecol 1985; 25:190-193

53. A.B. Caughey, N.E. Stotland, A.E. Washington, G.J. Escobar

Maternal and obstetric complications of pregnancy are associated

with increasing gestational age at term Am J Obstet

Gynecol, 196 (February (2)) (2007), pp. 155-156

54. Wong SF, Hui SK, Choi H, Ho LC. Does sweeping of membranes

beyond 40 weeks reduce the need for formal induction of labour?

BJOG. 2002;109(6):632-636. doi pubmed

55. Dare FO, Oboro VO. The role of membrane stripping in prevention

of post-term pregnancy: a randomised clinical tri

56. Boulvain M, Stan C, Irion O. Membrane sweeping for induction of

labour. Cochrane Database Syst Rev. 2005;(1):CD000451.

pubmed

57. de Miranda E, van der Bom JG, Bonsel GJ, Bleker OP, Rosendaal

FR. Membrane sweeping and prevention of post-term pregnancy in

low-risk pregnancies: a randomised controlled trial. BJOG.

2006;113(4):402-408.

58. Putnam K, Magann EF, Doherty DA, Poole AT, Magann MI,

Warner WB, Chauhan SP. Randomized clinical trial evaluating the

frequency of membrane sweeping with an unfavorable cervix at 39

weeks. Int J Womens Health. 2011;3:287-294.

59. Cunningham, Levano, Bloom, Hauth, Rouse, Spong.

Abnormalities of the Placenta, Umbilical Cord and Membranes.

Williams Obstetrics. 23rd. United States: McGraw-Hill; 2010.

Chapter 27.

60. Nachum Z, Garmi G, Kadan Y, Zafran N, Shalev E, Salim R.

Comparison between amniotomy, oxytocin or both for

augmentation of labor in prolonged latent phase: a randomized

controlled trial. Reprod Biol Endocrinol. 2010. 8:136.

61. Farah LA, Sanchez-Ramos L, Rosa C, Valle GO, Graudier LF,

Kaunitz MA. Randomized trial of two doses of prostaglandins Ei

analogue misoprostol for labour induction. Am J Obstet Gynecol.

1997;177:364–369. [PubMed] [Google Scholar]

62. Adiar CD, Jonathan WW, Scott B, Michael E, Budison K,

David FL. Oral or vaginal misoprostol administration for induction

of labour: A randomized double blind trial. Obstet Gynecol.

1998;92:810–813. [PubMed] [Google Scholar]

63. Sanchez-Ramos L, Peterson DE, Delke I, Gaudier LF, Kaunitz

MA. Labour induction with prostaglandins E1 compared with

dinoprostone vaginal insert; A randomized trial. Obstet Gynecol.

1998;91:3,401–3,405. [PubMed] [Google Scholar]

64. sushil kumar,RT awasthi,A kapur,#S Srinivas,#Hetal parikh,Dr,and

Shoba sarkar Dr.Med J Armed Forces India 2001 april;57(2):107-

109

65. Herrmann WL, Schindler AM, Wyss R, Bischoff P. Effects of the

antiprogesterone RU 486 in early pregnancy and during the

menstrual cycle. In: Beaulieu EE, Siegel S, eds. The Antiprogestin

Steroid RU 486 and Human Fertility Control. New York, NY:

Plenum; 1985:259-262.

66. Gravanis A, Schaison G, George M, et al. Endometrial and

pituitary responses to the steroidal anti-progestin RU 486 in post-

menopausal women. J ClinEndocrinolMetab. 1984;60:156-163.

67. "Cervical (Osmotic) Dilator". MyHealth.Alberta.ca.

Government of Alberta. Retrieved 6 August 2019.

68. "Dilateria - Laminaria - for Cervical Dilation". Cooper Surgical.

Retrieved 2019-07-09.

69. Newmann, Sara J.; Dalve-Endres, Andrea; Diedrich, Justin T.;

Steinauer, Jody E.; Meckstroth, Karen; Drey, Eleanor A. (2010-08-

04). "Cervical preparation for second trimester dilation and

evacuation". The Cochrane Database of Systematic Reviews (8):

CD007310. doi:10.1002/14651858.CD007310.pub2. ISSN 1469-

493X. PMID 20687085.

70. a b Fox, Michelle C.; Krajewski, Colleen M. (February 2014).

"Cervical preparation for second-trimester surgical abortion prior

to 20 weeks' gestation: SFP Guideline #2013-4". Contraception. 89

(2): 75–84. doi:10.1016/j.contraception.2013.11.001. ISSN 1879-

0518. PMID 24331860

71. "Laminaria (Cervical Dilator) by Medgyn Products, Inc".

www.medline.com. Retrieved 2019-07-23

72. a b Lerma, Klaira; Blumenthal, Paul D. (2019-05-25). "Current

and potential methods for second trimester abortion". Best Practice

& Research Clinical Obstetrics & Gynaecology.

`doi:10.1016/j.bpobgyn.2019.05.006. ISSN 1521-6

73. Gelber, Shari; Sciscione, Anthony (September 2006). "Mechanical

methods of cervical ripening and labor induction". Clinical

Obstetrics and Gynecology. 49 (3): 642–657. ISSN 0009-9201.

PMID 16885669. 934

74. Rebecca H Alen,Alisa B. Goldberg cervical dilatation before first

trimester surgical abortion (<14 weeks)http://dx.doi.org/10.1016/j.

contraception.2015.12.001

PROFORMA

Name : Age : Address :

Occupation :

Booked and immunized:

LMP: EDD:

Chief Complaints:

● H/O amenorrhoea ● Able to perceive fetal movements ● Any H/o bleeding /draining PV ● Any signs and symptoms of PIH,fever,urinary tract infection ● Menstrual H/O:

Marital H/O :

Past H/O :

Personal H/O :

Family H/O :

General Physical Examinaton:

Built and Nourishment

Anemia / Cyanosis / clubbing / Icterus / Pedal edema / generalised lymphadenopathy

Breast ,Thyroid ,Spine examination

Height: Weight: BMI:

Vitals

● BP : ● PR :

● RR :

Systemic Examination:

● CVS : ● RS : ● CNS : ● Abdomen examination Inspection Palpation Auscultation Per vaginal examination INVESTIGATION

 Complete Hemogram :

● Blood Sugar :

● RFT :

● LFT :

● Urine routine :

● USG Obstetrics :

CONSENT FORM

I Mrs______hereby volunteer to participate in the study ”A RANDOMIZED COMPARATIVE STUDY OF

MIFEPRISTONE WITH FOLEY’S CATHETER FOR

INDUCTION OF LABOUR IN POST DATED PREGNANCY”. I was fully explained about the nature of the study by the doctor, knowing which I fully give my consent to participate in this study

Date:

Place:

Signature of the patient / guardian

100

ஒத பவ

ெபய :

வய :

பான :

கவாி:

ேகாைவ அர மவகாி மவமைனயி மவ kh.jpt;ah தைலைமயி நைடெப இத ஆவி சமதட கலெகாள சமதிகிேற .இத ஆவி எைன பறி விவரகைள பாகாட இத ஆவி ெவளியிட ஆேசபைண இைல எ ெதாிவி ெகாகிேற .எத ேநரதி ஆவி இ எத ேநரதி விலகிெகா உாிைம உ எ அறிேவ .

இட :

ேததி:

101

INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

1 HEMA 25 20989 G2P1L1 40+1 MIFEPRISTONE LABOUR NATURAL 17 WELL BABY YES -

2 SANGEETHA 23 21028 G3P2L2 40+1 MIFEPRISTONE LABOUR NATURAL 16 WELL BABY YES -

3 DHARSHINI 18 22661 PRIMI 40+2 MIFEPRISTONE LABOUR NATURAL 14 WELL BABY YES -

4 KASTHURI 22 22727 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 18 WELL BABY YES -

5 RANI DEVI 24 26043 PRIMI 40+4 MIFEPRISTONE LABOUR NATURAL 15 WELL BABY YES -

6 AMEENA 23 26797 G3P1L1A1 40+1 MIFEPRISTONE LABOUR NATURAL 14 WELL BABY YES -

7 AMIRTHA ROSY 20 26130 PRIMI 40+3 MIFEPRISTONE LABOUR NATURAL 19 WELL BABY YES -

8 SAMPOORNA 24 29290 G3P2L2 40+5 MIFEPRISTONE LABOUR NATURAL 10 WELL BABY YES -

9 DURGA DEVI 31 26330 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 19 WELL BABY YES -

10 KOKILA 24 30175 G3P1L1A1 40+4 MIFEPRISTONE LABOUR NATURAL 15 WELL BABY YES -

11 INDHUMATHI 29 30424 PRIMI 40+6 MIFEPRISTONE LABOUR NATURAL 18 WELL BABY YES -

12 MALLIGA 19 30464 PRIMI 40+2 MIFEPRISTONE LABOUR NATURAL 14 WELL BABY YES -

13 NANDHINI 24 32612 G2P1L1 40+3 MIFEPRISTONE LABOUR NATURAL 18 WELL BABY YES -

14 RAMYA 15 31076 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 16 WELL BABY YES -

15 KABEETHA 24 32324 G2P1L1 40+3 MIFEPRISTONE+GEL LABOUR NATURAL 18 MSAF/VIGOROUS YES -

16 SIRAJ BANU 21 34373 PRIMI 40+2 MIFEPRISTONE+GEL LSCS 36 MSAF/VIGOROUS YES -

17 PORNESWARI 23 50428 G2P1L1 40+4 MIFEPRISTONE LABOUR NATURAL 12 WELL BABY YES -

18 SARADHA 22 36268 PRIMI 40+2 MIFEPRISTONE LSCS 38 WELL BABY YES -

19 NADHIYA 24 34567 G2P1L1 40+4 MIFEPRISTONE LABOUR NATURAL 12 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

20 MEENA 21 34441 PRIMI 41 MIFEPRISTONE LSCS 30 WELL BABY YES -

21 RAJI 28 35618 PRIMI 40+2 MIFEPRISTONE LABOUR NATURAL 32 WELL BABY YES -

22 KANAGA 23 35214 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 22 WELL BABY YES -

23 BHUVANA 26 34789 G2P1L1 40+5 MIFEPRISTONE LABOUR NATURAL 20 WELL BABY YES -

24 JULIE 27 35124 G3P2L2 40+2 MIFEPRISTONE LABOUR NATURAL 14 WELL BABY YES -

25 VINITHA 20 34110 G4P1L1A2 40+5 MIFEPRISTONE LABOUR NATURAL 22 WELL BABY YES -

26 DEEPA 24 39875 PRIMI 40+6 MIFEPRISTONE+GEL LSCS 34 RDS YES -

27 BAIRAVI 28 36741 G2P1L1 40+1 MIFEPRISTONE LABOUR NATURAL 22 MSAF/VIGOROUS YES -

28 SAKTHI 21 35991 PRIMI 40+3 MIFEPRISTONE LABOUR NATURAL 36 WELL BABY YES -

29 DHARANYA 27 36421 G3P1L1A1 40+4 MIFEPRISTONE+SYNTOLABOUR NATURAL 16 WELL BABY YES -

30 HARINI 23 37854 G2P1L1 40+1 MIFEPRISTONE LABOUR NATURAL 19 WELL BABY YES -

31 KOKILA 18 38492 PRIMI 40+5 MIFEPRISTONE LABOUR NATURAL 30 WELL BABY YES -

32 CELINE 18 35668 PRIMI 40+3 MIFEPRISTONE+GEL LSCS 32 WELL BABY YES -

33 MUMTAJ 21 34612 G2A1 40+1 MIFEPRISTONE+SYNTOLABOUR NATURAL 41 WELL BABY YES -

34 LILY 26 33789 G2P1L1 40+5 MIFEPRISTONE LABOUR NATURAL 26 WELL BABY YES -

35 SARASU 22 35420 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 36 WELL BABY YES -

36 NIROSHA 20 36741 G3P2L2 40+5 MIFEPRISTONE LABOUR NATURAL 16 WELL BABY YES -

37 MULLAI 29 36888 PRIMI 40+2 MIFEPRISTONE LABOUR NATURAL 38 WELL BABY YES -

38 DHANAM 30 38164 PRIMI 40+6 MIFEPRISTONE LABOUR NATURAL 38 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

39 BAKKIYAM 34 38559 PRIMI 40+2 MIFEPRISTONE+GEL LABOUR NATURAL 26 WELL BABY YES -

40 SASI 35 31684 PRIMI 40+5 MIFEPRISTONE+GEL LABOUR NATURAL 30 WELL BABY YES -

41 ARUNA 29 39403 G2P1L1 40+2 MIFEPRISTONE LABOUR NATURAL 20 WELL BABY YES -

42 MOHANAPRIYA 26 39761 PRIMI 40+2 MIFEPRISTONE+GEL LSCS 33 RDS YES -

43 RASATHI 20 39264 PRIMI 40+6 MIFEPRISTONE LABOUR NATURAL 34 WELL BABY YES -

44 BHUVANA 21 39521 PRIMI 40+4 MIFEPRISONE+SYNTO LABOUR NATURAL 30 WELL BABY YES -

45 SUGANYA 28 39624 PRIMI 40+5 MIFEPRISTONE+GEL LSCS 36 WELL BABY YES -

46 THULIR 26 39220 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 32 WELL BABY YES -

47 PRAVEENA 24 36746 G2A1 40+1 MIFEPRISTONE+GEL LABOUR NATURAL 28 MSAF/VIGOROUS YES -

48 GAYATHRI 28 38931 PRIMI 40+2 MIFEPRISTONE+GEL LABOUR NATURAL 31 WELL BABY YES -

49 NASRIN 27 39730 PRIMI 40+5 MIFEPRISTONE LABOUR NATURAL 38 WELL BABY YES -

50 LAILA 24 39772 G3P1L1A1 40+4 MIFEPRISTONE LABOUR NATURAL 24 WELL BABY YES -

51 VIDHYA 21 39333 PRIMI 40+6 MIFEPRISTONE LABOUR NATURAL 24 WELL BABY YES -

52 JANAKI 21 39451 G4P2L2A1 40+4 MIFEPRISTONE LABOUR NATURAL 21 WELL BABY YES -

53 KARTHIGA 27 36748 PRIMI 40+5 MIFEPRISTONE LABOUR NATURAL 34 WELL BABY YES -

54 MANIYAL 20 36550 PRIMI 40+2 MIFEPRISTONE+GEL LSCS 32 WELL BABY YES -

55 UTHRA 30 36721 PRIMI 40+5 MIFEPRISTONE LABOUR NATURAL 36 WELL BABY YES -

56 GOMATHI 21 39337 G2P1L1 40+4 MIFEPRISTONE LSCS 40 WELL BABY YES -

57 FARINA BANU 23 39000 PRIMI 40+4 MIFEPRISTONE LABOUR NATURAL 28 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

58 KAJAL 27 38971 PRIMI 40+5 MIFEPRISTONE+GEL LABOUR NATURAL 29 MSAF/VIGOROUS YES -

59 MINUTHIROY 26 39881 G3P1L1A1 40+2 MIFEPRISTONE LABOUR NATURAL 20 WELL BABY YES -

60 JANANI 24 39000 G2P1L1 40+1 MIFEPRISTONE LABOUR NATURAL 18 WELL BABY YES -

61 BUELA 28 39657 PRIMI 40+6 MIFEPRISTONE LABOUR NATURAL 34 WELL BABY YES -

62 THIRUMAGAL 21 39886 PRIMI 40+3 MIFEPRISTONE+GEL LSCS 31 MSAF/VIGOROUS YES -

63 DANYA 32 39994 PRIMI 40+1 MIFEPRISTONE+GEL LABOUR NATURAL 32 WELL BABY YES -

64 MALAR 27 39624 G2A1 40+5 MIFEPRISTONE LABOUR NATURAL 31 WELL BABY YES -

65 RITHANYA 30 40871 PRIMI 40+5 MIFEPRISTONE+GEL LABOUR NATURAL 30 WELL BABY YES -

66 SATYAPRIYA 21 41657 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 29 WELL BABY YES -

67 CINDRELLA 27 40001 G2P1L1 40+2 MIFEPRISTONE LABOUR NATURAL 20 WELL BABY YES -

68 SINDHU 26 40987 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 35 WELL BABY YES -

69 GUNA 24 40883 PRIMI 40+1 MIFEPRISTONE+GEL LSCS 36 RDS YES -

70 RANI 21 40265 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 38 WELL BABY YES -

71 VIJI 23 41000 G3P1L1A1 40+5 MIFEPRISTONE+SYNTOLABOUR NATURAL 28 WELL BABY YES -

72 LAKSHMI 26 41267 PRIMI 40+3 MIFEPRISTONE LABOUR NATURAL 39 WELL BABY YES -

73 LEELAVATHY 26 41337 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 30 WELL BABY YES -

74 MOHANA 27 41865 G2A1 40+2 MIFEPRISTONE+GEL LABOUR NATURAL 31 WELL BABY YES -

75 NATHIYA 24 40330 PRIMI 40+6 MIFEPRISTONE+GEL LSCS 34 WELL BABY YES -

76 FIRTHOSE 20 41756 G3P2L2 40+4 MIFEPRISTONE LABOUR NATURAL 14 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

77 VEENA 20 41912 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 32 WELL BABY YES -

78 CINTHIYA 21 41687 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 34 WELL BABY YES -

79 JEYA 23 42660 PRIMI 40+2 MIFEPRISTONE+GEL LSCS 38 WELL BABY YES -

80 DHINU 26 42335 G3P1L1A1 40+5 MIFEPRISTONE LABOUR NATURAL 24 WELL BABY YES -

81 AKSHAYA 27 42746 PRIMI 40+6 MIFEPRISTONE+GEL LABOUR NATURAL 30 WELL BABY YES -

82 HAJIRA BANU 20 40241 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 36 WELL BABY YES -

83 TAMIL SELVI 30 42563 PRIMI 40+1 MIFEPRISTONE+GEL LABOUR NATURAL 28 WELL BABY YES -

84 GANDHIMATHI 27 40754 G2P1L1 40+2 MIFEPRISTONE LABOUR NATURAL 25 WELL BABY YES -

85 THENMOZHI 21 42658 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 33 WELL BABY YES -

86 PRIYANKA 21 42751 PRIMI 40+1 MIFEPRISTONE+GEL LSCS 36 MSAF/VIGOROUS YES -

87 LILY 26 42576 G2P1L1 40+5 MIFEPRISTONE LABOUR NATURAL 26 WELL BABY YES -

88 JANANI 25 42182 G3P1L1A1 40+5 MIFEPRISTONE LABOUR NATURAL 20 WELL BABY YES -

89 VAISNAVI 26 43100 PRIMI 40+1 MIFEPRISTONE+GEL LABOUR NATURAL 36 WELL BABY YES -

90 SHRUTHI 22 45126 G2P1L1 45+2 MIFEPRISTONE LABOUR NATURAL 18 WELL BABY YES -

91 CHITRA 21 43681 PRIMI 40+1 MIFEPRISTONE+GEL LSCS 40 MSAF/VIGOROUS YES -

92 MAHANADI 24 43658 G2A1 40+3 MIFEPRISTONE+SYNTOLABOUR NATURAL 32 WELL BABY YES -

93 KANALI 28 43691 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 30 WELL BABY YES -

94 TIRUMAGAL 27 43779 PRIMI 40+2 MIFEPRISTONE LABOUR NATURAL 26 WELL BABY YES -

95 POOMANI 21 43865 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 28 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

96 VAISHALI 20 43762 PRIMI 40+1 MIFEPRISTONE LABOUR NATURAL 26 WELL BABY YES -

97 TAMIZHALAGI 35 43990 G2P1L1 40+3 MIFEPRISTONE+SYNTOLABOUR NATURAL 18 WELL BABY YES -

98 BARATHI 32 45780 PRIMI 40+1 MIFEPRISTONE+GEL LSCS 22 MSAF/VIGOROUS YES -

99 SANGEETHA 30 44658 PRIMI 40+1 MIFEPRISTONE+GEL LABOUR NATURAL 30 WELL BABY YES -

100 THENMOZHI 22 20864 PRIMI 40+2 FOLEY+GEL LABOUR NATURAL 38 WELL BABY YES -

101 VIDHYA SRI 27 22541 G2P1L1 40+2 FOLEY+GEL LABOUR NATURAL 32 WELL BABY YES -

102 RITHU KUMARI 24 22981 G2A1 40+6 FOLEY+GEL+SYNTO LABOUR NATURAL 36 WELL BABY YES -

103 FARIDA BANU 23 22675 PRIMI 40+5 FOLEY+GEL+SYNTO LABOUR NATURAL 34 RDS YES -

104 RUKMANI 26 21653 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 38 WELL BABY YES -

105 PORKODI 28 22000 G3P1L1A1 40+2 FOLEY+GEL LABOUR NATURAL 32 WELL BABY YES -

106 AKILA 21 21410 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 42 MSAF/VIGOROUS YES -

107 RENUGA 25 23654 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 34 WELL BABY YES -

108 SEETHA 24 22861 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 32 WELL BABY YES -

109 MONISHA 26 23550 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 34 RDS YES -

110 JEEVITHA 30 23741 G2P1L1 40+5 FOLEY+GEL LABOUR NATURAL 28 WELL BABY YES -

111 KIRTHIKA 27 24668 PRIMI 40+1 FOLEY +GEL+SYNTO LABOUR NATURAL 38 WELL BABY YES -

112 SABITHA 29 25771 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 37 WELL BABY YES -

113 BHARATHI 24 26571 G3P1L1A1 40+5 FOLEY+GEL LABOUR NATURAL 30 WELL BABY YES -

114 NIRANJANA 26 21638 PRIMI 40+1 FOLEY+GEL LSCS 30 MSAF/VIGOROUS YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

115 PRIYANKA 26 22974 G2A1 40+3 FOLEY+GEL LABOUR NATURAL 34 WELL BABY YES -

116 CELINE MARY 28 21335 PRIMI 40+3 FOLEY+GEL LSCS 40 RDS YES -

117 VANI 20 20456 PRIMI 40+5 FOLEY+GEL LABOUR NATURAL 31 WELL BABY YES -

118 HARINI 20 24116 PRIMI 40+3 FOLEY+GEL+SYNTO LABOUR NATURAL 38 WELL BABY YES -

119 THARANI 21 25339 G2P1L1 40+2 FOLEY+SYNTO LABOUR NATURAL 24 WELL BABY YES -

120 LILY 23 25889 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 40 WELL BABY YES -

121 DEEPIKA 24 24751 G3P1L1A1 40+2 FOLEY+GEL LABOUR NATURAL 28 WELL BABY YES -

122 RINSA 26 22365 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 47 WELL BABY YES -

123 ELAVARASI 22 24586 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 38 WELL BABY YES -

124 THULASI 20 25336 PRIMI 40+5 FOLEY+GEL LSCS 30 MSAF/VIGOROUS YES -

125 RATHIMEENA 21 24186 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 34 WELL BABY YES -

126 NEELAMATHI 21 24720 G2P1L1 40+4 FOLEY+GEL+SYNTO LABOUR NATURAL 40 WELL BABY YES -

127 FARITHA 24 25369 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 38 WELL BABY YES -

128 GNANAM 23 26841 PRIMI 40+1 FOLEY+GEL LSCS 36 RDS YES -

129 KUSHBOO 26 24661 PRIMI 40+4 FOLEY+GEL+SYNTO LABOUR NATURAL 38 WELL BABY YES -

130 SAINDHAVI 25 25880 G3P2L2 40+2 FOLEY+SYNTO LABOUR NATURAL 20 WELL BABY YES -

131 THAIYALNAYAKI 24 25679 PRIMI 40+1 FOLEY+GEL LSCS 30 MSAF/VIGOROUS YES -

132 MITHRA 26 26871 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 37 WELL BABY YES -

133 SUBBU 29 25675 PRIMI 40+2 FOLEY+GEL+SYNTO LABOUR NATURAL 35 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

134 SAGUNTHALA 27 26851 G2A1 40+5 FOLEY+GEL LSCS 36 RDS YES -

135 BABY 25 25410 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 34 WELL BABY YES -

136 MANJULA 20 26712 G3P1L1A1 40+2 FOLEY+GEL LABOUR NATURAL 28 WELL BABY YES -

137 SWATHI 21 26413 PRIMI 40+1 FOLEY+GEL LSCS 30 WELL BABY YES -

138 VAISHU 26 25139 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 41 WELL BABY YES -

139 KULAZHI 29 24863 PRIMI 40+3 FOLEY+GEL LSCS 30 MSAF/VIGOROUS YES -

140 NIRANJANA 24 25907 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 35 WELL BABY YES -

141 THILAGA 26 29673 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 45 MSAF/VIGOROUS YES -

142 GEETHA 24 26601 PRIMI 40+2 FOLEY+GEL+SYNTO LABOUR NATURAL 38 WELL BABY YES -

143 PORKODI 27 26841 G2P1L1 40+5 FOLEY+SYNTO LSCS 40 MSAF/VIGOROUS YES -

144 ANUSHYA 29 25997 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 30 WELL BABY YES -

145 INBARANI 28 26304 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 34 WELL BABY YES -

146 JOTHI 23 26410 G3P1L1A1 40+6 FOLEY+GEL+SYNTO LABOUR NATURAL 43 WELL BABY YES -

147 PALANIAMMAL 26 27156 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 44 RDS YES -

148 BINDHU 27 27001 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 38 WELL BABY YES -

149 VRIKSHA 21 27683 PRIMI 40+5 FOLEY+GEL LABOUR NATURAL 37 WELL BABY YES -

150 GIRIJA 25 27600 G2P1L1 40+1 FOLEY+SYNTO LABOUR NATURAL 30 WELL BABY YES -

151 MANGAI 27 27981 PRIMI 40+1 FOLEY+GEL LSCS 30 WELL BABY YES -

152 PARVATHY 26 27139 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 38 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

153 NANDHINI 24 25103 PRIMI 40+2 FOLEY+GEL+SYNTO LSCS 46 MSAF/VIGOROUS YES -

154 VIJAYSRI 29 26814 G3P1L1A1 40+2 FOLEY+GEL+SYNTO LABOUR NATURAL 35 WELL BABY YES -

155 SABINA 25 26904 PRIMI 40+1 FOLEY+GEL LSCS 36 MSAF/VIGOROUS YES -

156 SHANTHI 21 27938 G2P1L1 40+3 FOLEY+GEL+SYNTO LABOUR NATURAL 26 WELL BABY YES -

157 INDHUJA 20 27641 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 42 WELL BABY YES -

158 LEELA 24 28741 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 47 WELL BABY YES -

159 TRISHA 27 28641 PRIMI 40+3 FOLEY+GEL LSCS 33 WELL BABY YES -

160 NAYAKI 20 27652 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 32 WELL BABY YES -

161 KANALI 22 28881 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 48 RDS YES -

162 RAJESWARI 21 28631 PRIMI 40+2 FOLEY+GEL LABOUR NATURAL 30 WELL BABY YES -

163 VANI 24 27643 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 37 WELL BABY YES -

164 PRIYA 26 28571 PRIMI 40+1 FOLEY+GEL LSCS 31 MSAF/VIGOROUS YES -

165 SNGEETHA 34 27543 G3P2L2 40+3 FOLEY+SYNTO LABOUR NATURAL 22 WELL BABY YES -

166 DURGASREE 26 28660 PRIMI 40+1 FOLEY+GEL LSCS 34 RDS YES -

167 RITHANYA 27 28730 G2P1L1 40+5 FOLEY+SYNTO LABOUR NATURAL 27 WELL BABY YES -

168 JENIFER 28 27993 G4P2L2A1 40+6 FOLEY+GEL LABOUR NATURAL 29 WELL BABY YES -

169 YUVARANI 25 27614 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 48 RDS YES -

170 PRINCY 21 28337 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 36 WELL BABY YES -

171 VALARMATHI 24 30264 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 44 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

172 INDRA 33 30886 PRIMI 40+2 FOLEY+GEL LABOUR NATURAL 37 WELL BABY YES -

173 MERLIN 29 31496 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 39 WELL BABY YES -

174 KAVYA 30 31220 PRIMI 40+1 FOLEY+GEL LSCS 36 RDS YES -

175 KAVITHA 27 32684 G2P1L1 40+5 FOLEY+GEL LABOUR NATURAL 29 WELL BABY YES -

176 SIVARANJANI 22 36210 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 42 WELL BABY YES -

177 GEETANJALI 21 32657 G3P1L1A1 40+6 FOLEY+GEL+SYNTO LABOUR NATURAL 45 WELL BABY YES -

178 KOUSHIKA 27 33851 PRIMI 40+2 FOLEY+GEL LSCS 30 WELL BABY YES -

179 SUMATHI 26 33709 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 36 WELL BABY YES -

180 MENISRI 25 37861 G2A1 40+6 FOLEY+GEL+SYNTO LSCS 44 WELL BABY YES -

181 VINISHA 23 33500 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 41 WELL BABY YES -

182 SHEELA 24 34239 G3P1L1A1 40+3 FOLEY+GEL LABOUR NATURAL 30 WELL BABY YES -

183 VANDHANA 22 34200 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 43 RDS YES -

184 RAKSHITHA 27 34751 PRIMI 40+3 FOLEY+GEL+SYNTO LABOUR NATURAL 45 WELL BABY YES -

185 JULIET 21 35217 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 39 WELL BABY YES -

186 FILOMINAVIJAYA 26 35890 PRIMI 40+1 FOLEY+GEL LSCS 40 MSAF/VIGOROUS - 600 ML

187 ISHWARYA 28 34610 G3P2L2 40+6 FOLEY+SYNTO LABOUR NATURAL 29 WELL BABY YES -

188 ABIRAMI 34 36889 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 42 WELL BABY YES -

189 PATTU 30 37467 PRIMI 40+2 FOLEY+GEL+SYNTO LSCS 44 MSAF/VIGOROUS YES -

190 JAYAMANGALA 19 39887 PRIMI 40+5 FOLEY+GEL LABOUR NATURAL 39 WELL BABY YES - INDUCTION - BLOOD BLOOD GESTATIONAL AGE MODE OF NEONATAL SL.NO NAME AGE IP NO PARITY MODE OF DELIVERY DELIVERY LOSS <500 LOSS>500 IN WKS INDUCTION OUTCOME INTERVAL IN HRS ML ML

191 DIVYA 21 39776 G4P1L1A2 40+3 FOLEY+SYNTO LABOUR NATURAL 28 WELL BABY YES -

192 NAVEENA 25 37614 PRIMI 40+3 FOLEY+GEL LABOUR NATURAL 40 WELL BABY YES -

193 VENI 22 40121 PRIMI 40+1 FOLEY+GEL+SYNTO LSCS 40 WELL BABY YES -

194 RITHIKA 31 41687 G2A1 40+2 FOLEY+GEL LABOUR NATURAL 36 WELL BABY YES -

195 HARSHITA 27 43876 PRIMI 40+1 FOLEY+GEL LSCS 31 MSAF/VIGOROUS YES -

196 ANU 23 40178 PRIMI 40+1 FOLEY+GEL+SYNTO LABOUR NATURAL 44 WELL BABY YES -

197 NIVETHITHA 24 39880 PRIMI 40+5 FOLEY+GEL+SYNTO LSCS 48 RDS YES -

198 ROSHNI 26 36247 G2P1L1 40+1 FOLEY+GEL LABOUR NATURAL 27 WELL BABY YES -

199 MAGHIZHINI 28 41759 PRIMI 40+6 FOLEY+GEL+SYNTO LSCS 40 WELL BABY YES -

200 RAJI 26 42764 PRIMI 40+1 FOLEY+GEL LABOUR NATURAL 36 WELL BABY YES -