Abstract

The management of labour is basic to the practice of obstetrics. Induction of labour has become an integral part of modem obstetrics. The aim of induction is to achieve successful vaginal delivery where continuation of pregnancy presents a threat to the life or wellbeing of the mother or the unborn child. Unfavorable cervix is one of the main causes of failed induction. In order to overcome this, cervix should be ripened. Over the years a variety of pharmacological and physical ripening agents have been evaluated to convert a firm, rigid, long cervix to a soft, effaced and slightly dilated cervix. Among these are amniotomy, oxytocin infusion, breast stimulation, estrogen gel, mechanical and electrical devices and local and systemic prostaglandins. The present study is designed to see if multiple instillations of intracervical prostaglandin gel will improve the success of induction of labour where single instillation has failed and to compare the maternal and foetal outcome between the single instillation group and multiple instillation group.

Objectives

1. To evaluate the efficacy of instillation of more than one dose of intracervical prostaglandin E2 gel in cervical ripening.
2. To compare the maternal and foetal outcome between patients who had single instillation and multiple instillations.
3. To study the adverse effects, if any of multiple instillations of intracervical prostaglandin E2

Materials and Methods: This study was conducted in the Department of Obstetrics and Gynaecology, JIPMER, Pondicherry.

Results: Four hundred patients who were treated with intracervical PGE2 gel were included in the study. Out of this 300 patients who had spontaneous labour or adequate cervical ripening with a single instillation of PGE2 gel formed Group A and 100 patients who required multiple instillations formed Group B. Majority of the patients (more than 60%) belonged to the 21-25 years age group and were equally distributed in both the groups. There were significantly more teenagers in group B (35%) compared to Group A (18%).There was no difference between both the groups when parity was considered. The period of gestation was similar in both the groups, the mean being 40.71 weeks in Group A and 40.84 weeks in Group B. There were more indications for Pregnancy Induced Hypertension in Group B 28% as against 18% in Group A. Ninety three patients had either spontaneous labour (43%) or favourable cervix (50%) with 2 instillations making the second instillation successful in 93% in Group B. Seven patients required 3rd instillation and out of these 3 (42.8%) had spontaneous labour and 2 (28.6%) had favourable cervix. Hence 71.4% of 3rd instillations were successful. After each instillation more multigravida had spontaneous labour. The improvement in cervical status was also better in multigravida. The change in Bishop score improved with each instillation, but this was significant only in the multigravida between first and second instillations. The cumulative improvement on Bishop score by second and third instillation was significant. About 50% of patients had cervical ripening and required oxytocin for induction of labour after first and second instillation of gel and 28.6% after the third instillation. Multigravida required less oxytocin infusion rates in Group A than primigravida. Premature rupture of membranes was the main complication in both the groups (10%).There was no difference in the incidence of meconium staining of liquor between both the groups (8% vs 5%). There were more instrumental deliveries in the multiple instillation group (29% Vs 18%).Caesarean section rates were similar in both the groups. The indications for caesarean section were similar in both the groups. The mean birth weight in Group A was 3.06 Kg and in Group B it was 3.16 Kg. Neonatal outcome was similar in both the groups

Conclusion: My study concluded that intracervical prostaglandin E2 gel is useful for cervical ripening. Some patients develop spontaneous labour with intracervical PGE2gel.Multiple instillations of intracervical PGE2 gel are useful. Some patients have spontaneous labour while in others Bishop score improves. It is probable that teenage mothers require more than one instillation of PGE2 gel for cervical ripening. The maternal risks like infection or hyperstimulation are not increased by multiple instillations of intracervical PGE2gel.There is no increased foetal risk with multiple instillation Sointracervical PGE2gel. Multiple instillations of intracervical gel can be beneficially used in appropriately selected cases

Keywords: Induction, Ripening, PGE2 gel.