Intra cervical
Foley catheter as a method for induction of labour
: King Hussein Medical Centre Experience
......................................................................................................................................................................
Fatima Edwan
Correspondence:
Dr Fatima Edwan
King Hussein Medical Centre,
Amman, Jordan
Email: baceel@hotmail.com
ABSTRACT
Aim of study: To assess the efficacy
of using intra cervical Foley catheter induction
of labour among pregnant women with and
without previous caesarean section and their
neonatal out come at King Hussein Medical
Centre, Amman, Jordan.
Material and methods: The study was
conducted in the labor department of King
Hussein Medical Center (KHMC) Amman, Jordan
during the period from August 2013 to January
2014 using a data sheet including patient
questionnaire to review demographic characteristics
of patients, indication for induction of
labor and results of inductions regarding
outcome, success rate and neonatal outcome.
During the study period (August 2013 to
January 2014) a total of 200 patients were
admitted for induction of labor and their
data were reviewed.
Results: The most prevalent age group
of induced patients was (25 - 34 years)
which accounts for (54.5%) followed by (16-24)
which accounts for (30.5%); 15% only were
between the age of 35 and 45.
Booking status : A little more than
half of the patients were booked (only 58.5%);
more than half of our patients were either
para one (39.5% of the cases) or primigravida
(24.5%).
Only 35 of the cases had previous one caesarian
rate (17.5) and (82.5%) had previous normal
deliveries. Most of the studied cases were
below 41 weeks of gestational age where
(53.0%) of the cases were between gestational
age 40-41 week while post term were (10%)
of cases and only (1.5%) were less than
34 weeks.
Intra cervical Foley's catheter was the
most common used method for induction of
labour, where more than half of our patients
used this method (54.5%) followed by prostaglandin(23.0%).
Artificial rupture of membranes followed
by oxytocin or seeping of membranes was
the least used method with each method accounting
for around 10 %.
The most common indication for induction
of labour was post date (47.5%) followed
by others (40.5%) which include (non reactive
NST, isolated decreased fetal movement,
oligohydromimious, unstable lie, Intra uterine
fetal death IUFD, congenital abnormality
of the fetus and bad obstetric history;
maternal diseases represent (8.5%) of the
cases.
Pre eclampsia (PET) cases represented the
majority of cases (70.5%) followed by Diabetes
Mellitus (17.5%); only 2 cases were essential
hypertension (12.0%).
More than half of the cases of induction
ended with vaginal deliveries (58%); instrumental
deliveries were used in 5.5% of cases and
in 72 cases the induction ended by caesarean
section which represents (36%) of cases.
Mode of delivery in patients with previous
CS: 65.5% of those cases ended up with a
second CS. Vaginal delivery was achieved
in more than 34% of the cases : instrumental
deliveries in (6%) and normal vaginal deliveries
in (28.5%).
Failure to progress represented the most
common indication for C/S in pregnant women
with previous C/S who underwent induction
of labour (60%) followed by fetal distress
(37%), while obstructed labour was reported
in only one case. (3%) normal body weight
was seen in (63%) of babies, good Apger
score (8-9) was reported for 90% of the
cases, with 3% had Apgar score less than
7.
Conclusion: Induction
of labor in still one of the major indications
for admissions to the labor ward causing
a lot of worries to both the patients, their
family and the health care providers.
Although the practice recommendation for
the best method of induction especially
for patients with previous uterine scar
is still unclear, with a favor for use of
prostaglandin preparation , our results
suggested cervical Foley's catheter as a
reasonable alternative. More studies are
needed to validate this option.
Key words: Foley
catheter, induction of labour, Jordan |
Induction of labour is one of
the most common interventions practiced in modern
obstetrics. It is indicated where the benefits
to mother and/or fetus of discontinuing the pregnancy
outweigh the risks of awaiting spontaneous onset
of labour (1,2). However, induction of labour
is not without risk. The World Health Organization
(WHO) recommends induction be performed with a
clear medical indication and when expected benefits
outweigh potential harms (3). Induction of labor
describes the process of artificially ripening
the cervix and stimulating uterine contractions
with the intention of precipitating the active
phase of labour, thus leading to progressive dilation
and effacement of the cervix with the intention
of achieving a vaginal delivery. In the developed
world, the ability to induce labour has contributed
to the reduction in maternal and perinatal mortality
and morbidity.(4)
Rates of labour induction vary between maternity
units because of case-mix but the UK average is
around 20% (NHS 2006). Induction accounts for
approximately 20% of deliveries in the UK and
USA (1) and rates have been rising steadily. This
has been attributed to patient and physician factors,
however elective induction rates are increasing
disproportionately [8,9], accounting for 10 to
30% of inductions in some countries.
Induction of labour should only be considered
in situations when the balance of risks are such
that the if the pregnancy is allowed to continue,
and when vaginal birth is thought to be the appropriate
route of delivery. In general, this limits induction
to pregnancies of gestation greater than the legal
limits of viability (usually 24 weeks' gestation).(4)
Study design
This was a prospective descriptive study to identify
the most indications and, different methods of
induction of labour and success rate of induction
of labor between pregnant women with and without
previous caesarean section and their neonatal
outcome.
Study setting
The study was conducted in the labor department
of King Hussein Medical Center (KHMC), Amman,
Jordan during the period from August 2013 to January
2014.
Study population:
All pregnant women attending the labor department
for induction of labor during the study period
Study tool:
A preformed data collection sheet including a
questionnaire for the patients was used to collect
the data from the pregnant women and follow them
up to identify the end result of induction.
All patients consented to allow us to use their
data in the study.
The approval of the ethical committee at KHMC
was obtained.
The data sheet includes pregnant women's name,
age, occupation, booking status, gestational age,
parity, indications and mode of previous deliveries,
mode of delivery in the studied cases and the
indication for caesarean deliveries and neonatal
outcome.
Table 1: Age of women
1. Age distribution: the most prevalent age group
of induced patients was (25 -34 years) which accounts
for (54.5%) followed by (16-24) which accounts
for (30.5%); 15% only were between the age of
35 and 45.
Table 2: Occupation
2. Occupation status : More than (84.5%) of the
cases under study were working pregnant women
with only15% not working
Table 3: Booking status
3. Booking status: a little more than half of
the patients were booked (only58.5%),
Table 4: Parity
4. Parity status: more than half of our patients
were either para one (39.5% of the cases) or primigravida
( 24.5%).
The rest of the cases were distributed in different
parity groups, although it is worth noticing that
around 10% were grand multipara with parity of
5 and more.
Table 5: Mode of previous deliveries
5. Mode of previous delivery:
Only35 of the cases had previous one caesarian
rate (17.5) and (82.5%) had previous normal deliveries
Table 6: Gestational Age at induction of labour
6. Gestational age: Most of the studied cases
were below 41 weeks of gestational age where (53.0%)
of the cases were between gestational age 40-41
week while post term were (10%) of cases and only
(1.5%) were less than 34 weeks.
Table 7: Method of Induction
7. Method of induction : intra cervical Foley's
catheter was the most common used method for induction
of labour , where more than half of our Patients
used this method (54.5) followed by prostaglandin
(23.0%).
Artificial rupture of membranes followed by oxytocin
or seeping of membranes was the least used method
with each method accounting for around 10 %.
Table 8: Indication of Induction
8. Indication of labour : The most common indication
for induction of labour was post date (47.5%) followed
by others (40.5%) which included (non reactive NST,
isolated decreased fetal movement, Oligohydramnios
, unstable lie, Intra uterine fetal death IUFD,
congenital abnormality of the fetus and bad obstetric
history,); maternal diseases represented (8.5%)
of the cases.
Table 9: Maternal Disease
9. Maternal diseases necessitate
induction of labour : pre eclampsia (PET) cases
represent the majority of cases (70.5%) followed
by Diabetes Mellitus (17.5%) with only 2 cases
of essential hypertension (12.0%).
Table 10: Mode of Delivery
10. Mode of delivery in the induction
episode : More than half of cases of induction
ended by vaginal deliveries (58%); instrumental
deliveries were used in 5.5% of cases and in 72
cases the induction ended by caesarean section
which represented (36%) of cases.
Table 11: Instrumental Delivery
11. Type of instrumental delivery
: Vacuum deliveries were the most common followed
by forceps (73%.-27%) respectively.
Table 12: Mode of Delivery
for patients with previous C/S
12. Mode of delivery in patients
with previous CS: 65.5% of those cases ended up
with a second CS. Vaginal delivery was achieved
in more than 34% of the cases : instrumental deliveries
in (6%) and normal vaginal deliveries in (28.5%).
Table 13: Indication of C/S for patients with
Previous C/S
13. Indication for CS in the present episode:
failure to progress represents the most common
indication of C/S in pregnant women with previous
C/S who underwent induction of labour (60%) followed
by fetal distress (37%) while obstructed labour
was reported in only one case (3%).
Table 14: Neonatal outcome
14. Neonatal outcome : normal body weight was
seen in (63%) of babies , good Apgar score (8-9)
was reported for in 90% of the cases, with 3%
having Apgar score less than 7.
In Western countries, labour
is induced in 20-30% of all pregnant women for
various reasons. Until now different methods for
labour induction have been used.
Mean maternal age at birth has increased in most
developed countries due to postponement of childbearing
due to social, economic and educational factors.(19)
In the USA, the birth rate for women aged 35-39
years has risen nearly 50% since 1990 (20). This
is not the case in our study population where
the mean maternal age was less than 34 years (85%)
, most of them were either para one or nullipara
(39.5%, 24.5%) respectively. Similar to many other
studies, post-term pregnancy was the most common
indication for induction (47.5%) (Shetty et
al. 2004; Chilaka et al.2004).
Nulliparity was an independent risk factor for
prolonged pregnancy in our study which is consistent
with previous findings(21,22). Nulliparity was
associated with a fivefold increased risk for
CS following labor induction among post term pregnancies
constituting almost one-third of all failures.
This is in line with prior studies on term pregnancies
(23,24,25).
Maternal diseases represented (8.5%) of the cases.
PET cases represent (70.5%) followed by DM (17.5%).
This is due to the fact that the only definitive
treatment for PET is delivery. It is one of the
most common maternal diseases to end up with induction
of labour in many studies (4); other causes were
responsible for (40.5%) of the cases which includes
NST, decreased fetal movement, Oligohydramnios
, unstable lie, IUFD, abnormal baby and bad obstetric
history.
The most common method of induction
of labour used in KHMC is Foley's catheter (54.5%)
followed by prostaglandin (23.0%). The PROBAAT
trial showed that induction of labour with a Foley
catheter is as effective as induction with intravaginal
Prostaglandin E2 gel, with fewer maternal and
neonatal side-effects [5], where caesarean section
rate was comparable. In the meta-analysis of three
trials on the subject, the Foley catheter revealed
a lower rate of hyper stimulation, resulting in
fewer cases of asphyxia and less post partum Hemorrhage.
Consequently, the transcervical Foley catheter
was recommended for induction of labour in women
with an unfavorable cervix at term [4]. The Foley
catheter shows similar success rates as induction
of labour with misoprostol (vaginal and oral),
and is associated with less uterine hyper stimulation
with and without fetal heart rate (FHR) changes
and a comparable caesarean section rate [6-7].
Although the National Institute for Health and
Clinical Excellence (NICE) guidance recommends
vaginal prostaglandin E 2 (PGE 2) as the preferred
method of induction of labour ,NICE prostaglandin
E 2 was the second most used method of induction
of labour(23.0%).
In our population (58.5%) of
pregnant women who underwent induction of labour
succeeded in achieving vaginal delivery while
36.0% were by caesarean section and only 5.5%
delivered by instrumental deliveries. Our rate
of caesarean section is higher than in other studies
(Mansour Ghanaie et al). This is probably because
most of our studied group were with low parity
: para one (39.5%) and nulliparous patients (24.5%).
Nulliparity is one of the most important factors
known to increase cesarean rate due to failure
to progress (Mansour Ghanaie et al.) and this
is similar to our result where the most common
cause of caesarean section after induction of
labour is failure to progress (60.0%).
(17.5%) of the pregnant
women who underwent induction of labour in our
group had previous caesarean section. The low
percentage of those patients is consistent with
the observed decreasing trends in women undertaking
vaginal birth after caesarean delivery in other
studies (26). 65% of them end by caesarean section.
This is a higher rate than other studies like
the NICHD study, in which the rates of caesarean
section in women undergoing planned VBAC were
33%, 26% and 19% for induced, augmented and spontaneous
labour groups, respectively.(27)
Failure to progress (60.0%) was the most common
cause of caesarean section in pregnant women with
previous caesarian who underwent induction of
labor, followed by Fetal distress in (37.0%) of
the cases. This may result from the practice in
KHMC protocol where Foley's catheter is the method
of induction in pregnant women with previous c/s,
and not using prostaglandin or oxytocin for induction
or augmentation of labour in those pregnant women
with previous caesarian which probably accounts
for the increase rate of cs in those patients
because of failure of progress.
Neonatal outcome in our study (neonatal weight,
most of them normal body weight (63%) and APGAR
scores between (8-9) were (34.5-55.5%) respectively),
indicates that the three methods used were safe
for neonates and that no major differences are
seen in neonates born to women delivered with
each method. This supports similar reports from
other studies (28,29).
Induction of labor in still one
of the major indications for admissions to the
labor ward causing a lot of worries to both the
patients, their family and the health care providers.
Admissions for induction of labour could be reduced
by proper evaluation of indications for induction
although the practice recommendation for the best
method of induction, especially for patients with
previous uterine scar, is still unclear with a
favor for use of prostaglandin preparation. Our
results suggested cervical Foley's catheter as
a reasonable alternative.
More studies are needed to validate this option.
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