•January To February

MISOPROSTOL •Eleni, Mumta, Sheryl, Sereana,

INDICATION OF NavisheeL, Navneet

LABOUR
 AIM
• To audit the fetal and maternal outcome of patients who underwent 
misoprostol induction in maternity unit, from January to February
2023.
• To do a minor comparison between misoprostol and other forms of
induction (SI and foleys)
 OBJECTIVES
Misoprostol Induction from January to February 2023.

1. Identify the number of patients undergoing misoprostol induction

and the outcomes of each case.
2. Categorize them based on their parity, ethnicity and risk factors.
3. Identify the indication of induction.
4. Determine  the success and failure rate of miso induction.
 INTRODUCTION
• The timely onset of labor is an important determinant of perinatal
outcome.
• Induction of labor refers to techniques for stimulating uterine
contractions to accomplish delivery prior to the spontaneous onset of
such contractions. 
• Generally, induction of labor has merit as a therapeutic option when the
benefits of  delivery outweigh the risk of continuing pregnancy.
• Cervical ripening is one of the methods used for labor induction
• The two major techniques  are mechanical interventions (e.g. insertion of balloon
catheters), and application of pharmacological agents (e.g. prostaglandins). 
• Prostaglandins are one of the preferred methods for cervical ripening, including
the agents dinoprostone and misoprostol.
 PREVALENCE
• The frequency of labor induction in the United States was 31.4
percent in 2020, more than tripling since 1990 when it was 9.5
percent.
• World Health Organization data, which included 373 health-care
facilities in 24 countries, showed that approximately 10 percent of
births involved labor induction.
 METHOD
Sources of Data:
1. Ante-natal ward registers
2. IOL board
3. Folders from records department

Out of 63 patients that went for Miso IOL based on the watchlists group update
only 40 folders were located
DEMOGRAPHICS
 TOTAL NUMBER OF MISO INDUCTIONS: 40

BY ETHNICITY BY GRAVIDA
30 25
22
25
25 20 18
20
15
15
10
10 9
6
5 5

0
0 0
i-Taukei FOID Others Primip G2-G4 >G4
 INDICATIONS FOR MISO IOL
16 15
14

12
10
10

8
6
6

4 3
2
2 1
0
Decreased PPROM Failed foleys TPROM PIH GDMA
FMF
 OUTCOME OF MISO IOL
35
32
30
*C-Section rate –
25 20%

20

15

10 8

0
C-Section NVD
INDICATIONS FOR C-SECTION AFTER
MISO IOL
3.5
3
3

2.5
2 2
2

1.5
1
1

0.5

0
Failed IOL Fetal distress TPROM D3 Arrested labour
MISO INDUCTIONS THAT RESULTED IN
C-SECTION (N=8)
BY GRAVIDA
6
5
5

4
3
3

1
0
0
Primip G2-G4 >G4
TYPES OF IOL USED POST MISO
20 19
18
16
14
12
12
10
8 7
6
4
2
2
0
Miso only Miso/ foleys Miso/ SI Miso/ Foleys/ SI
 COMPARISON OF
DIFFERENT IOL’S
TYPES OF IOL USED (N=88)
2
7

Foleys only
19 Foleys / SI
Miso only
46 Miso/ Foleys
Miso/ SI
Miso/ Foleys/ SI

12
2
COMPARISON OF
OUTCOMES
 MISO
35 32 *C-Section Rate –
30
25 20%
*NVD Rate – 80%
20
15
10 8
5
0
C-Section NVD

FOLEYS SI
32
50 43 *C-Section Rate – 10% *C-Section Rate – 9%
30
40
20 *NVD Rate – 91%
30 *NVD Rate – 90%
20
10
10 5 3
0 0
C-Section NVD C-Section NVD
 COMPLICATIONS
• Uterine tachysystole​
• Meconium staining of liquor​
• Uterine rupture.​
• Fever​
• Chills​
• Vomiting​
• Diarrhoea
LITERATURE REVIEW
Low‐dose oral misoprostol
for induction of labour
Robbie S Kerr, Nimisha Kumar, Myfanwy J, Williams Anna, Cuthbert Nasreen,
Aflaifel David, M Haas, Andrew D Weeks
published on 22 June 2021
 INTRODUCTION
• Misoprostol as a commonly used drug for labor indication but as it is
with all drugs it poses side effects such as extra stimulation of uterine
contractions which can lead to C-sections. This study aims to assess
the efficacy and safety of low‐dose oral misoprostol for labor
induction in women with a viable fetus in the third trimester of
pregnancy
 METHODS
• Randomized trials comparing low‐dose oral misoprostol (initial dose ≤ 50 µg)
versus
1. placebo
2. vaginal dinoprostone
3. vaginal misoprostol
4. oxytocin
5. mechanical methods
or comparing oral misoprostol protocols (one‐ to two‐hourly versus four‐ to
six‐hourly; 20 µg to 25 µg versus 50 µg; or 20 µg hourly titrated versus 25 µg
two‐hourly static).
 RESULTS
61 trials involving 20,026 women.
TRIAL RESULT
Oral misoprostol versus Oral misoprostol may make little to no difference in the rate of caesarean section, while its
placebo/no treatment effect on uterine hyperstimulation with foetal heart rate changes is uncertain.Vaginal births
(four trials; 594 women) within 24 hours was not reported. In all trials, oxytocin could be commenced after 12 to 24
hours and all women had pre‐labour ruptured membranes.

Oral misoprostol versus vaginal Oral misoprostol probably results in fewer caesarean sections. Subgroup analysis indicated
dinoprostone that 10 µg to 25 µg. May differ from 50 µg for caesarean section. Oral misoprostol may
(13 trials; 9676 women) decrease vaginal births within 24 hours and hyperstimulation with fetal heart rate changes

Oral misoprostol versus vaginal Oral use may result in fewer vaginal births within 24 hours, and less hyperstimulation with
misoprostol fetal heart rate changes, with subgroup analysis suggesting that 10 µg to 25 µg orally may be
(33 trials; 6110 women) superior to 50 µg orally. Oral misoprostol probably does not increase caesarean sections
overall but likely results in fewer caesareans for fetal distress.

Oral misoprostol versus Misoprostol may make little or no difference to vaginal births within 24 hours, but probably
intravenous oxytocin (6 trials; results in fewer caesarean sections. The effect on hyperstimulation with fetal heart rate
737 women, 200 with changes is uncertain.
ruptured membranes)
TRIAL RESULT
Oral misoprostol versus mechanical Six trials compared oral misoprostol to transcervical Foley catheter. Misoprostol
methods may increase vaginal birth within 24 hours, and probably reduces the risk of
(6 trials; 2993 women) caesarean section. There may be little or no difference in hyperstimulation with
fetal heart rate changes

Oral misoprostol one‐ to two‐hourly versus The evidence on hourly titration was very uncertain due to the low numbers
four‐ to six‐hourly (1 trial; 64 women) reported.

Oral misoprostol 20 µg hourly titrated The difference in regimen may have little or no effect on the rate of vaginal
versus 25 µg two‐hourly static (2 trials; 296 births in 24 hours. The evidence is of very low certainty for all other reported
women) outcomes.
 CONCLUSION
• Low‐dose oral misoprostol is probably associated with reduced caesarean sections than vaginal
dinoprostone, and lower rates of hyperstimulation that causes fetal heart rate changes.
However, the time it takes to deliver is increased
• Compared to transcervical Foley catheter, low‐dose oral misoprostol is associated with fewer
caesarean sections, but the rates of hyperstimulation is the same.
• Low‐dose misoprostol given orally rather than vaginally is probably associated with similar rates
of vaginal birth, although the timing of delivery within the first 24 hours is increased, but there
is likely less hyperstimulation with fetal heart changes, and fewer caesarean sections performed
due to fetal distress.
• The best available evidence suggests that low‐dose oral misoprostol probably has many benefits
over other methods for labor induction. This review supports the use of low‐dose oral
misoprostol for induction of labor, and demonstrates the lower risks of hyperstimulation than
when misoprostol is given vaginally. More trials are needed to establish the optimum oral
misoprostol regimen, but these findings suggest that a starting dose of 25 µg may offer a good
balance of efficacy and safety.
 LIMITATIONS
• Register not updated in the ward
• Folders are not readily available
• Missing folders – maternal and neonatal folders, inability to obtain all
folders
• Administration office opening hours
• Poor documentation- IOL checklist/ missing checklists and consents
• Bishop score are not done in majority of the cases
 CONCLUSION
• In conclusion our audit states that out of all the forms of induction,
miso has the highest C-sec outcomes (20%) compared to foleys (10%)
and SI (9%).
• It was also noted that the most common indication for Miso IOL was
TPROM Day 3 followed by failed foleys IOL.
• Our audit also reflected that maternal and fetal outcomes were
favourable.
 RECOMMENDATION
• Proper documentation and timely updating in the IOL register
• Compliance to filling of IOL Checklist
• Proper assortment and placement of folders
• Separating IOL folders from other folders for future researches
 REFERENCE
• Kerr, R.S., Kumar, N., Williams, M.J., Cuthbert, A., Aflaifel, N., Haas, D.M. and Weeks, A.D. (2021).
Low-dose oral misoprostol for induction of labour. Cochrane Database of Systematic Reviews,
2021(6). doi:https://doi.org/10.1002/14651858.cd014484

• Grobman, W. and Prabhu, M. (no date) Induction of Labor with Oxytocin, WWW. Available at:
https://www-uptodate-com.idm.oclc.org/contents/induction-of-labor-with-oxytocin?
search=Labor+indications&source=search_result&selectedTitle=1~150&usage_typ
e=default&display_rank=1 (Accessed: March 30, 2023).

• Caughey, A.B. et al. (2009) Maternal and neonatal outcomes of elective induction of Labor,
Evidence report/technology assessment. U.S. National Library of Medicine. Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4781541/ (Accessed: March 30, 2023).