ST.

PAUL’S HOSPITAL MILLENNIUM MEDICAL COLLEGE

DEPARTMENT OF PUBLIC HEALTH

PREVALENCE OF FAILED INDUCTION CASES, ASSOCIATED FACTORS AND

THEIR SUBSEQUENT MANAGEMENTS AT SPHMMC

BY Dr. DANIEL GARANG ALUK

A research paper submitted to department of public health of SPHMMC in partial

fulfillment of the requirement for the degree of doctor of medicine

July 2018

Addis Ababa, Ethiopia

 ST. PAUL’S HOSPITALMILLENNIUM MEDICAL COLLEGE

DEPARTMENT OF PUBLIC HEALTH

PREVALENCE OF FAILED INDUCTION CASES, ASSOCIATED FACTORS AND

THEIR SUBSEQUENT MANAGEMENTS AT SPHMMC

By: Dr. Daniel Garang Aluk

Advisors: Dr. Ayalew Zewdie (MD, Assistant professor of Emergency medicine).

Mr. Belayneh Lulseged (MPH)

July 2018

Addis Ababa, Ethiopia

Acknowledgment
I do hereby extend my sincere appreciation and gratitude to SPHMMC administration for the
chance that was provided for me to do this research. The special thanks goes to SPHMMC Public
health department and to my two advisors, Mr. Belayneh and Dr. Ayalew for their undivided
support along the way regarding this research. It’s a golden opportunity to have a practical training
on how to carry out a complete research under supervision of public health and medical advisors
whose advices and encouragements change the way I perceived research as a requirement for my
undergraduate program, I consider it now as a life time duty and relatively a long term diagnostic
tool that I must use to make a clear change in life of people I serve.

It is a common fact that once you become a medical doctor, you are a researcher by default because
there is always a need to investigate any health hazard in question to reach facts that would help
in formulating new policies to tackle those health problems. This research therefore is considered
to be the first of series of researches that I would conduct in my future career life.

I can’t thank enough all those who dedicated their time and resource in training me on how to
make a good research. I’m so grateful to God Almighty for I believe that being here was no
accidental rather it was part of his meaningful and merciful plan.

I would write forever but I sincerely believe that I won’t be able to thank you enough for all
assistance I got from your esteemed administration. I therefore would try really hard to make full
use of it all instead.
 Table of contents

Acknowledgment ............................................................................................................................. i

Table of contents ..............................................................................................................................ii

List of tables ……………………………...……………………………………………………...iii

List of figures ………………………………………………………………………………….....iv
Abbreviations (acronyms) ................................................................................................................v

Abstract (Summary) ........................................................................................................................vi

CHAPTER 1: Introduction.............................................................................................................. 1

CHAPTER 3: Objectives .............................................................................................................. 10

3. Objectives .............................................................................................................................. 10

CHAPTER 4 Method and materials ............................................................................................. 11

CHAPTER 5: Results ................................................................................................................... 17

CHAPTER 6: Discussion.............................................................................................................. 24

CHAPTER 7: Strength and limitations of the study ..................................................................... 28

CHAPTER 8: Conclusion and recommendations ......................................................................... 29

8.1 Conclusion...................................................................................................................... 29

8.2 Recommendation:........................................................................................................... 29

References ..................................................................................................................................... 30

Appendix ......................................................................................................................................... 1

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LIST OF TABLES

Table1: Socio-demographic of mothers who were induced at labor Ward of SPHMMC, in Addis
Ababa-Ethiopia.

Table 2: obstetric factors of induced mothers, at labor Ward of SPHMMC, in Addis Ababa-
Ethiopia.

Table 3: Perinatal outcomes of induction for mothers who were induced at labor Ward of
SPHMMC, in Addis Ababa-Ethiopia.

Table 4: Binary logistic regression analysis of factors associated with failed induction for
mothers who were induced at labor Ward of SPHMMC, in Addis Ababa-Ethiopia.

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LIST OF FIGURES

Figure: The percentage of failed induction for mothers who were induced at labor Ward of
SPHMMC, in Addis Ababa-Ethiopia.

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ABBREVIATIONS (ACRONYMS)

ACOG: American College of Obstetricians and Gynecologists

APH: Antepartum Hemorrhage

C/S: Cesarean Section

EFW: Estimated Fetal Weight

GBS: Group B Streptococcus

GC: Gregorian calendar

GDM: Gestational DM

IOL: Induction of Labor

NICU: Neonatal Intensive Care Unit

NRFHRP: Non-reassuring Fetal Heart rate Pattern

SPHMMC: St. Paul’s Hospital Millennium Medical College

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Abstract (Summary)
Background: Induction of labor is a common medical practice in department of obstetrics and it’s
meant to decrease the adverse outcome associated with waiting the spontaneous labor to start. It’s
therefore, indicated in the most of the cases where benefits of terminating pregnancy outweigh
those of continuing the pregnancy. Though there are some complications, among which failure of
induction is one of them, which on the other hand subjects a pregnant mother to more traumatic
option of delivery (C/S).

Objective: To determine the prevalence of fail induction and associated risks at and subsequent
management at SPHMMC between Dec 2017 to Feb 2018.

Method: This study is a facility based cross-sectional retrospective study, which was conducted
at SPHMMC, at obstetric department, in the Labor Ward. A sample size was determined using a
single population formula and as a result, a total number of 212 mothers were included in this
study. A systematic sampling technique was used to select participants. Medical records of selected
mothers were reviewed and abstracted data were entered into SPSS version 20 and were analyzed.
The results of analysis are represented in this paper in form of text, tables and graphs.

Results In this study the prevalence of failed induction was found to be 5.7% and binary logistic
regression was used to determine factors associated with failed induction and it was found that
mothers with pre-induction rupture of members were 3.66 likely to have failed induction but with
insignificant p-value of 0.057. No association was found between failed induction cases and
maternal age, or parity.

Conclusion: Outcome of induction in this study are promising and therefore the more inclusive
study at larger scale is recommended to better view of magnitude of fail induction. The
documentation of pre-induction Bishop Score and other relevant information is highly
recommended since such factors might have effect on outcome of induction of labor.

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 CHAPTER 1

1. Introduction
1.1 Background of the study
Labor is defined as the process by which the fetus is expelled from the uterus, and this
process requires regular, effective contractions of uterus that lead to dilation and
effacement of cervix. Induction of labor is defined as an iatrogenic stimulation of uterine
contractions before the onset of spontaneous labor to accomplish vaginal delivery, it is
said to be one of the most frequently performed obstetrics procedures in US [1]. It’s
performed when the continuation of the pregnancy carry more risks to the mother’s and
or fetus’s health than its termination though it can as well be performed electively in
women to whom vaginal delivery is not contraindicated nor is termination of pregnancy,
the indications for induction of the labor must therefore be convincing to the reader and
it should be clearly documented, the care provider should inform the mother about need
for induction so as to obtain informed consent [1, 2].

Successful induction is as a vaginal delivery of induced mother within 24 to 48 hours

from time of induction of the labor. If the labor is induce in absence of clear fetal or
maternal indication then the term elective induction is applied. Cervical ripening if
crucial for success of induction of labor and it is therefore use to soften, efface or dilate
the cervix to increase the chance of vaginal delivery in induced mothers
Some indications for induction are: preeclampsia at G/A >37 wks, stable APH,
chorioamnionitis, term (PROM) especially in mother with GBS colonization, post term
pregnancy, poorly controlled GDM, IUFD, PROM at or near term.

The induction of labor should be avoided in under some circumstances for studies have
proved that it either has no known benefits or rather adverse outcomes so it’s
contraindicated in cases as placenta previa, vasa previa, cord prolapse, abnormal fetal lie
or presentation (e.g. transverse lie or footling breech), patients who have prior classical
or inverted T uterine incision, in those with significant uterine surgery (e.g. full thickness
myomectomy), active genital herpes, If there is deformity of pelvic structures (e.g.
 contracted pelvis), Invasive cervical carcinoma, previous history of uterine rupture. Since
the ultimate goal in induction is to achieve vaginal delivery, it signify that the factors that
may lead to failure of induction must be assess prior to induction the process that termed
as pre-induction assessment in medical and obstetrical practice. It is meant to decrease
the high risk of C/S that is related to induction of labor when compare with spontaneous
labors, some of these factors includes; Bishop Score, parity or prior vaginal delivery,
BMI, maternal age, EFW, and DM [1,2]
Besides failure of induction there are some other risks associated with induction of labor
such as uterine hyper stimulation, increased rate of operative vaginal deliveries and C/S,
abnormalities in fetal heart rate patterns (e.g. NRFHRP), premature deliveries and
infections and in worst case scenario uterine rupture would occur [3].

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 1.2 Statement of the problem
Ensuring the delivery of a healthy baby to a healthy mother in a content family is the
overall goal of safe motherhood. Achieving this goal sometimes may require the delivery
of the fetus before the spontaneous onset of the labor to prevent adverse outcome to the
baby and or to the mother. This kind of intervention becomes necessary when the benefit
of terminating the pregnancy far more outweigh the benefits of continuing it [4].

The criteria for failed induction are well agreed upon though it is estimated that the failed
induction is about 15% in the presence of unfavorable cervix. The failed induction must
be clearly from failure of labour progress due to CPD since latter is contraindication for
vaginal delivery making C/S the option from the outset [5].

Though C/S is considered to be relatively safe, it does pose some risks and complications
when compared with vaginal deliveries. It has be shown to predispose mother to
infection. Those who delivered by C/S are at risk of losing much blood. The C/S could
subject those mother delivering by this mode into some injury to their internal organs
such as bladder, bowel and so forth, though it is rare, death is an important complication
of C/S delivered which was reported as high as 2 in 100,000 [6].

It worth mentioning that even though in most cases delivery by C/S is relatively safe,
recovery from C/S takes longer time than vaginal, because the woman requires a time to
heal from the wound of CS (it is a major operation) and in some instances if the C/S
wound is infection the may stay even longer in the hospital, for those women who had
C/S without complications stay about 3 days in average compared with those who had
vaginal deliveries whose stay does not go beyond 2 days hospital stay. However full
recovery from C/S delivery takes about 4 to 6 weeks whereas the recovery after vaginal
delivery has been reported to take only 1 to 2 weeks in average. The C/s delivery poses
a long-term risk at mother as well, for instance women who had C/S deliveries and
therefore uterine scars in their preceding deliveries are at certain risk for uterine rupture
in their subsequent vaginal deliveries [2, 6].

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 C/S deliveries has been implicated to be a risk for placenta previa in some other studies
in which case the placenta grows low in uterus. It has been reported that Cesarean Section
is a risk for morbid adhere placenta which has three known forms: placenta accrete,
placenta increta and placenta percreta, these problems are due to growth of placenta deep
into uterine wall beyond normal growth, this condition can cause PPH which would result
in death or in order to stop the bleeding hysterectomy is sometimes required all these
should have been prevented if vaginal delivery could have been accomplished without
further need for C/S which has both health related problems and of high cost to the
families[6].
The prevalence of failed induction need to be determined for it is important to understand
the extend of problem and to decreased number of C/S due to failed inductions which
would have effect not only in the maternity health but also in the economy of the country.

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 1.3 Significant of the study
This study is considered to be important in terms of knowledge that would be generated
from this tertiary hospital (SPHMMC) about the number of induced labors and their
outcomes during the selected time period, it would as well provide policy makers on
health sector to take matter into account and eliminate unnecessary inductions that would
end up otherwise in C/S procedures if associated risk factors were known.

Health providers would use this results to evaluate the extent of the failed induction at
this hospital and caution would be taken to identify the factors that could lead to failure
of inductions in pre-induction assessment. And would significantly decrease the
prevalence of failed induction and thereafter the C/S deliveries for indication of failed
induction would drop as well for betterment of delivering mothers at our hospital.

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 CHAPTER 2

2. Literature review
Induction and failed inductions
Though the importance of the induction of the labor cannot be denied especially if ending the
pregnancies has benefits that outweighs continuing it (continuation of pregnancy has risks to
the mother and/or fetus. Nevertheless this practice may come with undesired results and that
signify the pre-induction evaluation of the pregnancy to avoid the adverse outcome, it should
therefore be done with clear inductions that has be proven scientifically [6].

The induction of the labor is common obstetrics practice but the prevalence of this practice
varies between different countries and even in some cases between different regions of the
same countries. It has been reported that it’s higher in the developing countries when compared
with developing countries. It has been reported in some research that the rate of the induction
of labor is as high as 20% in developing countries by the rule of thumb. The study done in
Latin America, has reported that the common indications for induction of labor to be the same
and are: Hypertensive disorder of pregnancy, Post-term pregnancy, premature rupture of
membranes, chorioamnionitis, diabetes, Intra-uterine growth restriction, isoimmunisation,
fetal death and other maternal conditions. In addition to these conditions the induction of the
labor may be perform merely based on the request by the woman in which case it is known as
elective induction [6].

This study included about 97095 among which 11077 (11.4) were induced with 74.2%
occurring in public institutions, about 20.9% of these cases were induced in the social security
hospitals whereas private institutions has inductions of 4.9% only. The induction rate was
found to range between 5.1% in Peru to 20.1% in Cuba. Different indications were noticed in
this study, 25.3% of these cases were induced for an indication of premature rupture of
membranes and the rate of elective inductions was found to be 28.9% of the cases. The success
of the induction was compare between those who were induced using oxytocin and those for
who misoprostol was used and the results of two groups were comparable; the success rate
with oxytocin was 69.9% whereas with misoprostol the rate of success was 74.8%, with overall

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 success rate being 70.4%. The same study found out that the induced labor was more common
in women over 35 years of age. Other study was conducted in Pakistan on factors associated
with failed induction of labor in a secondary care hospital, this study included a total number
of 719 wen out of which 130 (18.1%) had failed inductions. The study reported that the rate of
failed induction was 4.6 times higher in nulliparous women (25.3%) as opposed to their
counterparts who are multiparous in which 6.8% only had failed inductions. The odds of
having cesarean section was found to be higher in those with gestational age greater than 40
weeks (47.7%) than those whose gestational age was less that forty, in these group about 36.7%
only had cesarean section after induction of labor [6, 7].

In the same study, the women who had failed inductions where 2.5 more likely to have
macrosomic babies when compare with their counterparts who had successful vaginal delivery
after induction of labor; the outcome was that 3.1% of mothers with macrosomic babies
underwent C/S deliveries whereas only 1.5% mothers whose babies had normal birth weight
delivery by C/S. There was a significant association between Bishop’s score and failed
induction; the rate of the induction failure was said to be 1.9 times higher in those women
whose Bishop score was 5 or less, in this group about 84% had failed induction compared to
only 18% from those with favorable cervix (good Bishop score). The study found a
relationship between rupture of membranes and failed induction; it was reported that women
who had Cesarean section were 1.3 times likely to have rupture of membranes that than those
who delivered vaginally. The other finding was that women with failed inductions were 2.9
times more at odds of having prolonged latent phase and 1.4 times more likely to have
prolonged second stage of labor than their counterparts. There are no association noted
between failed induction and booking status of the patient and level of responsible physician
during induction [7]

A total number 156 women underwent induction of labor were included in study done at
university teaching hospital of Lusaka – Zambia from 03/06/2013 to o13/09/2013 among these
women 127 met inclusion criteria and they were included in the study. The total number of
deliveries in the above specified period was 5892 and the prevalence rate of induction was
2.6%. From the 127 participants of the study who enrolled in the study 17 of them delivered

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 by Cesarean section. 37.8% of participants were nulliparous women and the mean parity in the
study group was 1.4 (ranging between 0 to 8 children). The mean Bishop score was found to
be 3 but the range of Bishop Score was from 0 to 8 and the mean gestational age was 36.7
whereas the range was from 28 to 43 completed weeks. Among these mothers who were
induced for different indications, 69.3% where induced because of their hypertensive
disorders, those who were induced for premature rupture of membranes were 15%, the postdate
induction was 12.6% whereas 3.1% were induced for other reasons. Membranes were ruptured
already when the induction was started in about 18.1% of these study group but it was intact
in about 81.9% of them [8].

The study carried out in India under title; an overview regarding obstetric outcome and its
significant in a health resource poor setting over a period of 11 months, this study reported that
there was no fixed protocol for induction of labor and it defines the failed induction as inability
to achieve cervical dilatation > 4 cm after 12 hours > 3h of oxytocin administration. Although
many physicians consider successful vaginal delivery following induction of labor to negate
the failure of induction. Despite the definition provided in this study, the time interval between
the 2nd dose of PGE2 gel and the delivery process has not been determined. It was also
mentioned in this study that the most important parameter of Bishop Score was cervical
dilatation. Women with failed induction were found to be 2.9 more likely to have prolonged
latent phase of labor and 1.4 time more at odds for having prolonged second stage of labor.
Then mean induction to delivery interval in this study was found to be 18.9 hours [9, 10].

It was reported that the induction of labor is a common procedure in modern day of obstetrics
practice, it has been estimated that the incidence of this practice is 25% in the developed world
but it’s lower than that in the developing world, though its incidence differ even in the different
regions of the same country [11].

Study done at Hawassa –Ethiopia at Public health facilities on prevalence of failed induction
and associated factors among women delivered in Hawassa public health facilities included
294 medical records of who underwent induction of labor. Regarding socio-demographic
factors the mean age was 26.9 and 242 of whole sample of study were below 30 years of age.
As per obstetrics factors, the mean gestational age was 38.98 weeks. Primigravida mothers
were 55.8% and the Bishop Score of 185 mothers was below five prior to induction of labor.

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 In this study. As for the induction of labor, it was reported that most inductions were for
premature rupture of membranes followed by preeclampsia, post term pregnancy then
chorioamnionitis [11, 12].

The method used for induction labor in this study, oxytocin infusion took the highest ranking
whereby 73.5% where induced by this method and 26.5% were induced by either oral or
vaginal misoprostol. The study reported that 9.5% of participants has prior history of abortion
whereas 5.4 had previous history of other obstetrics complications. The mean time of induction
was found to be 8.89 hours but the range of time taken from induction to delivery was between
2 to 23 hours. All the mother in the sample of study were all of singleton pregnancies. Out of
294 study participants, 181 (61.6%) delivered by vaginal delivery and the remaining delivered
by Cesarean Section. The APGAR SCORE of 70.1% in the first minutes was reported to be
greater than 7, after five minutes about 83.3% of newborns reached score greater than seven.
The reason for C/S in this study participants were, Cephalopelvic disproportion, fetal distress
and failures of induction [12].

Different variable were considered to be associated with failed induction and these variables
were parity, premature rupture of membranes, age of mother, pre-induction Bishop Score. A
Bishop score of 7 or more is said to be a favorable factor for success of induction. Primiparous
mothers were reported to have 3.11 times likelihood of ending up in failed induction than their
counterparts. The mothers whose ages greater than 30 were 9.1 times at odds of failed induction
than others. Mothers with pre-induction Bishops score of less than five were 4.54 more like to
have failed induction than those with pre-induction Bishop score greater than five. The failed
induction were 5.66 times more likely in those with premature rupture of membranes than
those with intact membranes during induction. The odds for failed induction were 6.57 times
more likely in mothers who have greater gestational age than others. Mothers with post terms
were also found to be 4.52 times more likely for failed induction than their counterparts. Those
with previous obstetrics complications have 5.60 times more likely than those who didn’t have
bad previous obstetrics history [12].

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 CHAPTER 3

3. Objectives
3.1 General objectives
To assess the prevalence of failed induction of labor, associated factors and their
subsequent management at SPHMMC from Dec 2017 to Feb 2018

3.2 Specific objectives

1. To determine the prevalence of failed inductions at SPHMMC from Dec 2017
to Feb 2018
2. To identify the associated factors of failed induction
3. To describe the subsequent management option of failed inductions

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 CHAPTER 4

4. Method and materials

4.1 Study area and period
This is a facility based cross sectional retrospective descriptive study which was carried out at
St. Paul Hospital Millennium Medical College (SPHMMC) in Addis Ababa – Ethiopia
department of obstetrics and gynecology, labor ward. The lobar word of this hospital is well
equipped with modern obstetric beside ultrasounds and external fetal heart rate monitoring
devices. It has over 34 bed for admission of mothers in labor, induction and post C/S recovery.
Medical interns, resident, midwives and nurses work in labor ward to insure the better outcome
of deliveries.

Medical student also attached to labor ward to observe all the procedures that are done in this
section of the hospital for their better understanding and so as to develop knowledge, skill and
confidence needed to perform those procedures when they become interns and eventually
resident and senior, would they chose to specialize in department of Obstetrics and
Gynecology.

The labor ward of St. Paul’s Hospital is equipped with operation theatre were the C/S
deliveries are performed for different inductions, among which failed indication is one of
indications besides elective and emergency C/S.

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 Study Design
Facility based retrospective cross sectional descriptive study was applied for this
research

4.2 Population
4.2.1 Source population
Source population for this study were all women who underwent IOL at SPHMMC
Obs/Gyn, Labor ward from Dec 2017 to Feb 2018

4.2.2 Study population

All selected women who underwent IOL with failed induction at SPHMMC during
the specified duration of time.

4.3 Variables
4.3.1 Dependent variables
The dependent variable for this study is failed induction irrespective of
factors associated

4.3.2 Independent variables

 Age
 Parity
 Gestational age
 Rupture of membranes
 Birthweight
 Bishop Score

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 4.4 Operational definition
 Induction of labor: Iatrogenic stimulation of uterus to achieve vaginal
delivery before onset of spontaneous labor but after viability of fetus (after 28
completed weeks of gestation) irrespective of indication, method used or
outcome.
 Elective induction of labor: If mother is induced based on her preference but
not based on feto-maternal indication.
 Vaginal delivery: Expulsion of newborn(s) out of uterus after 28 completed
weeks of gestation irrespective of whether by induction or spontaneous vertex
delivery.
 Failed induction: If induced mother failed to deliver after 24 hours or more
from time of induction of labor.
 Nulliparous: Woman who does not have history of previous deliveries
 Multiparous: Mother who has at least 2 and maximum of four deliveries
 Grandmultiparous: A woman with five or more deliveries.
 Cesarean section delivery: Any women who delivered by operation in which
incision in made on the abdominal wall and on the uterus to deliver the fetus
irrespective of the indication and outcome.

4.5 Inclusion and Exclusion criteria

4.5.1 Inclusion criteria
 All women who underwent IOL at SPHMMC and are registered at the labor
ward delivery registry book with outcome being failed induction between
Dec 2017 to Feb 2018
 All women with different age and parity

4.5.2 Exclusion criteria

 All women with incomplete registration
 All women who were induced but with no clear indication.

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 4.6 Sample size calculation
Sample size (n) required for this study was determined using single population
formula, by taking proportion (p) from previous study done in Hawassa under title of
“prevalence of failed induction of labor and associated factors among women
delivered in Hawassa Public health facilities, Ethiopia 2015 which was 17.3% ≈17%,
with 95% confidence level (α) and 5% margin of errors (d)

Where n = estimated sample size

z = confidence level (alpha, )
p = Prevalence
d = marginal errors

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 4.7 Sampling technique
The study sample was selected using systematic sampling technique based on the
patient date of induction and or delivery, after the study group was listed by the date
of their induction and or delivery, the systematic sampling technique was applied.
Some of mothers who didn’t meet inclusion criteria were excluded and the list was
refined according to inclusion and exclusion criteria. The sample interval was
determined using the formula K=N/n.

4.8 Data collection

Data were collected from records of mothers who were induced from Dec 2017 to
Feb 2018 using structured standard questionnaire adopted from other researches with
some modification. Trained data collectors gathered necessary information after
permission have been obtained from relevant authorities who were responsible of
patient record keeping with direct supervision of principal investigator.
The questionnaire contained demographic data information, socioeconomic status,
past and current obstetric history, and mode of delivery. The questionnaire was in
English and it was not translated to any other language. Only those data collectors
with basic understanding of English language were recruited in this survey. No
pretest was applied for questionnaire, the medical records of selected mothers in
sample size were used to extract and fill information required for this survey.

4.8.1 Data Quality control:

The filled questionnaires were checked consistently for completeness by
supervisor (s) and were crosschecked subsequently by principal investigator.
Supervisor(s) and Principal investigator were reachable throughout the data
collection period to answer any questions that might arise regarding the
questionnaire and data collection process.

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 4.8.2 Data analysis
After filling all questionnaires and completeness and consistency were checked,
the data were coded by principal investigator and others assigned individuals
under his direct supervision. The data were thereafter entered into SPSS version
20 for data processing and analysis.

Descriptive statistics output of SPSS are represented in text, tables and graphs.
Logistic regression analyses was used as well to determine factor(s) that have an
effect on outcome of induction of labor and for controlling cofounders. The
outcome information is as well presented using text, tables and graphs.

4.8.3 Ethical considerations

Ethical clearance was obtained from the research and Ethics committee of Public
Health Department of St. Paul’s Hospital Millennium Medical College. Further
permission was obtained from department of Obstetrics and Gynecology of the
same institution as well as from relevant authorities of medical record keeping.
The confidentiality of information obtained from medical records was assured
and the information obtained from chart review was used for the research
purpose only.

4.8.4 Dissemination of results

The final results of this study was bsubmitted to Department of Public Health
Administration in two forms (soft and hard copy) as to be considered for
dissemination to governmental and private hospitals administrations and to
policy makers and possibly to Federal Ministry of Health of Ethiopia for possible
use in amending health policies in regard to the topic of research.

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 CHAPTER 5

5 Results
5.1 Socio-demographic:
The age of participants was ranging from 16 to 40 with mean age of 26.44 (Std. Deviation: 4.9).
Among these 212 participants 77 were between age of 16 and 24 years (36.3%), majority were
between 25 and 34 years of age (115 which was 54.2%), the age from 35 to 40 were found to be
only 20 mothers (9.4 %). It was found that 119 (56.1%) were from Oromo region whereas 93
(43.9%) only were from Addis Ababa.

Majority were housewives constituting 137 (64.6%) of participants, followed by daily laborers in
which category there were 29 mothers (13.7%). Unemployed were 18 (8.5%). Thirteen of them
(6.1%) were merchants. Farmers were 7 (3.3%), One mother was a medical doctor

Out of 212 mothers who were induced, 187 of them (88.2) were married, 21 (9.9%) were single,
and 3 (1.4%) were divorced and marital status of one (0.5%) was not known.

Table1: Socio-demographic of mothers who were induced at labor Ward of SPHMMC in Addis Ababa-Ethiopia.

Variable Categories Frequency Percent

16-24 77 36.3
Age 25-34 114 53.8
35-40 20 9.4
25 1 0.5
Oromo region 119 56.1
Residence Addis Ababa 93 43.9
Total 212 100
Unemployed 18 8.5
Housewife 137 64.6
Farmer 7 3.3
Occupation Daily laborer 29 13.7
Merchant 13 6.1
Unknown 2 0.9
Student 5 2.4
Medical Doctor 1 0.5
Total 212 100
Marital Status Single 21 9.9
Married 187 88.2
Divorced 3 1.4
Unknown 1 0.5
Total 212 100

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5.2 Obstetric factors
Among 212 mothers who were included in this study, it was found that 97 of them (45.8%) were
para 1, followed by para 2 mothers who were 41(19.3) para 3 were 25 (11.8%). Para 1 abortion 1
constituted 15 (7.1%) of the study group, para 2 abortion 1 were 13 (6.1) in number, Para 3 abortion
1 were 9 (4.2), para 4 mothers were 6 (2.8), para 1 abortion 2 were 2 (0.5%). Whereas para 5, para
5 abortion 1, para 3 abortion 2 and para 7 were 1 each in this study. The maximum parity was para
7 among these mothers whereas minimal parity was para with standard deviation of 2.9.

Among all the mothers within this study group 17 of them were preterm pregnancies (8%), the
majority were term pregnancies, 168 (79.2%). Post-term pregnancies were 23 mothers (10.8%).
There were 4 mothers (1.9%) whose gestational ages were unknown.

Prior to induction membranes were ruptured in 113 (53.3%) mothers whereas membranes were
found to be intact in 99 (46.7) of them. Out of 113 whose membranes were ruptured, only 8 of
them had foul smelling of liquor. Concerning the meconium 39 of participants were found to have
meconium stained amniotic fluid and the rest were clear liquor.

Among the participants, there were varieties of indications for induction but those induced as an
indication of PROM top the list of indications. This category constituted about 45 mothers who
were induced as a case of PROM and they represented 21.2 % of all the mothers included in this
study. The second most common indication for induction in this study was for hypertensive
disorders (Preeclampsia and Eclampsia) these mothers were 35 (16.5%), the third common
indication for induction was PROM with GIMSAF for which 17 mothers (8%) were induced. The
post term was another common indication for induction in this study were 16 (7.5%) mothers were
induced as a case of post term pregnancies.

The method of induction in this study group was invariably by oxytocin for all mothers who were
included in this survey.

Among all 212 mothers included in this studies who were induced 12 (5.7%) of inductions failed.
All of failed cases were delivered by Cesarean Section (C/S) subsequently. It worth mentioning
that the ultimate mode of delivery was varying among these mothers, the majority delivered by
vaginal delivery; women who delivery by unassisted vaginal delivery were 122 that’s 57.5% of all
the deliveries. C/S delivery was found to be the second most common mode of delivery in this

Page | 18
study, in which 71 (33.5) mothers delivery by C/S. Among those mothers who delivered by C/S
12 of them as mentioned early delivered for an indication of failed induction.

Majority of indications for C/S were for NRFHRP and there were 56 of cases (26.4 %). Two
mothers delivered by C/S for an indication of GIIIMSAF with severe oligohydraminos. One C/S
delivery was indicated for cord prolapse and the other case was for CPD.

The third commonest mode of delivery was instrumental assisted Vacuum vaginal delivery, the
method by which 14 mothers (6.6%) were delivered. The remaining five mothers (2.4%) delivered
by outlet forceps vaginal delivery.

In all these induction cases, there was no any record of uterine rupture case in 212 mother
underwent induction of labor.

From binary logistic regression analysis no any association found between maternal age and failed
induction, between gestational age and failed induction. Nevertheless, as for membranes status it
was found that mother whose membranes ruptured prior to induction where 3.667 times likely to
have failed induction as compared with their counterparts with intact membranes during induction
but the p-value of this mother was 0.57 making it insignificant for this study.

From para 1 mothers 8 case were failed inductions, but there was no failed case for para 2, para 4,
para five, para 1 abortion 1, para 3 abortion 1, para 5 abortion 1, para 3 abortion 2, or para 7. There
were 2 cases of failed induction in mothers who had 3 deliveries (including the current delivery)
there was one case of failed induction for mothers with para 2 abortion 1 as well as in para 1
abortion 2 in this study.

About 14 (6.6%) mothers presented with negative fetal heart beats from outset, whereas 69
(32.5%) of them showed NRFHRP after induction has commenced. The remaining 129 (60.8%)
mothers did not manifest any sign of fetal heart beat abnormalities.

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Table 2: obstetric factors of induced mothers, at labor Ward of SPHMMC, in Addis Ababa-Ethiopia.
Variable Category Frequency Percent

para 1 97 45.8
Para 2 41 19.3
Para 3 25 11.8
Para 4 6 2.8
para 5 1 0.5
para 1 Abortion 1 15 7.1
Parity Para 2 abortion 1 13 6.1
Para 3 abortion1 9 4.2
para 5 abortion 1 1 0.5
para 1 abortion 2 2 0.9
Para 3 Abortion 2 1 0.5
Para 7 1 0.5
Total 212 100
28 to 36 weeks 17 8
37 to 42 weeks 168 79.2
Gestational age greater than 42 weeks 23 10.8
Unknown 4 1.9
Total 212 100
Ruptured 113 53.3
Membrane Status Not ruptured 99 46.7
Total 212 100
Yes 8 3.8
Liquor foul smelling No 204 96.2
Total 212 100
Yes 39 18.4
Meconium staining No 173 81.6
Total 212 100
Induced by Oxytocin 212 100
Yes 12 5.7
Induction failed No 200 94.3
Total 212 100
C/S 71 33.5
Vaginal delivery 122 57.5
Mode of delivery Instrumental-assisted SVD outlet forceps 5 2.4
Instrumental-assisted SVD Vacuum 14 6.6
Total 212 100
Failed induction 12 5.7
NRFHRP 56 26.4
GIIIMSAF + Severe oligohydrainos 2 0.9
Indication for C/S Cord Prolapse 1 0.5
CPD 1 0.5
Total 72 34
Total 212 100
Uterine rupture No 212 100
Yes 69 32.5
NRFHRP No 129 60.8
negative FHB from outset 14 6.6

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 5.3 Perinatal factors
The weights of neonates were ranging from 1060 grams to around 4000 gram, and the most weight
was between 2010 grams to 3000 grams in 114 (53.8%) neonates followed by those between 3010
grams to 4000 grams 82 (38.7%) were in this category. The minority were those with weight
ranging between 1000 grams to 2000 grams which were only 16 (7.5) of all newborns.

Among all the deliveries after induction 173 (81.6%) of them has Apgar score ranging between 7
to 9 in the first minute and between 7 and 9 in the 5th minutes. Those with APGAR score of zero
at first and fifth minutes were 22 (10.4%) whereas the group of newborns that have APGAR score
ranging between zero and six ate first minutes and between zero and 6 at fifth minutes were
13(6.1%) in number.
Among all deliveries only 19 (9%) of newborns were transferred to NICU for intensive care. In
this study the number of newborn who died were 22 (10.4). Two neonates (0.9%) were of unknown
outcome whereas 188 (88.7%) were alive newborns.

Table 3: Perinatal outcomes of induction for mothers who were induced at labor Ward of SPHMMC,
in Addis Ababa-Ethiopia.
Variable Category Frequency Percent
Yes 69 32.5
NRFHRP No 129 60.8
negative FHB from outset 14 6.6
At first minutes between 0 and six, at 5 minutes
13 6.1
between 0 and 6
At 5 minutes between 7 and 10, at 10 minutes
173 81.6
between 7 and 10
APAGAR Zero at 5 and 10 minutes 22 10.4
Score 1, 4, 8 at 1st, 5th, 10th, respectively 1 0.5
1 and 5 at first and fifth minutes respectively 1 0.5
2, 6, 7, at 1st, 5th and 10th minutes respectively 1 0.5
5,1 at 1st and 5th minutes respectively 1 0.5
Total 212 100
Yes 19 9
Admission to
NICU
No 193 91
Total 212 100
Yes 22 10.4
Perinatal No 188 88.7
death Unknown 2 0.9
Total 212 100

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5.4 Failed induction and associated factors analysis
5.4.1 Prevalence of failed induction

Among all 212 mother who were including in this study, it was found that 12 of (5.7%) had failed
induction whereas 200 of them had successful deliveries by either vaginal delivery, vaginal
assisted delivery or C/S for other indications than failed induction (all failed induction cases were
delivered by C/S as well).

94.3%

5.7%

Figure: The percentage of failed induction for mothers who were induced at labor Ward of
SPHMMC, in Addis Ababa-Ethiopia.

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5.4.2 Binary logistic regression analysis of associated factors
The association was determine using binary logistic regression analysis the software that
was used was SPSS version 20.
There was not association found between failed induction and age of mothers included in
the study with OR of 0.001 (95% CI 0.07-1.23) and P-value of 0.200), AOR 1.20 (95%
CI 0.02-0.232) and P-value of 1.00
Likewise, parity was found to have OR of 0.765 (CI 0.161- 3.632), P-value of 0.736, and
AOR was 0.11 (CI 0.002 – 0.205) and P-value of 0.320
As for gestational age of these mothers the OR was 1.0 (CI 0.001 – 0.0067), P-value of
1.001 and AOR of 0.390 (CI 0.210 – 1.022) with P-value of 0.949
Those mothers with ruptured membranes prior to their induction were found to be 3.66 at
odd of having failed induction with CI of 0.964 - 13.947 but P-value was insignificant (P-
value 0.057 their AOR was 2.321 (CI 0.539 – 9.986) with P-value of 0.258.
The meconium staining of amniotic fluid, liquor foul smelling and birth weight did not
have associated as in the table below.

Table 4: Binary logistic regression analysis of factors associated with failed induction for
mothers who were induced at labor Ward of SPHMMC, in Addis Ababa-Ethiopia.
Factor COR (95% CI) AOR (95% CI ) P-value

Age 0.001 (0.07 – 1.20 (0.02-0.232) 0.200

1.230)
Parity 0.765 (0.161- 0.11 (0.002 – 0.205) 0.736
3.632)
Gestational age 1.0 (0.001 – 0.390 (0.210 – 1.022) 1.001
0.0067)
Membranes status 3.667 (0.964 - 2.321 (0.539 – 9.986) 0.057
13.947)
Liquor smelling 1.60 (0.009 – 1.03) 0.99 (0.002 – 0.130) 0.999
Meconium stained 0.589 (1.003 – 0.85 (0.20 - 1.320) 0.101
1.99)
Birth weight 0.993 (0.304 – 1.335 (0.334 – 5.331) 0.100
3.245)

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 CHAPTER 6

5 Discussion
The induction of the labor is one of the fast growing medical practice. It has been reported that
between the late eighties and late nineties the practice has doubled and some of indications for
induction of labor were not justifiable by taking into account the risk of failure and cost of
subsequent C/S deliveries coupled with burden it imposed on mothers and newborns and varying
outcomes as well.

Study done at multiple hospitals including public hospitals and private hospital as well has shown
that 74.2% of inductions were in public hospitals as compared to only 20.9% in social security
hospital while even less numbers of cases were induced in private hospital, 4.9%, the prevalence
of induction rate was almost uniform in these studies though, it was 13.2%, 14.5% and 12.1 in
public, private and social security hospitals respectively. As per country the prevalence of
induction of labor was reported 5.1% in Peru, 20% in Cuba and 12% in Brazil and Mexico. In our
study there was no way of knowing how the labor started and therefore it was difficult to compute
the prevalence of induction rate without having to review about 2000 medical records of mothers
who delivered within three months, it was found difficult to assess the prevalence of induction at
a time given manpower, time and financial that was required to overview these medical records.
Interestingly the rupture of membranes was found to be the most frequent medical indication of
labor at Peru, Cuba, Brazil and Mexico which is the same in our study, PROM was the single most
frequent indication for induction of labor.

The rate of successful inductions were ranging from 60% in Argentina and Cuba it was found to
be 70-75% in Brazil, Peru, Nicaragua and Mexico, it was 80% in Paraguay and Ecuador. The
striking result was the rate of vaginal delivery after induction which was found to be 5% points
higher when misoprostol was used as compared to oxytocin but the reverse was true in Brazil and
Ecuador. When comparing with our study, the rate of success of induction was as high as 94.3%
which might be explained by the fact that the study was conducted at one single hospital. Since
the method of induction was oxytocin in all the case included in our study, there was no way of
finding out the difference in outcomes of induction when using either oxytocin or misoprostol but

Page | 24
simple fact remain the same that in those countries (Brazil, Nicaragua, Paraguay, Mexico) mostly
used mean of induction was oxytocin whereas misoprostol constituted only 10%, though that was
not the case when it comes to Peru in which misoprostol was used in 52% of cases of induction.

In this studies which included 212 mothers who underwent induction of labor between Dec 2017
and Jan 2018, the prevalence of failed induction was found to be 5.7% (12 out of 212 mother failed
to deliver after induction). This result is a little bit higher than the study done in Pakistan in which
the prevalence of failed induction was found to be 4.6%. In this study the method of induction of
labor was oxytocin infusion as opposed to use of oxytocin, misoprostol and Balloon method that
was reported in study done in Pakistan which probably account to the noticed difference in the
success rate of induction.

In the study done in Cuba the prevalence was said to be 25.3% it was, reported that the commonest
indication for induction was PROM amounting to 25.3 % of all cases of induction, this goes in line
with finding of this study in which commonest induction was PROM, 45 mother (21.2%) were
induced for an indication of premature rupture of membranes. The association found between
mothers who had rupture of membranes prior to induction and failed induction was insignificant
though it was found that those with PROM prior to their induction have odds of 3.66 likelihood
for failed induction but with p-value of 0.057 which was slightly insignificant.

In study done in Zambia in 2013 the mean gestational age was found to be between 36.7 with range
of 28 to 43. The gestational age in this study also range between 28 weeks to 43weeks, the mean
age was found to be almost the same (36.2). In the Zambia study the mothers who were induced
for an indication of hypertensive disorders were 69.3%, those who induced for premature rupture
of membranes were only 15%, about 12.6% were induced for an indication of post term
pregnancies, and 3.1% were reported to have been induced for other indications. Whereas in our
study on contrary 45 mothers (21.2%) were induced for an indication of PROM, those who were
induced for an indication of hypertensive disorders were 35 mothers (16.5%) the induction for post
term constituted 16 participants (7.5%) in our study. Compared to our study, membranes ruptured
in about 18.1% in Zambia study, whereas in this study group, membranes ruptured in more than
half of mothers that were induced (53.3%) which may account the fact that PROM is topping the
list for indication of induction in this study.

Page | 25
In study that was carried out at Hawassa in Ethiopia it was reported that the mean age of mothers
who underwent the induction the labor was 26.9 years. Out of 294 participants who were included
in this study 242 of them were below age of 30, the mean gestational age was 38.98 completed
weeks. Primigravida mothers represent 55.8%. The most frequent indications of induction was
PROM followed by preeclampsia, post term pregnancies then chorioamnionitis was the least on
the list. Concerning the method of induction it was stated that 73.5% were induced by oxytocin
infusion whereas 26.5% were induced either by oral or vaginal misoprostol. On the other hand, in
our study, age of most of mothers were between 25 and 34 (53.8%) followed by the age group
ranging between 16 and 24 (36.3%). Those whose ages were 35 and above were only 20 mothers
(9.4%).

Our study showed the similar results regarding the ranking of indications for induction where
PROM accounted for 21.2% ranking first in prevalence, followed by hypertensive disorders
(16.5%) and post term was the least, only 7.5% were induced as an indicated of post term
pregnancies. In our study the method of induction was oxytocin infusion in all cases (100%). In
study done at Hawassa, 61.6 % of mother who were induced delivered vaginally and the remaining
mothers delivered by C/S. In our study the percentages of those who delivered with vaginal
delivery were comparable with that of Hawassa, 57% delivered by unassisted vaginal delivery,
and 33.5 % delivered by C/S assisted vaginal deliveries were 6.6 for instrumental assisted vacuum
delivery whereas 2.4% delivered by instrumental assisted outlet forceps delivery.

Among those who delivered by C/S NRFHRP was the commonest indication for C/S (26.4%)
followed by failed induction (5.7%). It was reported also in study done at Hawassa that most of
C/S deliveries were for CPD, Fetal distress and failure of induction making these findings to be
similar to ours. The APGAR score of most newborns (81.6%) in our study was between 7 and 8 at
first minute and between 8 and 9 after 5th minutes, this results was comparable with finding in the
study that was carried out in Hawassa which showed the APGAR score of 70.1% of newborns to
be greater than 7 at first minutes and number of newborn who reached APGAR score greater than
7 reached 83.3% after the fifth minute. Some factors has been incriminated to have association
with failure of induction, for instance; parity, PROM, age of mother, pre-induction Bishop score
where mentioned to have varying effect on success or failure of induction, it was reported that
bishop score of 7 or more was favorable factor for success of labor, the fact that we couldn’t test

Page | 26
in our study because there were no records of pre-induction bishop scores in our study group
medical records (only favorable and unfavorable is the common documentation in cards of clients).

It was reported also in study done in Hawassa that primigravida mothers were 3.11 times likely to
ton end up in failed induction when compared to their counterparts. There was no strong
association found in our study between parity and failed induction (OR: 0.736, P-value: 0.765).
The mothers whose ages were greater than 30 years were said to be 9.1 times at odd for failed
induction which is not the case in our study, no association has been found between maternal age
and failure of induction. Rupture of membranes has been found to increase the odds of failure of
induction by 3.66 times when compared to mothers whose membranes were intact at before
induction, but this finding was not statistically significant (P-value of 0.057).

Page | 27
 CHAPTER 7

7. Strength and limitations of the study

7.1 Strength:
- The study was carry out in one hospital in the single setting and medical records were
reviewed in presence of principal investigator to insure the completeness of data collected.

7.2 Limitations:
- There was no documentation of how the labor started, making it difficult to known the
total number of induced cases within study period.
- There was no documentation of pre-induction Bishop Score, the factor that would have
been computed to determine how it might have affected outcome of induction.
- The budget allocated for this study was not adequate for the study.
- It was difficult to review perinatal outcomes beyond first day of delivery.

Page | 28
 CHAPTER 8

8. Conclusion and recommendations

8.1 Conclusion
In this study, the rate of success of labor was interestingly higher compared to other studies done
in the western setting and even compared to those studies in Africa. The commonest
medical/obstetric indication for induction was consistently the premature rupture of membrane as
compared to other studies. All the cases of failed induction were managed by Cesarean section in
our study.

8.2 Recommendation:
- Documentation need to be improved in the delivery registry book since it would be difficult for
investigator to review every Medical record of all the deliveries to determine how labor started.
For instance, it has to be cleared stated how the labor commenced whether it was a spontaneous
labor or was induced one and if the latter was the case then the indication should be added.
- If use of misoprostol was review and considered, it might give us full view of possibility of
applying in our setting.
- Most indication for C/S were indicated for non-reassuring fetal heart rate pattern, and some of this
would have been avoided have there been a better of intra-partum follow of fetal heart rate pattern.
- There is need to carry out the similar research at larger scale to include multiple hospital
in order to get full view about the magnitude of failed inductions and factors incriminated
in failure of induction.

Page | 29
References

1. Leduc, D. (2013). Induction of labor. NY: SOGC PLC

2. Gabbe G. Steven, Niebyl R. Jennifer, Simpson Joe Leigh (2012), Obstetrics Normal
and problem Pregnancies, 6th edition, Philadelphia, Elsevier.

3. Hurissa BF, Geta M, Belachew T (2015) Prevalence of failed induction of labor and
associated factors among women delivered in Hawassa Public health facilities, Ethiopia,
2015. J Women’s health care 4: 253. Doi: 10.4172/2167-0420. 1000253

4. Lydon-Rochelle MT, Ca´rdenas V, Nelson JC, Holt VL, Gardella C, Easterling TR.
Induction of labor in the absence of standard medical indications: incidence and
correlates. Med Care 2007;45:505–12.

5. Indications of failed induction and complications

www.ncbi.nlm.nih.gov/books/NBK53624/ (accessed on Feb.12.2018)

6. Hoffman MK, Vahratian A, Sciscione AC, Troendle JF, Zhang J. Comparison of labor
progression between induced and noninduced multiparous women. Obstet Gynecol
2006;107:1029–34.

7. Khan B. N. ,Ahmed I. ,Malik A. , Sheikh L. (2012) Factors Associated With Failed

Induction Of Labour In A Secondary Care Hospital: Karimabad: pp 7- 8.

8. Chirwa M. (2014) factors associated with failed induction of labour at the university
teaching Hospital, Lusaka. HIA: pp 21-22.

9. Bassetty C. K. , Ahmed D. R (2017) Failed induction of labor: an overview regarding

obstetrics outcome and its significance in a health resource poor setting over period of
11 months International Journal of Reproduction, Contraception, Obstetrics and
Gynecology Bassetty KC et al. Int J Reprod Contracept Obstet Gynecol. Aug;6(8):3646-
3650 www.ijrcog.org

10. Michelson K, Carr D, Easterling T 2008. The impact of duration of labor induction
on caesarean rate. Am J Obstet Gynecol; 199: 299.e1-4

11. WHO 2011 recommendations for induction of labour. Geneva: World Health
Organization, (available at:

Page | 30
 http://whqlibdoc.who.int/publications/2011/9789241501156_en .pdf) accessed on 12th
February 20118

12. Vrouenraets F, Roumen F, Dehing C 2005. Bishop score and risk of cesarean
delivery after induction of labor in nulliparous women. Obstet Gynecol, 105, 690–697.
WHO 2010 Global Survey on Maternal and Perinatal Health. Induction of labour data.
Geneva, World health Organization, (accessed 12 February 2018 at
http://www.who.int/reproductivehealth/topics/best_practices/global_survey) accessed
on 12 Feb 2018

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Appendix
Questionnaire

A questionnaire prepared to determine prevalence and factors associated with failed

induction at St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia.

Data Collector Code__________

This questionnaire is prepared to assess prevalence and associated factors of failed induction
at SPHMMC from Dec 2017 to Feb 2018. The data collected will be used only for research
purposes. You’re voluntarily filling this questionnaire so please be honest while answering to
each section. Thank you.

Language of questionnaire: English

Languages that the data collector can speak: _____, ______, _____ and ______
 Fill all the follow questions by either circling one option or entering the information where
appropriate from participant medical records

Participant No____________ MRN__________ Date__________

Part I. 101. Age ………………..
Socio-Demographic 102. Parity ………………..
and baseline health 103. Marital status 1. Single
information 2. Married
3. Widowed
4. Divorced
5. Other (specify)……
104. Ethnicity 1. Oromo
2. Amhara
3. Tigrie
4. Guragie
5. Somali
6. Other (specify)…….
105. Education level 1. Illiterate
2. From grade 1 to grade 5
3. From grade 5 to grade 8
4. From grade 8 to grade 12
5. Diploma
6. Degree
7. Master Degree
8. PhD
9. Others (specify)…….
106. Occupation 1. Unemployed
2. Farmer
3. Others ……..
107. Religion 1. Christianity
2. Islam

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 3. Other (specify)……….
108. Residential address …………………………
Part II 109. Date and time 1. Date in EC.……
Induction of labor induction commenced 2. Time in international …
110. Indication for 1. Post term
induction 2. PROM
3. Hypertensive disorders
4. Diabetes
5. IUGR
6. Other (specify)
111. Gestational age in G/A: ………….weeks
weeks
112. Membranes ruptured 1. Yes
before induction 2. No
If yes go to number 113
if no jump number 113
and go to 114
113. Liquor foul smelling 1. Yes
2. No
114. Bishop Score (if any) …………
115. Method of induction 1. Oxytocin
2. Misoprostol
3. Foley catheter
4. Other (Specify)………
116. If misoprostol only, 1. Vaginal
route of administration 2. Oral
3. Sublingual
4. Not applicable
117. If misoprostol, what 1. 50µg
was total amount given 2. 100 µg

Page | 3
 3. 150 µg
4. 200 µg
5. > 200 µg
118. Was there uterine 1. Yes
hyper-stimulation 2. No
3. Unknown
119. Was fetal heart rate 1. Yes
pattern non reassuring 2. No
after induction 3. Unknown
120. Was the color of liquor 1. Yes
meconium stained 2. No
121. What was the ultimate 1. Vaginal delivery
mode of delivery 2. Instrumental-assisted SVD
3. Cesarean section (C/S)
122. If delivery was by C/S 1. Failed induction of labor
what was the indication 2. Fetal distress
3. CPD
4. Malposition
5. Other (specify)………..
123. Did uterus rupture 1. Yes
2. No
124. Other serious Specify ……………….
morbidity
125. Date and time of 1. Date: ……..…..………
delivery 2. Time: …………………
126. Birthweight in grams Birth weight……Grams
127. APGAR Score 1. 1st min ………
2. 5th min ………
3. 10 min ………

Page | 4
 128. Admission to NICU 1. Yes
after delivery 2. No
129. If yes to Q129, Reason: ………………..
mention reason for ……………………….
admission
130. Perinatal death 1. Yes
2. No
3. Unknown

Thanks for your help

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