Transcript Induction and Augmentation of Labor with Oxytocin or

Use of oxytocin
and misoprostol
for induction or
augmentation of
labor
in low-resource
settings
A Report of a Working Meeting
POPPHI project, PATH, Washington DC
March 20, 2008
Prepared by: Ann Lovold, BHSc, RM, MPH
Cynthia Stanton, PhD
Department of Population, Family and Reproductive Health
The Johns Hopkins Bloomberg School of Public Health
Baltimore, Maryland
Background

International agencies, NGO projects and national
health programs are promoting the expanded
availability of uterotonics (particularly oxytocin) for
AMSTL purposes to prevent postpartum
hemorrhage


Especially to peripheral services
Such (needed) expansion raises concerns regarding
the inappropriate use of uterotonics for other
reasons – induction and augmentation
Background

The literature and anecdotal information
suggest induction and augmentation are
taking place in low resource settings





Electively
Improperly administered
Inadequately monitored
In all levels of health facilities
At home births
A few examples:

W Africa: Demi Demi - an observed practice of giving 5IU
oxytocin IM in each buttock to begin or speed up labor;

Nigerian study: 61% of inductions reviewed in the hospital had
incorrect dose, route and/or monitoring (Ezechi 2004);

Nepal: 22% of 527 mothers who had home births with TBAs
reported oxytocin injections during labor (Sharan et al. 2005);

Bangledesh: nurse negotiates with family and provides “an
injection” to avoid the cesarean recommended by the physician
(Parkhurst and Rahaman 2007)

Brazil: Women who cannot afford elective CS, choose elective
induction, only those who are very poor have no interventions
(Behague 2002);
Objectives of the Expert Meeting
1.
2.
3.
4.
5.
Summarize the literature review and working
paper.
Discussion of content.
Making a decision about whether this is an
important public health problem.
Seeking feedback on recommendations and
next steps.
To identify potential partners, agencies and
groups for leadership.
Summary of working paper: Data sources
for the review:
1.
Compilation of international obstetric
practice guidelines;
2.
Analysis of induction and augmentation
rates from a seven country study on
AMTSL; and
3.
A structured literature review
Literature Review Summary
Databases searched: PubMed; Embase; CINAHL Plus; Scopus; Cochrane database
Databases searched: PubMed; Embase; CINAHL Plus; Scopus; Cochrane database
References identified (excluding duplicates): 962
References identified (excluding duplicates): 962
References remaining after review
of abstracts: 278
References
References meeting
meeting
inclusion/exclusion
criteria
inclusion/exclusion criteria after
after full
full
review
of
article:
140
review of article: 140
Reference providing
Reference
providing
rates, trends
or
rates,
trends43
or
indications:
indications: 43
References specifically on
elective
inductions:
12 on
References
specifically
elective inductions: 12
References providing data
References
providing
data
on misoprostol
for
on
misoprostol for
induction/augmentation:
7
induction/augmentation: 7
References providing data
on
maternal/perinatal
References
providing data
outcomes:
24
on maternal/perinatal
References specifically
on low resource settings:
References
specifically
36
on low resource settings:
36
outcomes: 24
Meta-analyses identified
and reviewed in the
Meta-analyses
identified
Cochrane library:
18
and reviewed in the
Cochrane library: 18
Current Recommendations

Misoprostol
25ug vaginally every four hours until delivery
or 50ug orally every four hours until delivery
or 25ug vaginally, then after four hours start 25ug
solution orally every two hours (take 25mls of a
solution made up of a 200ug tablet dissolved in
200mls water
For IUFD, the dose may be doubled if two doses have
no effect
National induction rates in HRS
Country
Sweden
Reference year
Induction Rate
(in %)
2001-2002
33.2
2006
36.7
France
1981-1995
25.0
Scotland
2003-2004
24.0
New Zealand
2004
20.4
USA
2005
22.3
Canada
2000-2001
22.0
UK
2005-2006
20.2
2004
19.1
1993-2002
15.0
Australia
Wales
The Netherlands
0
5
10
15 20
30
40
Rising trends in induction in HRS
1988
1992
1996
2000
Reference Yr
UK
Canada
France
2004
USA
Netherland
New Zealand
2008
Outcome of CS with elective induction vs.
spontaneous labor. Odds Ratios and 95% confidence
intervals.
Scheiner 02
(Isreal)
Seyb '98
(USA)
Prysak '98
(USA)
Maslow '00
(USA)
Johnson '03
(USA)
Glantz '05
(USA)
Crane '03
(Canada)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Induction and augmentation rates from 7 LRS
countries (source: AMSTL study)
Nicaragua
17.1
Honduras
32.1
10.5
32.3
El Salvador
22.6
Indonesia
57.2
18.8
25.5
Tanzania
8.3
Ethiopia 0.5
58.6
18.3
56.2
8.7
83.0
11.9
Benin 3.2
0%
50.8
87.6
37.9
10%
20%
58.9
30%
40%
50%
60%
70%
% of deliveries
Induced
Augmented only
Neither
80%
90%
100%
Hospital specific rates of induction in LRS
from the literature.
Author/year
Country
Data collection year
Rate of induced
labor
(%)
Loto O, Fadahunsi
A, et al., 2004
Nigeria
Behague D, et al.,
2002
Brazil
Chigbu C, Exeome
I, et al., 2007
Saunders D and
Makutu S, 2001
Denominator
2002-3
18
All deliveries
1993
31.2
All deliveries
Nigeria
2003-06
16.3
All deliveries
Fiji
1986-96
14
All deliveries
Hospital specific rates of elective
induction in LRS
Author
Oboro V, Isawumi
A, et al., 2007
Reference
year
Country
Rate (in %)
2001-2005
Nigeria
13.7
Saunders D and
Makutu S,
2001
1986-96
Fiji
30.0
Chigbu C,
Ezeome I et
al., 2007
2003-2006
Nigeria
7.4
Uterine Rupture and induction in LRS
Author
Reference
year
Country
% of uterine
ruptures
associated with
induction
Notes from authors
Aboyeji A, Ijaiya M
et al., 2001
1992-1999
Nigeria
39 Unskilled use of
oxytocin
Ahmed S, 2001
1992-1997
Sudan
Al-Jufairi A, 2001
1990-1999
Bahrain
Chuni N, 2006
1999-2004
Nepal
Ezechi O, 2004
1991-2000
Nigeria
41 61%of inductions in
hospital had wrong
dose, route and
monitoring
Konje J, Odukoya
O, et al., 1990
1975-1986
Nigeria
4.9 Others suffered from no
access to
augmentation
10.5 Injudicious use of
oxytocin outside of
hospital
>50 Oxytocin used
excessively
44
Neonatal Outcomes in LRS

Most cases of ruptured uterus also result in
perinatal death.

Dujardin et al: increased risk of stillbirth and
resuscitation shown for those with oxytocin
use during normal labor (augmentation) in 3
sub-Saharan African countries.

High priority for research due to lack of data.
Non-pharmacological methods
Mechanical dilators:
Cochrane review shows
less risk than oxytocin or
misoprostol
Stripping of membranes:
shortens pregnancy,
reduces post-dates. No
increased infection risk.
ARM: no evidence to do it
routinely, avoid with HIV
positive.
Availability
Oxytocin
Misoprostol
Outcome of working group:

The group found the issue to be of public
health importance and that we should move
forward on it.
Next Steps

Define/quantify the public health problem in
terms of maternal and perinatal
mortaltiy/morbidity.

Prioritize recommendations

Build bridges between those responsible for
reproductive and neonatal issues in terms of
funding, programs and research.
Priorities
Research Priority: gathering empirical data to describe the
magnitude of the problem in public, private and home
based deliveries.
Clinical Practice Guidelines: ideally headed by WHO with
support of FIGO and ICM to address appropriate
indications, parameters and methods of both oxytocin
and misoprostol use for induction and augmentation
specifically in low resource settings.
Address out of hospital use of oxytocin and misoprostol
(materials, community based, research).
Thank you