AOGD BULLETIN

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AL COLLEGE &
DIC SA
ME FD
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VARDHMA

PITAL
ERVICE OF HUMAN
T HE S IT Y

Volume 21 I May 2021 I Monthly Issue 1

IN

Dedicated Issue:
“Labour: The Evidence-Based Management”

AOGD SECRETARIAT
Room Number 001, Ward 6, Department of Obstetrics & Gynaecology
Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi- 110 029
Email: aogdsjh2021@gmail.com | www.aogd.org | Tel: 01126730487
2 AOGD Bulletin
 AL COLLEGE &
D IC SA
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IR A
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AOGD Office Bearers 2021-22

R
AH

JU
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NG
HO S
VARDHMA

PITAL
Patrons Chief Advisor
Dr S N Mukherji Dr Pratima Mittal ERVICE OF HUMAN
T HE S IT Y
Dr Urmil Sharma IN

Dr Kamal Buckshee President

Dr Sheila Mehra Dr Achla Batra
Dr Indrani Ganguli
Dr V L Bhargava
Vice President
Dr Jyotsna Suri
AOGD Bulletin
Volume 21 • Monthly Issue 1 • May 2021
Advisors Secretary
Dr Alka Kriplani Dr Monika Gupta
Dr Neera Agarwal
• Foreword 5
Dr Pratima Mittal Treasurer • From the President’s Pen 6
Dr Renuka Sinha Dr Upma Saxena
Dr Shakti Bhan Khanna • From the Vice President’s Pen 7
Editor
Dr Sharda Jain Dr Rekha Bharti • From the Secretary’s Desk 8
Dr Shashi Prateek
Dr Shubha Sagar Trivedi Web Editor • From the Editor’s Desk 9
Dr Sudha Salhan Dr Sumitra Bachani • Important Announcement: Invitation 10
Dr Suneeta Mittal
Dr Swaraj Batra Joint Secretaries for Membership of AOGD Sub Committees
Dr Anita Kumar
Ex Officio Dr Divya Pandey Part 1: Invited Articles
Executive Past Presidents
Dr P Chaddha (1990-94) Co- Treasurer • Labour Management: Newer Perspective 11
Dr Neera Agarwal (1994-97) Dr Ritu Aggarwal Divya Pandey, Shivangi Sharma
Dr Maya Sood (1997-99) Co-Editors • Intrapartum Foetal Monitoring: The Art of Interpretation 16
Dr D Takkar (1999-2001) Dr Archana Mishra
Dr Sudha Salhan (2001-03)
Manju Khemani
Dr Sheeba Marwah
Dr Swaraj Batra (2003-05) Dr Saumya Prasad • Labour Analgesia: Where Epidural is not Feasible 22
Dr N B Vaid (2005-06) Kavita Agarwal, Bhawina Saran
Dr S S Trivedi (2006-07) Co-Web Editors
Dr Sunita Mittal (2007-08) Dr Sarita Singh • Induction of Labour: Monitoring and Management of 28
Dr I Ganguli (2008-09) Dr Nishi Chaudhary
Complications
Dr Shashi Prateek (2009-10) Scientific Committee Megha Mittal, Jyotsna Suri
Dr U Manaktala (2010-11) Dr Anjal Dabral
Dr Neerja Goel (2011-12) Dr H P Anand • Third Stage of Labour: Prevention and Management of PPH 31
Dr C Ragunandan (2012-13) Dr Rupali Dewan Aakriti Batra, Achla Batra
Dr Alka Kriplani (2013-14) Dr Sunita Malik
Dr U P Jha (2014-15) • Reducing Caesarean Birth: Non-clinical Interventions 38
Dr Vijay Zutshi
Dr Pratima Mittal (2015-16) Dr Sonam Topden
Zeba Khanam, Pratima Mittal
Dr Sudha Prasad (2016-17) Dr Bindu Bajaj
Dr Shalini Rajaram (2017-18) Dr Harsha S Gaikwad Part 2: Original Articles
Dr Abha Singh (2018-19) Dr Saritha Shamsunder • Simplified Bishop’s Score for Prediction of Successful 42
Dr Sunesh Kumar (2019-20) Dr Garima Kapoor Induction of Labour in Nulliparous Women
Executive Members CME Co-ordinators Suchandana Dasgupta, Rekha Bharti, Pratima Mittal
Dr Amita Suneja
Dr Anjali Dabral
Dr Renu Arora Jyotsna Suri, Sumitra Bachani, Divya Pandey
Dr K Usha Rani
Dr Ashok Kumar Dr Sujata Das • Correlation of Digital Vaginal Examination with 47
Dr Asmita Rathore
Dr Dinesh Kansal
Dr Dipti Sharma Transabdominal Ultrasound to Assess Foetal Head Position
Dr Ila Gupta Public Relation Committee Prior to Operative Vaginal and Caesarean Delivery
Dr Indu Chawla Dr Sunita Yadav Manisha Verma, Niharika Guleria, Sumitra Bachani
Dr Kawal Gujral Dr Yamini Sarwal Pratima Mittal, Jyotsna Suri, Rekha Bharti
Dr Manju Khemani Dr Kavita Aggarwal
Dr Manju Puri Dr Kashika • Journal Scan 53
Dr Meenakshi Ahuja
Immediate Past President
Sheeba Marwah, Saumya Prasad
Dr Mrinalini Mani
Dr Neerja Bhatla Dr Mala Srivastava • Cross Word Puzzle 55
Dr Nisha Jain Immediate Past Vice-President Niharika Guleria
Dr Ranjana Sharma Dr Kanika Jain
Dr Rekha Mehra
• Pictorial Quiz 55
Dr Renu Mishra Immediate Past Secretary Divya Pandey
Dr S N Basu Dr Mamta Dagar
• AOGD Membership Form 57
Dr Sangeeta Gupta Chairperson AOGD Sub-Committees
Dr Sanjeevani Khanna Dr Anita Rajorhia
Dr Sonia Malik
Disclaimer
Dr Anjila Aneja The advertisements in this bulletin are not a warranty, endorsement or approval of
Dr Sunita Lamba Dr Deepti Goswami
Dr Taru Gupta the products or services. The statements and opinions contained in the articles of the
Dr Geeta Mediratta
AOGD Bulletin are solely those of the individual authors and contributors, and do not
Finance Committee Dr Jyoti Bhaskar
Dr Kanika Jain necessarily reflect the opinions or recommendations of the publisher. The publisher
Dr Abha Singh
Dr Manju Puri Dr K Aparna Sharma disclaims responsibility of any injury to persons or property resulting from any ideas or
Dr N B Vaid Dr Kavita Aggarwal products referred to in the articles or advertisements.
Dr Pratima Mittal Dr Manju Puri Plagiarism Disclaimer
Dr Reva Tripathi Dr Sangeeta Gupta Any plagiarism in the articles will be the sole responsibility of the authors, the editorial
Dr Shalini Rajaram Dr Shashi Lata Kabra Maheshwari
board or publisher will not be responsible for this.
Dr Sudha Prasad Dr Seema Prakash
Dr Sunesh Kumar Dr Seema Thakur Publisher/Printer/Editor
Dr U P Jha Dr Sujata Das Dr Rekha Bharti on behalf of Association of Obstetricians & Gynecologists of Delhi.
Mr Pankaj Jain (CA) Dr Sunita Malik
Printed at
Dr Surveen Ghumman
Dr Sushma Sinha
Process & Spot C-112/3, Naraina Industrial Area, Phase-1, New Delhi 110 028
Published from
AOGD Secretariat Department of Obstetrics & Gynaecology
Room Number 001, Ward 6, Department of Obstetrics & Gynaecology Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi -110 029
VMMC & Safdarjung Hospital, New Delhi - 110 029
Tel.: 01126730487 Editor
E-mail: aogdsjh2021@gmail.com | www.aogd.org Dr Rekha Bharti
Ph. No. 01126730487; Email: editorsaogd2021@gmail.com

Vol.21, No.1; May, 2021 3

 AOGD Office-Bearers 2021-22

Dr Pratima Mittal Dr Achla Batra Dr Jyotsna Suri

Chief Advisor President Vice President

Dr Monika Gupta Dr Upma Saxena

Secretary Treasurer

Dr Anita Kumar Dr Divya Pandey Dr Ritu Aggarwal

Joint Secretaries Co-Treasurer

Editorial Board

Dr Rekha Bharti Dr Sumitra Bachani

Editor-in-chief Web Editor

Dr Archana Mishra Dr Sheeba Marwah Dr Saumya Prasad Dr Sarita Singh Dr Nishi Chaudhary
Co-Editors Co-Web Editors

Commi ees

Dr Anjal Dabral Dr H P Anand Dr Rupali Dewan Dr Sunita Malik Dr Vijay Zutshi

Dr Sonam Topden Dr Harsha S Gaikwad Dr Bindu Bajaj Dr Saritha Shamsunder Dr Garima Kapoor
Scientific Committee

Dr Renu Arora Dr K Usha Rani Dr Sujata Das Dr Dipti Sharma Dr Sunita Yadav Dr Yamini Sarwal Dr Kavita Aggarwal Dr Kashika
CME Co-ordinators Public Relation Committee

4 AOGD Bulletin
 Foreword
It is a great pleasure to write a Foreword for this excellent publication of the 1st issue
of AOGD Bulletin for 2021-22. One wonders with great satisfaction to see the admirable
growth and development of AOGD Bulletin during the last few years. The attractive cover,
get-up, valued informative and educative contents etc. are evidences of sincere efforts
put on by respective Editorial Boards. The esteemed bulletin may earn the distinction
of a regular scientific journal as it is now incorporating original peer review articles also.
Incidentally, one is reminded of our 1st AOGD Bulletin, of 1978, our humble attempt in the
form of a 4-paged folder with typed informative and educative materials for AOGD members.
I learn that the Theme of AOGD for 2021-22 is: Promote Women’s Health by Strong Will and Quality
Skill. It is a timely and appropriate approach towards care of women’s health. It should be the foremost
duty of each obstetrician and gynaecologist to protect, preserve and promote women’s health, with special
reference to maternal health.
The 1st AOGD Bulletin released by Safdarjung Hospital team is dedicated to “Labour: The Evidence- Based
Management“. Evidence based medicine forms the keyword in health care. Care based protocols for labour
management will improve the clinical outcome of the mother and the newborn. This issue contains several
important articles related to labour and its management. The last decade witnessed a few advances in
concept and understanding the dynamics and management of labour. The essence of labour management
lies on maternal well-being, fetal well -being and progress of labour. Constant nursing care in labour, upright
or lateral position, avoidance of epidural anesthesia, use of partograms and appropriate use of syntocinon
-- all help to reduce the requirement of instrumental delivery.
The scientific content of the bulletin is amply rich. The articles, contributed by learned experts, are educative,
comprehensive and up-to-date. The dedicated editors must be complimented for their excellent work. It is
sincerely hoped that this superb publication will be widely used by AOGD members and others.

Dr S N Mukherjee
Founder Member & Patron
AOGD

Vol.21, No.1; May, 2021 5

 From the President’s Pen
Warm Greetings to all esteemed AOGD members!
It is an honour and privilege to represent AOGD as its President and with it comes the
responsibility of serving the largest society in the country with almost 2500 members. We
are fortunate to have with us a galaxy of esteemed patrons, advisers and executive council
members to guide us with their wisdom and experience.
The theme this year is "Promote Women’s Health by Strong Will and Quality Skill". The
focus of the strong will would be on adolescent health and cancer prevention. Quality skill
would be provided to all health care workers so that they can provide quality maternity care to all women
with special emphasis on training in critical care.
We will continue to provide continuing medical education through webinars and also will keep apprising
all members about latest developments through bulletins and our website. Don’t forget to open the new
updates tab on our website. AOGD as the largest society also has some responsibility of creating database
and doing quality research. I request all of you to participate in whatever research is planned by AOGD.
This year we have asked our respected senior members to write a foreword to our bulletin so as to learn
from their wisdom. This issue has blessings of our respected Dr SN Mukherjee who is a founder member and
patron of AOGD.
The upheaval caused by COVID 19 has been something which has not been seen by any of us in our lifetime.
We medical professionals are being looked upon to provide help and guidance. Life goes on, procreation
does not stop. We as obstetricians must remember that there is a large population of noncovid pregnant
women who need our care. Hence AOGD has a huge responsibility in these testing times and it will be
a mammoth challenge to fulfil it. My team at VMMC and Safdarjung Hospital and all the subcommittee
chairpersons are the strength of AOGD. Together we will all sail through this crisis by supporting each other
and keeping positivity in mind.
In the past two decades, considerable efforts have been made to encourage and support pregnant women
to give birth in health facilities, where they ideally receive good‐quality intrapartum care from skilled health
personnel. An essential component of this care is ensuring that women are adequately monitored during
labour. WHO has initiated the development of a “next generation” partograph known as the WHO Labour
Care Guide. This design was intended to promote woman-centred care, stimulate practitioners to think
critically around labour decision- making and individualize labour monitoring. To commemorate this, our
first issue is dedicated to Labour management as it is Labour which redefines a woman in the form of a
mother.
I take this opportunity to announce the dates for our 43rd Annual Conference, 20th - 21st November 2021.
We plan to hold the precongress workshops and other scientific events in the preceding week. The event is
likely to be in the hybrid mode.
“Everything will be okay in the end. If it’s not okay, it’s not the end”......... John Lennon

Dr Achla Batra
President, AOGD (2021-2022)

Block your dates for 43rd Annual Conference 2021 to be held on 20th - 21st November, 2021

6 AOGD Bulletin
 From the Vice-President’s Pen
Dear Friends
It gives me immense pride to write this note for our AOGD Bulletin as the Vice President
of AOGD.
AOGD Bulletin has come a long way from its original ‘newsletter’. At the turn of this century
when the Secretariat was at Safdarjung Hospital, this scientific publication was for the first
time presented as a ‘bulletin’ and now after two decades we are striving to improve the
scientific content of this publication by including peer reviewed original research articles.
This will be a step in the direction of achieving some basic indexing. I am sure that our Editorial Team headed
by the dynamic and hard-working Dr Rekha Bharti will make this mammoth target plausible.
Notwithstanding the most difficult and challenging times we are facing, the Team of AOGD 2021-22 will
leave no stone unturned to provide our Fellow members with the latest updates through this Bulletin as
well as through the webinars and CMEs.
Stay well and safe

Dr Jyotsna Suri
Vice President, AOGD (2021-2022)

Vol.21, No.1; May, 2021 7

 From the Secretary’s Desk
Warm greetings to all!
First of all, I would like to express my heartfelt thanks to Dr. Achla Batra for trusting me with
responsibility of post of Secretary, AOGD. Her vision has always been a constant guiding
light. We are thrilled to have AOGD secretariat finally here at Safdarjung Hospital and as
Secretary, it’s my promise that I, with support of our great team would not leave any stone
unturned to make events at AOGD an enriching experience.
As the theme of this year at AOGD 2021-22 is "Promote Women’s Health by Strong Will
and Quality Skill", we at Safdarjung Hospital are committed to provide quality care to women with utmost
skill and strong will, which is all the more important in this challenging pandemic. Our team at AOGD
secretariat is meticulously planning events and academic feasts to promote and propagate a behaviour
which should be every woman’s right.
In today’s world, where conducting a normal delivery is increasingly becoming an art; with rate of caesarean
sections on rise, we bring you our first bulletin from VMMC and Safdarjung Hospital on “Labour: The
Evidence based Management”; just in time before it becomes a forgotten skill. Our editorial team has put
forward a fantastic line up which would definitely make up for a good read.
With a virtual world and screens between us being the new normal, we would keep on putting our best
efforts to continue the legacy of online learning with webinars and e-CMEs on various platforms. Being
restricted to our rooms won’t limit the learning process that our minds continuously strive for.
Saving lives is definitely going to be our primary objective in this grim situation but learning and growth
will never take a backseat. On that note, I’d like to end; rather I should say start with this great prose by Sir
J G Whittier
“So stick to the fight when you are hardest hit, it’s when things seem worst that you must not quit.”

Dr Monika Gupta
Secretary, AOGD (2021-2022)

8 AOGD Bulletin
 From the Editor’s Desk
Greetings from the editorial board,
It gives me immense pleasure to present to you the first issue of AOGD bulletin for the year
2021-2022. I am grateful to Dr Achla Batra, President AOGD for entrusting me with this
opportunity. Of course this opportunity has come with a huge responsibility of keeping
up with the standards set up by my predecessors.
The theme of AOGD for this year is “Promote Women’s Health by Strong Will and
Quality Skill”. Keeping in line with this theme we are dedicating our first issue to “Labour:
The Evidence based Management”. Providing quality care during labour has been identified as the most
crucial step in preventing adverse pregnancy outcome. The labour has been redefined and definitions of
the duration of various stages of labour have evolved in the recent past. Hence, the recommendations to
provide quality care for improving the health and well-being of women and their babies have also changed.
On behalf of the editorial team I thank all the authors for their contribution in covering important aspects
of labour management in their articles. WHO recently introduced “WHO Labour Care Guide- the next
generation partograph” for Labour Monitoring and Documentation. Intrapartum Foetal Monitoring is
important for delivery of healthy baby; however, the available technology has to be appropriately used to
avoid unnecessary interventions. With the change in the duration of normal labour, women are expected
to spend more time in labour and it is important to provide adequate pain relief. Although, epidural
analgesia is most appropriate for providing Intrapartum Pain Relief, it may not be feasible in all settings
and there is a need to resort to various pharmacological and non- pharmacological options. Induction of
Labour is the most frequent obstetric intervention done in approximately one fourth of pregnancies. It is
therefore important to know the complications associated with labour induction and their management.
Other important topics discussed in this issue are Prevention and Management of PPH and Nonclinical
Strategies for Reducing Caesarean Section Rates.
This year we have introduced two new features to our bulletin, the foreword by our respected senior
members of the society, and two original articles. We are thankful to Dr S N Mukherjee, Founder Member
and Patron of our society for giving a kick start to our bulletin by writing the foreword for our first issue.
To acknowledge the hard work put in by the authors and to encourage the readership of our bulletin, a
quiz on the articles published in the same month's bulletin will be organised during the monthly AOGD
meetings.
Happy Reading!

Dr Rekha Bharti
Editor, AOGD (2021-2022)
editorsaogd2021@gmail.com

Editorial Board 2021-2022

First Row: Archana Mishra, Sheeba Marwah, Saumya Prasad
Second Row: Zeba Khanam, Rekha Bharti, Niharika Guleria
Third Row: Akanksha Dwivedi, Aakriti Batra, Shubham Bidhuri

Vol.21, No.1; May, 2021 9

 Announcement
AOGD members are invited to become members of various Sub-committees.
Please contact respective Chairpersons.
Membership of Maximum two Sub-committees can be taken at a time.

AOGD Subcommi ee Chairpersons

Adolescent Committee Breast and Cervical Cancer
Dr Anita Rajorhia Awareness, Screening &
9711177891 Prevention Committee
anitarajorhia716@gmail. Dr Sushuma Sinha
com 9717691898
sushmasinha@gmail.com

Endometriosis Committee Endoscopy Committee Fetal Medicine and Genetics

Dr Anjila Aneja Dr Kanika Jain Committee
9810059519 9811022255 Dr Seema Thakur
anjilaaneja1966@gmail.com dr.kanika@gmail.com 9818387430
seematranjan@gmail.com

Infertility Committee Multidisciplinary Patient Oncology Committee

Dr Kavita Aggarwal Sub-committee Dr Sunita Malik
9990167888 Dr Shashi Lata 9818914579
drku93@gmail.com Kabra Maheshwari svmalik@yahoo.com
9718990168
drshashikabra@gmail.com

QI Obst & Gynae Practice Reproductive Endocrinology Rural Health Committee

Committee Committee Dr Seema Prakash
Dr K Aparna Sharma Dr Surveen Ghumman 9818225007
9711824415 9810475476 seemaprakash2502@gmail.com
kaparnasharma@gmail.com surveen12@gmail.com

Safe Motherhood Urogynaecology

Committee Committee
Dr Manju Puri Dr Geeta Mediratta
9313496933 9810126985
drmanjupuri@gmail.com gmediratta@yahoo.com

AOGD Subcommi ee Co-Chairpersons

Adolescent Committee Fetal Medicine and Genetics
Dr Sujata Das Committee
Co-chairperson Dr Sangeeta Gupta
9971346064 Co-chairperson
drdassujata2110@gmail.com 9968604349
drsangeetamamc@gmail.
com

QI Obst & Gynae Practice Reproductive Endocrinology

Committee Committee
Dr Jyoti Bhaskar Dr Deepti Goswami
Co-chairperson Co-chairperson
9711191648 9968604348
jytbhaskar@yahoo.com drdeeptigoswami@hotmail.com

10 AOGD Bulletin
 Labour Management: Newer Perspective
Divya Pandey1, Shivangi Sharma2
1 2
Associate Professor, Post graduate Resident, Department of Obstetrics and Gynaecology, VMMC & Safdarjung Hospital, Delhi

More than one third of maternal deaths, half of The above concept of labour progression was
stillbirths and a quarter of neonatal deaths result challenged by Zhang et al (2010). In their
from complications during labour and childbirth.1,2 multicentric retrospective study at 19 centres of US
Majority of these deaths occur in low-resource on 62,415 parturients, authors found that labour
settings and are largely preventable through may take over 6 hours to progress from 4 to 5 cm and
timely interventions.3 Monitoring of labour and over 3 hours to progress from 5 to 6 cm of dilation.
childbirth, and early identification and treatment Nulliparas and multiparas appeared to progress
of complications are critical for preventing adverse at a similar pace before 6 cm. However, after 6 cm
birth outcomes. labour accelerated much faster in multiparas than
Historical Perspective: The first graphical analysis in nulliparas. The 95th percentile of the 2nd stage
of labour was given by Emanuel Friedman in 1954 of labour in nulliparas with and without epidural
where in sigmoid curve represented normal labour analgesia was 3.6 and 2.8 hours, respectively. They
characteristics. The sigmoid shape was explained concluded that in a large, contemporary population,
by a slower rate of cervical dilatation till 3 cm (i.e. the rate of cervical dilation accelerated after 6 cm
latent phase) followed by abrupt acceleration in the and progress from 4 to 6 cm was far slower than
rate of dilatation (i.e. active phase) till 9 cm followed previously described by Friedman. Allowing labour
by a deceleration phase. Accordingly, the statistical to continue for a longer period before 6 cm of
minimum (5th centile) of normal cervical dilatation cervical dilation may reduce the rate of intrapartum
during active phase was given as 1.2 cm/hr in and subsequent repeat caesarean deliveries. It was
nullipara and 1.5 cm/hr in multipara respectively.4 also found that the transition from latent to active
Later in 1972, RH Philpott and Castle came up with phase occurred at 6 cm and the change was gradual
the concept of alert line in cervicographs for easing rather than abrupt.5 Their recommendations were
identification of abnormal labours and therefore adopted by ACOG in 2014 and they defined start of
their timely referral to the tertiary centre. active phase from 6 cm.

WHO Partographs: After WHO Safe Motherhood Meanwhile, the globe was observing a steep rise
initiative in 1987, different partograph designs were in the rate of Caesarean Sections (CS). WHO in
introduced. WHO Comprehensive Partograph was 2011 after systematic review and critical appraisal
introduced in 1994, with a latent phase of 8 hours of available classification systems, concluded that
and active phase of 3-cm. Alert line with a slope of Robson Ten Group Classification System (TGCS) is
1 cm/hr was there with an action line, 4 hours to the the best to fulfil local as well as international needs to
right and parallel to the alert line. In this partograph, compare, monitor and audit caesarean deliveries at
it was however difficult to show the transition from all centres. When applied, this TGCS showed that the
the latent to active phase. Moreover, it was observed major contributor group to CS were group 5 (term
that there was increased interference in form of pregnancy with cephalic presentation with previous
caesarean sections on account of prolonged latent CS) and Group 1 and 2 (nulliparous pregnant
phase. Hence in 2000, Modified WHO Partograph women with term gestation, cephalic presentation
was introduced. Here the latent phase representation in spontaneous/induced/not in labour). On further
was dropped and the active phase started from 4 cm. analysis it was found that 50-80% of primary CS
Colour coded zones were added in this and WHO were due to indications pertaining to intrapartum
Simplified partograph was introduced for easing management. Thus there was a clear need of proper
the use and interpretation. Area to left of the alert line labour monitoring in order to cut down the rising
was coloured green representing the normal progress figures of primary CS.
while that to the right of action line was coloured With all this background, WHO recommendations
red indicating dangerously slow progress. The area for intra partum care for positive childbirth
between the alert and action line was coloured amber experience (2018) were introduced. The main
indicating the need for greater vigilance. emphasis is on the supportive care throughout birth

Vol.21, No.1; May, 2021 11

and labour which include respectful maternity care, for women; (c) assist skilled health personnel to
effective communication and informed consent, promptly identify and address emerging labour
emotional support and companionship, pain relief complications, by providing reference thresholds
strategies, oral fluid and food intake, mobility in for labour observations that are intended to trigger
labour and adopting birth position of choice, regular reflection and specific action(s) if an abnormal
labour monitoring, documentation of events, audit observation is identified; (d) to prevent unnecessary
and feedback and maintaining continuity of care in use of interventions in labour; (e) support audit and
all healthy pregnant women by the use of essential quality improvement of labour management.
physical resources and motivated competent staff.6,7,8 Main Features: As per the LCG, active phase starts
Moreover, they redefined the phases of labour. at 5 cm. There is addition of a very important part
The latent, first stage is a period of time characterized i.e. the second stage of labour monitoring, which
by painful uterine contractions and variable changes was missing in previous partograph designs. There
of the cervix, including some degree of effacement is no action or alert line. It has 7 sections, which are
and slower progression of dilatation up to 5 cm for adapted from the previous partograph design: (figure
first and subsequent labours. The active first stage 1) Section 1: Identifying information and labour
is a period of time characterized by regular painful characteristics at admission; Section 2: Supportive
uterine contractions, a substantial degree of cervical care; Section 3: Care of the baby; Section 4: Care
effacement and more rapid cervical dilatation from of the woman; Section 5: Labour progress; Section
5 cm until full dilatation for first and subsequent 6: Medication; Section 7: Shared decision-making.
labours. The standard duration of the latent first These sections contain a list of labour observations.
stage has not yet been established. However, the For every observation, an alert parameter has been
duration of active first stage (from 5 cm until full defined. If the observation corresponds to any alert
cervical dilatation) usually does not extend beyond parameter, there is need to take action accordingly
12 hours in first labours, and usually does not extend after a “shared decision making” i.e. decision taken
beyond 10 hours in subsequent labours. after discussing the current situation with the
Progress of Labour: The use of medical interventions women in labour or with her companion. Thus, the
to accelerate labour and birth (such as oxytocin main emphasis is on Action Oriented Labour which
augmentation or caesarean section) before 5 cm includes: assessing, recording the observation and
threshold, use of amniotomy alone for prevention checking the values with alert column values and
of delay in labour (latent phase) and use of early deciding the plan along with the women.
amniotomy with early oxytocin augmentation for Assessment of Foetal Well Being: Routine CTG
prevention of delay in labour (latent phase) are is not recommended for the assessment of foetal
not recommended provided foetal and maternal well-being on labour admission or during labour in
conditions are reassuring healthy pregnant women undergoing spontaneous
A minimum cervical dilatation rate of 1 cm/hour labour. Intermittent Auscultation of FHR with
throughout active first stage is unrealistically fast for either a hand held Doppler ultrasound device or
some women and is therefore not recommended for a Pinard foetal stethoscope is recommended for
identification of normal labour progression. A slower healthy pregnant women in labour. The interval
than 1 cm/hour cervical dilatation rate alone should should be every 15–30 minutes in active first stage
not be a routine indication for obstetric intervention. of labour and every 5 minutes in second stage of
labour. Each auscultation should last for at least
For effective application of these new definitions 1 minute during a uterine contraction and for at
and recommendations, there was a need of a new least 30 seconds thereafter. Record the baseline as
partograph design. Thus WHO in December 2020, a single counted number in beats per minute and
introduced WHO LABOUR CARE GUIDE (LCG)- the acceleration and deceleration.
next generation partograph.
Applicability: LCG is essential for the care of all
Aims of LCG are: (a) guide the monitoring and pregnant women, regardless of their risk status.
documentation of the well-being of women, foetus High-risk women many require additional and
and the progress of labour; (b) guide skilled health specialized monitoring and care. Most important is
personnel to offer supportive care throughout LCG can be modified as per the need of local centre
labour to ensure a positive childbirth experience where it is being used.

12 AOGD Bulletin
When to Initiate LCG: Documentation on the LC first and second stage of active labour. Record all
should be initiated when the woman enters the observations with admission of woman to labour
active phase of the first stage of labour (5 cm or ward. Rest is completed following subsequent
more cervical dilatation), regardless of her parity assessments throughout labour. For all observations,
and membranes status. Once initiated, it will horizontal time axis and a vertical reference values
support continuous monitoring throughout the axis for determination of any deviation from normal

WHO LABOUR CARE GUIDE

Name Parity Labour onset Active labour diagnosis [Date ]
Section 1 Ruptured membranes [Date Time ] Risk factors

Time : : : : : : : : : : : : : : :
Alert Hours 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3
column ALERT ACTIVE FIRST STAGE SECOND STAGE
SUPPORTIVE CARE

Companion N

Pain relief N
Section 2 Oral fluid N

Posture SP

Baseline
<110, *160
FHR
FHR
deceleration L

Amniotic fluid M+++, B

Section 3
BABY

Fetal position P, T

Caput +++

Moulding +++

Pulse <60, *120

Systolic BP <80, *140

WOMAN

Section 4 Diastolic BP *90

Temperature ºC <35.0,
* 37.5
Urine P++, A++

Contractions )2, >5

per 10 min
Duration of
contractions <20, >60

10
9 * 2h In active first stage, plot ‘X’ to
Cervix 8 * 2.5h record cervical dilatation. Alert
LABOUR PROGRESS

[Plot X] triggered when lag time for

7 * 3h current cervical dilatation is
exceeded with no progress. In
Section 5 6 * 5h
second stage, insert ‘P’ to indicate
5 * 6h when pushing begins.

5
4
Descent 3
[Plot O]
2
1
0

Oxytocin (U/L, drops/min)

MEDICATION

Section 6 Medicine

IV fluids
SHARED DECISION-MAKING

ASSESSMENT

Section 7

PLAN

INITIALS

INSTRUCTIONS: CIRCLE ANY OBSERVATION MEETING THE CRITERIA IN THE ‘ALERT’ COLUMN, ALERT THE SENIOR MIDWIFE OR DOCTOR AND RECORD THE ASSESSMENT AND ACTION TAKEN.IF LABOUR EXTENDS BEYOND 12H,
PLEASE CONTINUE ON A NEW LABOUR CARE GUIDE.
Abbreviations: Y – Yes, N – No, D – Declined, U – Unknown, SP – Supine, MO – Mobile, E – Early, L – Late, V – Variable, I – Intact, C – Clear, M – Meconium, B – Blood, A – Anterior, P – Posterior, T – Transverse, P+ – Protein, A+ – Acetone

Fig 1: WHO Labour Care Guide (LCG): the next generation partograph

Vol.21, No.1; May, 2021 13

observations (ALERT Thresholds). It also provides a with ruptured membranes with no cervical change
second-stage section to continue the observations as per LCG despite adequate contractions or ≥6
made during the first stage of labour. hours of oxytocin administration but not adequate
Section Wise Entry in LCG: Supportive care is contractions and no cervical change.
provided in form of labour companion and adequate Before diagnosing Second stage arrest, if materno-
pain relief, both by non-pharmacological and foetal conditions permit, allow at least 2 hours of
pharmacological methods. Non pharmacological pushing in multiparous women and at least 3 hours
methods include music, aromatherapy, acupuncture of pushing in nulliparous women.
and acupressure, breathing and relaxation exercises, Strategies of LCG implementation in labour
whereas in pharmacological methods epidural wards: The implementation of new labour care
analgesia is preferred. PCA (patient controlled guide involves Critical Review, Adaptation and
analgesia) and opioids can also be given depending Training of the residents and staff nurses for its
on demand and availability. For all the low risk usage. Team work is of paramount importance for its
women oral fluids and food intake is recommended target universal implementation and handling of the
during labour and mobility should be encouraged guide in between shifts. Monitoring and evaluation
in low risk women however supine position should should also be undertaken by regular evaluation
be avoided. of indicators like neonatal outcomes or caesarean
Foetal assessment is done every 30 minutes and rates.7,8,9
baseline heart rate, type of deceleration, colour of
liquor, foetal position, presence or absence of caput Key Points
and moulding is noted and compared with alert
The emphasis must be given on respectful maternal
parameters.
care and supportive intrapartum care, so as to give
Maternal vitals are taken every 4 hours and include a positive experience to the labouring women.
blood pressure, temperature, pulse rate and urine The duration of latent phase is not defined and
for protein and ketones. expectant management in latent phase till maternal-
Number and duration and contraction should be foetal status reassuring. The active phase starts from
monitored every 30 minutes in first stage and every 5 cm. Labour care guide i.e. the next generation
5 minutes in second stage. Any abnormal or alert partograph can replace WHO partograph after
finding needs to be verified for next 10 minutes and modifications as per local settings after appropriate
any alert parameter warrants action. research.
After assessing maternal and foetal well-being,
internal examination, is done under aseptic References
technique to examine the cervix. In the active first 1. Say L, Chou D, Gemmill A, Tuncalp O, Moller AB, Daniels J,
et al. Global causes of maternal death: a WHO systematic
stage of labour, “X” is plotted in the cell that matches
analysis. Lancet Glob Health. 2014;2(6):e323–33.
the time and the cervical dilatation. In the second
2. Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers
stage “P” is used to indicate when pushing begins. C, Hogan D, et al. Stillbirths: rates, risk factors, and
Vaginal examination should be done every 4 hours acceleration towards 2030. Lancet. 2016;387(10018):587–
unless otherwise indicated. 603.
Descent is assessed abdominally and “O” is plotted 3. Trends in maternal mortality 2000 to 2017: estimates
in the cell that matches the time and the level of by WHO, UNICEF, UNFPA, World Bank Group and the
United Nations Population Division: executive summary.
descent. 5/5, 4/5, 3/5, 2/5, 1/5 and 0/5 are used to Geneva: World Health Organization; 2019. Contract No.:
describe the foetal station. It should be done before WHO/RHR/19.23.
vaginal examination and is repeated 4 hourly. Based 4. Friedman, EA. Primigravid labor; a graphicostatistical
on the findings and after informing the women, plan analysis.1955.Obstet Gynecol 6(6): 567-589.
should be made by shared decision making. 5. Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S,
In case of duration of active phase exceeding 12 Gregory KD, et al. Contemporary patterns of spontaneous
labor with normal neonatal outcomes. Obstet Gynecol.
hours, another LCG can be added. 2010;116(6):1281–7.
Active Phase Arrest: Based on LCG, active phase 6. WHO recommenations: intrapartum care for a
arrest can be defined as cervical dilation ≥5 cm positive childbirth experience. Geneva: World Health
Organization; 2018.

14 AOGD Bulletin
7. WHO, UNFPA, UNICEF. Pregnancy, childbirth, postpartum 9. Vogel JP, Comrie-Thomson L, Pingray V, Gadama L,
and newborn care: a guide for essential practice. Geneva: Galadanci H, Goudar S, et al. Usability, acceptability, and
World Health Organization; 2015. feasibility of the World Health Organization Labour Care
8. Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers Guide: A mixed-methods, multicountry evaluation. Birth.
and strategies in guideline implementation – a scoping 2020 Nov 22.
review. Healthcare (Basel). 2016;4(3):36.

Block your dates for 43rd Annual Conference 2021 to be held on 20th - 21st November, 2021

Calendar of Virtual Monthly Clinical Meetings 2021-22

28th May, 2021 B L Kapoor Hospital

25th June, 2021 All India Institute of Medical Sciences

30th July, 2021 Sitaram Bhartia Hospital

27th August, 2021 Army Hospital (Research & Referral)

24th September, 2021 Deen Dayal Upadhyay Hospital

29th October, 2021 PGIMSR & ESI Hospital

21st - 23rd November, 2021 43rd Annual Conference

26th November, 2021 MAMC & Lok Nayak Jai Prakash Narayan Hospital

31st December, 2021 Sir Ganga Ram Hospital

28th January, 2022 ABVIMS & Dr Ram Manohar Lohia Hospital

25th February, 2022 UCMS & Guru Tek Bahadur Hospital

25th March, 2022 VMMC & Safdarjung Hospital

29th April, 2022 LHMC & Smt. Sucheta Kriplani Hospital

27th May, 2022 Apollo Hospital

• Monthly Clinical Meeting Scheduled on 30th April, 2021 was postponed due to challenges brought on
by the surge in COVID 19 cases.

• To encourage the participation of AOGD members in the Monthly AOGD Meetings, from the next
monthly meeting we have planned to conduct a quiz based on the articles published in the same
month's bulletin. First two winners will be awarded attractive prizes

Vol.21, No.1; May, 2021 15

 Intrapartum Foetal Monitoring:
The Art of Interpretation
Manju Khemani
Senior Director, Max Smart Hospital, New Delhi, Ex Professor, Lady Hardinge Medical College, New Delhi

The goal of intrapartum foetal surveillance is to detect there is a rising baseline FHR or decelerations are
potential foetal decompensation and to allow timely suspected on intermittent auscultation, intermittent
and effective intervention to prevent perinatal/ auscultation should be carried out more frequently,
neonatal morbidity or mortality. Foetal heart rate for example after 3 consecutive contractions initially.
(FHR) characteristics can be assessed, and the fact If a rising baseline or decelerations are confirmed,
that changes in foetal heart rate precede brain injury further actions should include: continuous CTG
constitutes the rationale for FH monitoring. Timely monitoring.4
response to abnormal foetal heart patterns might SOGC recommends intermittent auscultation in
be effective in preventing brain injury.1 Foetal heart healthy women and recommend against foetal
rate monitoring can be used to see if foetus is well heart admission tracing.
oxygenated. Obstetric conditions like hypertensive
disorders, IUGR, preterm birth predisposes foetus to Electronic foetal heart monitoring (EFM) -
poor outcome but account for small proportion of The evidence for the benefits of continuous
asphyxial injury. In a study of term pregnancies with CTG monitoring, as compared with intermittent
foetal asphyxia, 63% had no known risk factors.2 auscultation, in both low and high-risk women is
scientifically inconclusive Meta-analysis of data on
During the contractions of normal labour there EFM has led to two significant observations. First,
is a decrease in uteroplacental blood flow and a EFM compared with IA has not been shown to
subsequent increase in foetal pCO2 and a decrease in improve long-term foetal or neonatal outcomes as
pO2 and pH. In the healthy foetus, these values do not measured by a decrease in morbidity or mortality.1
fall outside critical thresholds, and the foetus does Continuous EFM during labour is associated
not display any changes in heart rate characteristics. with a reduction in neonatal seizures but with
However, in the foetus with compromised gas no significant differences in long-term sequelae,
exchange, there may be an increase in pCO2 and including cerebral palsy, infant mortality, and other
a decrease in pO2 and pH which exceed critical standard measures of neonatal well-being. Secondly,
thresholds and the foetus may display changes in EFM is associated with an increase in interventions,
heart characteristics.1 Thus, FHR monitoring can be including Caesarean section, vaginal operative
used to determine if a foetus is well oxygenated. As delivery, and the use of anaesthesia.1 In spite of the
the FHR is sensitive to hypoxaemia (reduced systemic lack of evidence regarding benefit, this procedure
pO2) and hypoxia (reduced oxygen in the tissues), has become standard of care in many countries.
but lacks specificity for the development of acidosis
(increased acid H+ within the tissues), the clinically Continuous CTG monitoring should be considered
important end point of hypoxia, FHR monitoring in all situations where there is a high risk of foetal
even with secondary tests would result in an increase hypoxia/acidosis, whether due to maternal health
in the operative delivery of nonacidotic babies.3 conditions (such as vaginal haemorrhage and
maternal pyrexia), abnormal foetal growth during
Intermittent auscultation (IA) - Intermittent pregnancy, epidural analgesia, meconium-stained
auscultation of the foetal heart rate is still used liquor, or the possibility of excessive uterine activity,
in low resource setting in women at low risk of as occurs with induced or augmented labour.
complications in established first stage of labour. Continuous CTG is also recommended when
Intermittent auscultation should be carried out abnormalities are detected during intermittent
immediately after a contraction for at least 1 minute, foetal auscultation or if there is delay in first or
at least every 15 minutes, and recorded as a single second stage of labour, and also in hypertension.4
rate. Palpate the maternal pulse hourly, or more
often if there are any concerns, to differentiate Prolonged monitoring in maternal supine recumbent
between the maternal and foetal heartbeats.4 If position should be avoided. The lateral recumbent,

16 AOGD Bulletin
half-sitting, and upright positions are preferable tissues. Even in the presence of decelerations or
alternatives. In many countries throughout the world bradycardia a foetus that exhibits normal baseline
paper speed of 1 cm/min is used. Inadvertent use of FHR variability has a very low risk of acidaemia,
paper scales to which the staff is unaccustomed may immediate death, or asphyxial brain injury.3
lead to erroneous interpretations of CTG features. For Reduced variability– is defined as bandwidth
example, at 3 cm/min variability appears reduced to amplitude below 5 bpm for more than 50 minutes
a clinician familiar with the 1 cm/min scale, while it in baseline segments 7, or for more than 3 minutes
may appear exaggerated in the opposite situation.5 during decelerations.8
Reviewing and interpreting the cardiotocography Causes of reduced variability - Reduced variability
trace - 4 features of foetal heart rate have to be can occur due to central nervous system hypoxia/
assessed to review CTG trace. These are Baseline acidosis and resulting decreased sympathetic
rate, variability, accelerations, and decelerations. and parasympathetic activity, but it can also
1. Baseline - The baseline must be for a minimum of be due to previous cerebral injury, infection,
2 minutes in any 10-minute segment. administration of central nervous system
depressants or parasympathetic blockers.
• Normal FHR baseline: 110–160 beats per
During deep sleep, variability is usually in the
minute. Preterm foetuses tend to have values
lower range of normality, but the bandwidth
toward the upper end of this range and post-
amplitude is seldom under 5 bpm. Following an
term foetuses towards the lower end.5
initially normal CTG, reduced variability due to
• Tachycardia: FHR baseline is greater than 160 hypoxia is very unlikely to occur during labour
beats per minute. Maternal pyrexia is the without preceding or concomitant decelerations
most frequent cause of foetal tachycardia, and a rise in the baseline.6 In a recent systematic
and it may be of extrauterine or intrauterine review minimal or undetectable FHR variability
infection. Epidural analgesia may also cause a was the most consistent predictor of new-born
rise in maternal temperature resulting in foetal acidaemia.9
tachycardia. In the initial stages of a nonacute
Increased variability (saltatory pattern)- is defined
foetal hypoxemia, catecholamine secretion
as bandwidth value exceeding 25 bpm lasting
may also result in tachycardia. Other less
more than 30 minutes. According to NICE
frequent causes are the administration of beta-
guidelines, variability of > 25 beats/minute for 15
agonist drugs like terbutaline, parasympathetic
to 25 minutes is a non-reassuring feature.4
blockers like atropine, and foetal arrhythmias
such as supraventricular tachycardia.6 The pathophysiology of this pattern is
incompletely understood, but it may be seen
• Bradycardia: FHR baseline is less than 110 beats
linked with recurrent decelerations, when
per minute. Values between 100 and 110 bpm
hypoxia/acidosis evolves very rapidly. It is
may occur in normal foetuses, especially in
presumed to be caused by foetal autonomic
postdate pregnancies. Although a baseline
instability/hyperactive autonomic system.6
foetal heart rate between 100 and 109 beats/
minute is a non-reassuring feature, continue The clinical significance and interpretation of FHR
usual care if there is normal baseline variability variability has been reviewed and summarised as
and no variable or late decelerations with it.4 follows.10
2. Variability - Variability refers to the fluctuations • If the FHR variability is normal there is a limited
in the baseline FHR. It is determined by choosing role for foetal acid base analysis.
one minute of a 10-minute section of the FH • Unless foetal asphyxia can be reliably
tracing with at least 2 cycles/minute (normal is 2 excluded, intermittent or sustained reductions
to 4 cycles/ minute) that is free from accelerations in FHR variability may signal the onset of
and decelerations, and measuring the difference decompensation in the presence of intrapartum
between the lowest and highest rate.1 Normal or FHR decelerations.
reassuring: 5 to 25 beats/minute. • A foetus with a previously normal FHR variability
In order to exhibit a normal FHR variability will not switch to reduced or absent variability
the foetus requires an intact cerebral cortex, during labour without the input of asphyxial FHR
midbrain, vagus nerve, and cardiac conductive decelerations3

Vol.21, No.1; May, 2021 17

3. Accelerations –Abrupt (onset to peak in less than deceleration, rapid recovery to the baseline,
30 seconds) increases in FHR above the baseline, varying size, shape and relationship to uterine
of more than 15 bpm in amplitude, and lasting contractions.6 The decrease in FHR is 15 beats per
more than 15 seconds but less than 10 minutes. minute or greater, lasting 15 seconds or greater,
Before 32 weeks’ gestation, their amplitude and and less than 2 minutes in duration.2
frequency may be lower (10 seconds and 10 bpm Variable decelerations constitute the majority of
of amplitude).6 decelerations during labour, and they translate
Most accelerations coincide with foetal a baroreceptor-mediated response to increased
movements and are a sign of a neurologically arterial pressure, as occurs with umbilical cord
responsive foetus that does not have hypoxia/ compression. They are seldom associated with
acidosis. The presence of foetal heart rate an important degree of foetal hypoxia/acidosis,
accelerations, even with reduced baseline unless they evolve to exhibit a U-shaped
variability, is generally a sign that the baby is component, reduced variability within the
healthy. The absence of accelerations on an deceleration, and/or their individual duration
otherwise normal cardiotocograph trace does exceeds 3 minutes.6
not indicate foetal acidosis.4 After 32-34 weeks, Variable decelerations may be divided into two
with the establishment of foetal behavioural groups1
states, accelerations rarely occur during periods • Uncomplicated variable decelerations consist of
of deep sleep, which can last up to 50 minutes.7 an initial acceleration, rapid deceleration of the
Prolonged acceleration is ≥ 2 minutes and < FHR to the nadir, followed by rapid return to the
10 minutes in duration. Acceleration of ≥ 10 baseline FHR level with secondary acceleration.
minutes is a baseline change. The presence of Uncomplicated variable decelerations are not
accelerations is a normal/reassuring finding. consistently shown to be associated with poor
4. Decelerations – decreases in the FHR below the neonatal outcome (reduced 5-minute Apgar
baseline, of more than 15 bpm in amplitude, and scores or metabolic acidosis.
lasting more than 15 seconds. • Complicated variable decelerations with the
Following points should be noted while following features may be indicative of foetal
describing deceleration4 hypoxia:
• their timing in relation to the peaks of the • Deceleration to less than 70 bpm lasting more
contractions than 60 seconds
• the duration of the individual deceleration • Loss of variability in the baseline FHR and in the
• whether or not the foetal heart rate returns to trough of the deceleration
baseline • Biphasic deceleration
• how long they have been present for • Prolonged secondary acceleration (post
• whether they occur with over 50% of deceleration smooth overshoot of more than
contractions 20 bpm increase and/ or lasting more than 20
• the presence or absence of a biphasic (W) seconds.1
shape Late decelerations (U-shaped and/or with
• the presence or absence of shouldering reduced variability) – decelerations with a gradual
• the presence or absence of reduced variability onset and/or a gradual return to the baseline and/or
within the deceleration.4 reduced variability within the deceleration. Gradual
Early decelerations - are shallow, short-lasting, with onset and return occur when more than 30 seconds
normal variability within the deceleration and are elapse between the beginning/end of a deceleration
coincident with contractions. They are believed and its nadir. When contractions are adequately
to be caused by foetal head compression and monitored, late decelerations start more than 20
do not indicate foetal hypoxia/acidosis.6 These seconds after the onset of a contraction, a nadir after
decelerations are immediate and sharp. the acme, and a return to the baseline after the end
of the contraction6. Late decelerations are caused by
Variable decelerations (V-shaped) - decelerations
myocardial depression. It is widely believed that the
that exhibit a rapid drop (onset to nadir in less
purpose of these responses is to reduce myocardial
than 30 seconds), good variability within the

18 AOGD Bulletin
workload and oxygen demand.3 In the presence tooth” appearance, rather than the smooth sine-
of a tracing with no accelerations and reduced wave form. It lasts for less than 30 minutes and is
variability, the definition of late decelerations also there is normal pattern before and after it.
includes those with an amplitude of 10-15 bpm.6 Normal contractions last 45-120 seconds in total
Prolonged decelerations - (lasting more duration
than 3 minutes) These are likely to include a Tachysystole - represents an excessive frequency
chemoreceptor-mediated component and thus of contractions and is defined as the occurrence
to indicate hypoxemia. Decelerations exceeding 5 of more than 5 contractions in 10 minutes, in two
minutes, with FHR maintained <80 beats per minute successive 10-minute periods, or averaged over a
and reduced variability within the deceleration, are 30-minute period.2,6
frequently associated with acute foetal hypoxia/
acidosis 8 and require emergent intervention. Based on all above factors a tracing is classified into
3 categories.
Sinusoidal pattern - Visually apparent, smooth, sine
wave-like undulating pattern in FHR baseline with ACOG Guidelines classify into category I, II, III.
a cycle frequency of 3–5 per minute which persists category 1, normal FHR pattern predictive of
for 20 minutes or more.2 This pattern coincides with normal acid base status at the time of observation;
absent accelerations.6 Sinusoidal pattern occurs category II, intermediate FHR pattern not classified
in association with severe foetal anaemia, as is as category I or III, but not predictive of abnormal
found in anti-D allo-immunisation, foetal-maternal acid base status; and category III, abnormal FHR
haemorrhage, twin-to-twin transfusion syndrome pattern associated with abnormal acid base at the
and ruptured vasa praevia.6 time of observation.3 Nice guidelines classify tracing
based on these features as normal, suspicious and
Pseudo-Sinusoidal Pattern - It resembles the pathological. Overall major protocols are same for all
sinusoidal pattern, but with a more jagged “saw- the guidelines.

Table 1: NICE(2017) classification of CTG features

Description Feature
Baseline Baseline variability Decelerations
(beats/minute) (beats/minute)
Reassuring 110 to 160 5 to 25 None or early
Variable decelerations with no concerning characteristics* for
less than 90 minutes
Non- 100 to 109t Less than 5 for Variable decelerations with no concerning characteristics for 90
reassuring OR 30 to 50 minutes minutes or more
161 to 180 OR OR
More than 25 Variable decelerations with any concerning characteristics* in
for 15 to up to 50% of contractions for 30 minutes cv more
5 minutes OR
Variable decelerations with any concerning characteristics* in
over 50% of contractions for less than 30 minutes
OR
Late decelerations in over 50% of contractions for less than 30
minutes, with no maternal or fetaL
clinical risk factors such as vaginal bleeding or significant
meconium
Abnormal Below 100 Less than 5 for more Variable decelerations with any concerning characteristics* in
OR than over 50% of contractions for 30 minutes
Above 180 0 minutes (or less if any maternal or fetal clinical risk factors [see above])
OR OR
More than 25 for more Late decelerations for 30 minutes (or less if any maternal or fetal
than 25 minutes clinical risk factors)
OR OR
Sinusoidal Acute bradycardia, or a single prolonged deceleration lasting 3
minutes or more

Vol.21, No.1; May, 2021 19

Re-evaluation of the tracing should be carried out at • Improve hydration with IV fluid bolus
least every 30 minutes. While evaluating CTG tracing • Perform vaginal examination to relieve pressure of
other parameters like gestational age, medication presenting part off cord
administered and other medical conditions also • Administer oxygen by mask
should be kept in mind. Do not apply them in
• Consider amnioinfusion if variable decelerations
isolation and intervene for foetal compromise on
present
the basis of isolated FHR tachycardia, reduced
variability, lack of acceleration, or uncomplicated • Reduce maternal anxiety (to lessen catecholamine
variable decelerations.3 impact)
• Coach women to modify breathing or pushing
Management- Normal tracing –One important
techniques1
feature of normal CTG tracing is, periods of reduced
FHR variability, which alternate with periods of Ongoing foetal evaluation is required, and delivery
increased variability with or without accelerations: should be considered if the situation persists over
so-called cycling behaviour. Foetal cycling activity is time or if the pattern deteriorates.1
a key behavioural state of the normal term or near- Pathological - 1 abnormal feature OR 2 non-
term foetus. It suggests neurological integrity and reassuring features.4 For example late deceleration
the absence of significant acidaemia or acidosis3. for 30 minutes with variability between 5-25 for 30-
When a normal tracing is identified, it may be 50 minutes.
appropriate to interrupt the EFM tracing for up to 30
In such cases exclude acute events (for example,
minutes to facilitate periods of ambulation, bathing,
cord prolapse, suspected placental abruption
or position change.1
or suspected uterine rupture) Correct any
Suspicious - If there is 1 non reassuring and 2 underlying causes, such as hypotension or uterine
reassuring feature4. For example, if FHS is 140, hyperstimulation Start 1 or more conservative
variability is good but there are variable decelration measures.4 In the presence of an abnormal foetal
with no cocerning characterstics. Any reversible heart rate pattern, usually operative delivery should
cause of compromise should be identified and be undertaken promptly unless there is clear
modified (correction of maternal hypotension, indication of normal foetal oxygenation by means
treatment of excessive uterine contractility).1 Further of scalp pH assessment or spontaneous delivery is
foetal evaluation by means of scalp stimulation (>34 imminent. Scalp sampling should not be considered
weeks) is recommended. in the case of prolonged deceleration of greater than
Digital foetal scalp stimulation during a vaginal exam three minutes. Usual action in the presence of an
provides an indirect assessment of acid-base status. abnormal tracing includes preparing for operative
The goal is to elicit a sympathetic nerve response, delivery (operative vaginal delivery or Caesarean
and an acceleratory response to stimuli may be section).1
indicative of a normoxic fetus.11 An acceleration of During the second stage of labour, due to the
15 bpm amplitude with a duration of 15 seconds additional effect of maternal pushing, hypoxia/
has been shown to have a very high negative acidosis may develop more rapidly. Therefore,
predictive value (i.e., normal tracing) and very high urgent action should be undertaken to relieve the
sensitivity with regard to the absence of foetal situation, including discontinuation of maternal
acidosis1 Digital scalp stimulation is best avoided pushing, and if there is no improvement, delivery
during a deceleration, as the deceleration reflects a should be expedited.6
vagal response that prevents any sympathetic nerve
Limitations of Cardiotocography - suspicious and
response during scalp stimulation.1
pathological tracings have a limited capacity to
When an atypical tracing is apparent, intrauterine predict metabolic acidosis and low Apgar scores,
resuscitation should be commenced to improve i.e. a large percentage of cases with suspicious and
uterine blood flow, umbilical circulation and pathological tracings do not have these outcomes.
maternal oxygen saturation. Steps to accomplish this While there is a strong association between certain
include the following: FHR patterns and hypoxia/acidosis, their capacity
• Stop or decrease oxytocin to discriminate between newborns with or without
• Change maternal position of left or right lateral metabolic acidosis is limited. Thus, they are sensitive

20 AOGD Bulletin
indicators, but have a low specificity and low positive monitoring: Cardiotocography. Int J Gynaecol Obstet.
predictive value.6 2015 Oct;131(1):13-24.
6. FIGO Consensus Guidelines on Intrapartum Fetal
Monitoring 2019.
References 7. Suwanrath C, Suntharasaj T. Sleep–wake cycles in normal
1. Liston R, Sawchuck D, Young D. No. 197b-Fetal Health foetuses. Arch Gynecol Obstet 2010;281:449-54.
Surveillance: Intrapartum Consensus Guideline. J Obstet
8. Hamilton E, Warrick P, O’Keeffe D. Variable decelerations:
Gynaecol Can. 2018 Apr;40(4):e298-e322.
do size and shape matter? J Matern Fetal Neonatal Med
2. ACOG Practice Bulletin No. 106: Intrapartum fetal heart 2012;25:648-53.
rate monitoring: nomenclature, interpretation, and
9. 0 Parer JT, King T, Flanders S, Fox M, Kilpatrick SJ. Fetal
general management principles. Obstet Gynecol. 2009
acidaemia and electronic fetal heart rate patterns: is
Jul;114(1):192-202.
there evidence of an association? J Matern Fetal Neonatal
3. Ugwumadu A. Are we (mis)guided by current guidelines Med 2006;19:289–9
on intrapartum fetal heart rate monitoring? Case for a
10. Ugwumadu A. Understanding cardiotocographic
more physiological approach to interpretation. BJOG
patterns associated with intrapartum fetal hypoxia and
2014;121:1063–1070.
neurologic injury. Best Pract Res Clin Obstet Gynaecol
4. Fetal monitoring during labour: Intrapartum care. http:// 2013;27:509–36.
pathways.nice.org.uk/pathways/intrapartum-care NICE
11. Elimian A, Figueroa R, Tejani N. Intrapartum assessment
Pathway last updated: 20 April 2021
of fetal well-being: a comparison of scalp stimulation
5. Ayres-de-Campos D, Spong CY, Chandraharan E; with scalp blood pH sampling. Obstet Gynecol. 1997
FIGO Intrapartum Fetal Monitoring Expert Consensus Mar;89(3):373-6.
Panel. FIGO consensus guidelines on intrapartum fetal

Vol.21, No.1; May, 2021 21

 Labour Analgesia:
Where Epidural is not Feasible
Kavita Agarwal1, Bhawina Saran2
1
Assistant Professor, 2Senior Resident, Vardhman Mahavir Medical College & Safdarjung Hospital, Delhi

Introduction trained in performing instrumental birth are required

The first stage of labour is associated with visceral for providing epidural analgesia. To ensure safety
pain transmitted via nerve roots T10 to L1 and of the mother and baby, epidural analgesia should
in second stage of labour, pain is from uterine only be offered in the settings with appropriate
contractions and from distension of vaginal and resources.
perineal tissues transmitted through nerve roots
S2 to S4. Labour pains during first stage of labour Inhalational Analgesia
produces neuroendocrine stress response leading Entonox used as a mixture of 50% nitrous oxide
to hyperventilation, increased blood pressure, and 50% oxygen gas for labour analgesia. It is easy
diminished uterine perfusion and impaired uterine to administer, provides pain relief to a significant
contractility1. In addition to this, labour pains are also degree and is a good alternative option where facility
associated with emotional distress and women are of epidural analgesia is not there. Its safety is well
more likely to develop posttraumatic stress disorder proven. The most common side effects are nausea,
and postpartum depression2. WHO and American vomiting and light-headed. It does not accumulate
College of Obstetrician and Gynaecologists (ACOG) in mother or foetus and is eliminated quickly by the
recommends that labour analgesia should be lungs. Also, it does not affect the progress of labour.6
offered to all healthy pregnant women requesting
for pain relief in labour.3 Multiple pharmacological
Patient Controlled Analgesia (PCA)
and non- pharmacological options are available for
labour analgesia. Patient controlled intravenous (IV) analgesia is
self administration of a programmed dose of IV
medication with lockout intervals between doses.
Pharmacological Options for Labour PCA is the most effective option for facility where
Analgesia epidural analgesia is not available. It provides better
Drugs can be administered systemically or regional pain control and rapid onset of analgesia compared
i.e. spinal epidural, combined spinal-epidural and with bolus administration.
pudendal block. Bilateral pudendal nerve block Short acting opioids like Remifentanil and fentanyl
involves the infiltration of 1% lidocaine without are used for PCA7. Remifentanil is given in bolus of
epinephrine around pudendal nerve at the level of 15 to 50 mcg with lockout times of 1 to 5 minutes. It
ischial spine. It provides relief in pain arising from has rapid onset of action and is an ultra short acting
vaginal and perineal distension during second stage drug. It provides better pain relief than long acting
of labour and pain arising from low forceps delivery.4 opioid analgesics.8,9 But is a potent respiratory
It does not interfere with uterine contraction and depressant and has been observed to cause more
hence does not interfere with progress of labour.5 drowsiness than pethidine. Respiratory rate and
oxygen saturation monitoring needs to be done.10
Epidural Analgesia Fentanyl PCA also has rapid onset of action and is
Epidural analgesia is a proven method for relieving short acting (although longer than remifentanil). It is
pain in healthy pregnant woman requesting pain given as loading dose of 50 -100mcg with 10-25 mcg
relief during labour. It requires more expertise and demand doses and lockout time of 5 to 10 minutes.
equipment to monitor, detect and manage any
undesirable effect of the procedure. An anaesthetist Intermittent Parenteral Opioids
with training in epidural insertion and management (intramuscular/ intravenous route)
of complications associated with epidural, nurse
Parenteral opioids provide some form of pain relief
trained in for monitoring woman and an obstetrician
in labour. WHO recommends parenteral opioids

22 AOGD Bulletin
such as fentanyl, diamorphine and pethidine for Self- initiated soothing activities like walking,
pain relief during labour. Short acting opioids have moving during labour, upright positions have
few undesirable side effects. shown benefit. Evidence suggest that progressive
A recent Cochrane review11 found that on comparing muscle relaxation and breathing techniques like
intramuscular pethidine in dose of 50mg/ 100mg slow breathing, counting breath, reciting a mantra
with a saline placebo, pethidine reduced pain score in rhythm with breathing provide pain relief during
to 40mm on a scale of 100mmm; 30 minutes after latent phase of labour.17 Women practicing relaxation,
its administration. Pain relief was rated as good / fair breathing and yoga postures experienced less pain
after 1 hour of administration. Its administration was during labour.18,19 According to a recent Cochrane
associated with nausea, vomiting and drowsiness. review, there is low quality evidence to suggest
However, no long term side effects have been noted reduced pain intensity in latent phase of labour and
with opioid analgesia. Anti-emetics may be given greater satisfaction in pain relief with relaxation
to treat nausea/ vomiting. Neonatal respiratory techniques (such as guided imagery, breathing
depression can occur as opioids cross the placenta exercises), yoga and music therapy compared to
and hence naloxone should always be available12. usual care. Use of birth ball reduces pain score. In
The effect on the neonate is particularly important sitting position on ball, pressure on perineum blocks
when the drug is given within 2 hours of delivery. nociceptive fibres and reduces pain sensation.20
Opioids should not be administered near delivery Labour companion (such as doula) refers to a trained
to avoid sedation while parturient is pushing and companion during labour who helps the woman
to avoid foetal effects3. Pethidine, diamorphine or cope up with labour pains by guidance, reassurance,
other opioids may interfere with breastfeeding. encouragement, soothing touch, hand holding and
Cochrane review11 found evidence suggestive of massage.4 Massage reduces pain scores in first stage
better pain relief with diamorphine, fentanyl and of labour.21 Reduced muscle tension in the body by
remifentanil rather than with pethidine. Diamorphine massage is associated with decreased pain intensity
lowered more pain scores at 30 and 60 minutes in first stage of labour and a positive childbirth
after administration and was associated with less experience as suggested in a recent Cochrane
nausea and vomiting. Both the groups required review.21 Superficial heat application of warm packs/
prochlorperazine as anti-emetic. As compared to towels on parturient’s back, lower abdomen, groin
pethidine, pain scores were reduced by fentanyl at during active phase of labour provide pain relief and
1 hour of administration but more doses of fentanyl reduce labour discomfort.22
were required. Less maternal sedation was seen with Labouring in warm shower, water birth helps
fentanyl. Remifentanil causes more drowsiness than in coping labour pains and reduce VAS pain
pethidine. More number of patients reported poor scores.23 Water immersion reduces labour pain and
pain relief with tramadol compared to pethidine. enhances relaxation.24 ACOG recommends to offer
Women should not enter a birthing pool within 2 water immersion to parturient during first stage
hours of opioid administration or if they feel drowsy. of labour.25 For women labouring in water, the
Acetaminopen and Non steroidal anti inflammatory temperature of the woman and the water should
drugs (NSAIDS): NSAIDS are avoided as they can be monitored hourly to ensure that the woman
precipitate premature closure of ductus arteriosus13. is comfortable and not becoming pyrexial. The
Two randomised control trials found significantly temperature of the water should not be above
reduced visual analog pain scores with paracetamol 37.5°C. Baths and birthing pools should be kept
infusion compared to placebo along with reduced clean using a protocol agreed with the microbiology
need of rescue medication.14,15 In another RCT department and, in the case of birthing pools, in
comparing intravenous acetaminophen with accordance with the manufacturer’s guidelines.
intravenous morphine, similar reduction in pain Music (audio analgesia) is for a pleasant distraction
scores and similar side effect profiles were seen with and decreases pain perception. Evidence supports
both but more patients needed rescue dose with that pain intensity is reduced by acupressure,
acetaminophen.16 Aromatherapy, acupuncture, acupressure, sterile
water subcutaneous injections also help reduce
Non pharmacological pain relief options: They do labour pains. Hypnosis prevents pain experience
not make pain disappear instead help woman cope reaching the conscious mind. Transcutaneous
labour pains. They are unlikely to be harmful.

Vol.21, No.1; May, 2021 23

electric nerve stimulation and biofeedback has not intramuscular pethidine for pain relief in labour (RESPITE):
shown any benefit in labour analgesia. an open-label, multicentre, randomised controlled trial.
Lancet 2018; 392:662.
To summarize, WHO recommends labour analgesia 10. Van de Velde M, Carvalho B. Remifentanil for labor
should be offered to all healthy pregnant woman analgesia: an evidence-based narrative review. Int J
requesting for pain relief in labour. Bilateral Obstet Anesth 2016; 25:66.
pudendal nerve block helps in relieving pain in 11. Smith LA, Burns E, Cuthbert A. Parenteral opioids
second stage of labour and low forceps delivery. for maternal pain management in labour. Cochrane
Epidural analgesia is a proven method for relieving Database Syst Rev 2018; 6:CD007396.
labour pains but it requires more expertise and 12. Mattingly JE, D’Alessio J, Ramanathan J. Effects of
equipment. Inhalational analgesia and patient obstetric analgesics and anesthetics on the neonate : a
review. Paediatr Drugs 2003; 5:615.
controlled analgesia is a good alternative option
13. Koren G, Florescu A, Costei AM, et al. Nonsteroidal
where facility of epidural analgesia is not there. WHO
antiinflammatory drugs during third trimester and the
recommends fentanyl, diamorphine and pethidine risk of premature closure of the ductus arteriosus: a
to be used for pain relief during labour.32 Short acting meta-analysis. Ann Pharmacother 2006; 40:824.
opioids should be preferred. Naloxone and anti 14. Abd-El-Maeboud KH, Elbohoty AE, Mohammed WE, et
emetic should be available. Opioids should not be al. Intravenous infusion of paracetamol for intrapartum
administered near delivery to avoid sedation while analgesia. J Obstet Gynaecol Res 2014; 40:2152-57.
parturient is pushing and to avoid fetal effects. Non- 15. Zutshi V, Rani KU, Marwah S, Patel M. Efficacy of
pharmacological pain relief options like progressive Intravenous Infusion of Acetamino-phen for Intrapartum
muscle relaxation, breathing, music, mindfulness and Analgesia. J Clin Diagn Res 2016; 10:QC18.
Manual techniques, such as massage or application 16. Ankumah NE, Tsao M, Hutchinson M, et al. Intravenous
Acetaminophen versus Morphine for Analgesia in Labor:
of warm packs are recommended by WHO to help
A Randomized Trial. Am J Perinatol. 2017;34(1):38-43.
woman cope up labour pains.
17. Boaviagem A, Melo Junior E, Lubambo L, et al. The
effectiveness of breathing patterns to control maternal
References anxiety during the first period of labor: A randomized
1. Brownridge P. The nature and consequences of childbirth controlled clinical trial. Complement Ther Clin Pract 2017;
pain. Eur J Obstet Gynecol Reprod Biol 1995; 59 Suppl:S9. 26:30.
2. Suhitharan T, Pham TP, Chen H, et al. Investigating 18. Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation
analgesic and psychological factors associated with risk techniques for pain management in labour. Cochrane
of postpartum depression development: a case-control Database Syst Rev. 2011 Dec 7;(12):CD009514.
study. Neuropsychiatr Dis Treat 2016; 12:1333. 19. Babbar S, Parks-Savage AC, Chauhan SP. Yoga during
3. American College of Obstetricians and Gynecologists’ pregnancy: a review. Am J Perinatol 2012; 29:459.
Committee on Practice Bulletins—Obstetrics. ACOG 20. Makvandi S, Latifnejad Roudsari R, Sadeghi R, Karimi
Practice Bulletin No. 209: Obstetric Analgesia and L. Effect of birth ball on labor pain relief: A systematic
Anesthesia. Obstet Gynecol 2019; 133:e208. review and meta-analysis. J Obstet Gynaecol Res 2015;
4. Jones L, Othman M, Dowswell T, et al. Pain management 41:1679.
for women in labour: an overview of systematic reviews. 21. Smith CA, Levett KM, Collins CT, Jones L. Massage,
Cochrane Database Syst Rev 2012; :CD009234. reflexology and other manual methods for pain
5. Tomimatsu T, Kakigano A, Mimura K, et al. Maternal management in labour. Cochrane Database Syst Rev.
carbon dioxide level during labor and its possible effect 2012 Feb 15;(2):CD009290.
on fetal cerebral oxygenation: mini review. J Obstet 22. Taavoni S, Abdolahian S, Haghani H. Effect of sacrum-
Gynaecol Res 2013; 39:1. perineum heat therapy on active phase labor pain and
6. Rooks JP. Safety and risks of nitrous oxide labor analgesia: client satisfaction: a randomized, controlled trial study.
a review. J Midwifery Womens Health 2011; 56:557. Pain Med 2013; 14:1301.
7. Douma MR, Verwey RA, Kam-Endtz CE, et al. Obstetric 23. Lee SL, Liu CY, Lu YY, Gau ML. Efficacy of warm showers
analgesia: a comparison of patient-controlled meperidine, on labor pain and birth experiences during the first labor
remifentanil, and fentanyl in labour. Br J Anaesth 2010; stage. J Obstet Gynecol Neonatal Nurs 2013; 42:19.
104:209. 24. Cluett ER, Burns E, Cuthbert A. Immersion in water during
8. Weibel S, Jelting Y, Afshari A, et al. Patient-controlled labour and birth. Cochrane Database Syst Rev 2018;
analgesia with remifentanil versus alternative parenteral 5:CD000111.
methods for pain management in labour. Cochrane 25. American College of Obstetricians and Gynecologists’
Database Syst Rev 2017; 4:CD011989. Committee on Obstetric Practice. Committee Opinion
9. Wilson MJA, MacArthur C, Hewitt CA, et al. Intravenous No. 679: Immersion in Water During Labor and Delivery.
remifentanil patient-controlled analgesia versus Obstet Gynecol 2016; 128:e231.

24 AOGD Bulletin
 Events held under the aegis of AOGD in April 2021
DGF OUTER DELHI
& INFERTILITY COMMITTEE OF AOGD
Invite you to a Webinar
1
ICOG
Fibroid FOCUS Credit
Point

Date : 1st April 2021 T

Time : 4:30 to 6
6:30 pm

Chief Guest Guest of honour

Dr. Ragini Agarwal Dr Achla Batra
National VP, FOGSI President, AOGD
President HARObGyn VMMC & Safdarjung Hosp.
Delhi

Program Director Special Guest

Dr. Sharda Jain Dr. Shivani Sachdeva
Founder and secretary Gaur
Director SCI hospital, Delhi
General DGF
Vice chair person ,Delhi ISAR

TOPIC : MAPPING OF FIBROIDS..HOW IMPORTANT IT IS ?

SPEAKER

CHAIRPERSON
Dr. Kishore Rajurkar
President DGF Outer Delhi

Dr. Ashok khurana

Director
The Ultrasound Lab, New Delhi

Dr. Archna Pathak

Sec. DGF West
Infertility expert MKW
Visiting consultant Apollo Cradle

TOPIC : MEDICAL MANAGEMENT OF FIBROIDS

SPEAKER

CHAIRPERSON
Dr. Punita Mahajan
Sr. V. President DGF Outer Delhi
Consultant Obs & Gyn,
Medical Superintendent at
Dr. Baba Saheb Ambedkar
Hospital
Dr. Jyoti Malik
Director
JJ Hospital & Roots IVF, B.garh
Secretary
HARObGyn & DGF Outer Delhi
Dr. Akta Bajaj
Treasurer DGF Outer Delhi
Obgyn,Cygnus hospital

TOPIC : LAP MYOMECTOMY, THE BEST FOOT FORWARD

SPEAKER

CHAIRPERSON
Dr. Kavita Aggarwal
Chairperson Infertility committee
AOGD
Gynaecologist, Safdarjung hospital
Vice President IMA-SDB

Dr. Dinesh Kansal

BLK Hospital, Delhi
President DGES
Dr. Alka jain
Vice President DGF Outer Delhi
Associate Director & HOD
Obs Gyn Dep. & Lap Surgeon,
Sehgal Neo Hospital Delhi

PANEL DISCUSSION : FIBROIDS AND INFERTILITY

PANELISTS
MODERATOR

Dr. Renu Mishra Dr. Anjali Tempe Dr. Shalini chawla

Senior Consultant Ex,-HOD, MAMC Infertility consultant ,MAX
Endoscopic surgery & IVF Director-Professor and Head, Panchsheel hospital, Delhi
Sitaram Bhartia Institute of Science & Research Department of Obstetrics and
Miracles Fertility & IVF, Gurgaon Gynaecology, Maulana Azad
Former Additional Professor, Medical College, New Delhi
All India Institute of Medical Sciences
Dr. K. D. nayyar
Director
Akanksha IVF Centre and
Mata Chanan Devi Hospital,
Delhi

Dr. Leena Wadhwa Dr. Tarini Taneja Dr. Meenu Handa

Executive Member AOGD Chairperson Delhi ISAR Senior IVF consultant,
Infertility Committee (2020-22) Fortis GurugramTreasurer,
Professor & IVF Incharge Haryana ISAR
Deptt. of Obst & Gynae, ESI-PGIMSR
Basaidarapur New Delhi

Dr. Anita Kaushik

Q&A, VOTE OF THANKS Joint Treasurer,
DGF Outer Delhi

JOIN ZOOM MEETING

https://emcure.zoom.us/j/97031544728? pwd=Ri94MW0yNHE4V2tXOExPU0YxSXhMQT09
Meeting ID : 970 3154 4728 Passcode: MATERNA

Safdarjung Hospital took over AOGD Secretariat Fibroid FOCUS, Webinar on 1st April, 2021

Managing Committee Meeting held on 8th April, 2021 Webinar by Gynae Forum Dwarka & Multidisciplinary
Committee of AOGD

Vol.21, No.1; May, 2021 25

 Events held under the aegis of AOGD in April 2021

Public Awareness Programme An Update on Medical Termination of Pregnancy, e- CME

on Breast and Cervical Cancer Screening

Virtual Meeting of AOGD Subcommittee Chairpersons held on 20th April, 2021

26 AOGD Bulletin
 Events Held, April 2021
1. Webinar titled “Fibroid Focus” was organized by DGF, Outer Delhi and Infertility committee of AOGD on 1st April
2021. Dr Ashok Khuranna deliberated on “Mapping of fibroids: How important it is?” Medical management
of fibroids was discussed by Dr Jyoti Malik and Dr Dinesh Kansal talked about “Lap Myomectomy: The best
foot forward”. The lectures were followed by a Panel discussion on “Fibroids and Infertility”.
2. On 2nd April 2021, “FAQs on Care of Pregnant Women” was organized by Sir Ganga Ram Hospital under
the aegis of AOGD.
3. Virtual AOGD Managing Committee Meeting was held on 8th April 2021. The meeting was attended by
the executive members and chairpersons of AOGD subcommittees.
4. A Webinar was organized by Gynae Forum Dwarka in association with Multidisciplinary Committee of
AOGD on 10th April 2021. "Evaluation of Cases of Breast Lump" was discussed by Dr Sunil Kumar Gupta
and Dr Nikita Banerjee deliberated on, “Breast Cancer and Contraception”.
5. Public Awareness Programme on Breast and Cervical Cancer Screening was held on 15th April 2021.
It was organized by Lioness Club in association with Multidisciplinary Committee of AOGD. Dr Geeta
Kadayaprath explained “Breast Self Examination & Early Detection of Cancer” and Dr Swasti discussed
“Cervical Cancer Screening”.
6. Virtual Meeting of AOGD Subcommittee Chairpersons was held 20th April 2021.
7. An Update on Medical Termination of Pregnancy, e- CME was held in association with the Department
of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, on 23rd April, 2021. New amendment
in the MTP act was discussed by Dr M C Patel and panel discussion on “MTP decision: Case Based
Scenarios”, was moderated by Dr Rupali Dewan and Dr Sujata Das. The CME was a huge success with
170 participants.

Forthcoming Events May 2021

1. Web CME on “Management of COVID in Pregnancy: A Medical perspective for Obstetrician” is planned
to be held on 7th May 2021 between 6-8pm by AOGD Safe Motherhood & QI Committee.
2. Virtual CME on “Prevention & Management of Thalassemia Major: An Obstetrician’s Perspective” will be
held on 8th May 2021 between 3-5pm by AOGD Foetal Medicine and Genetics Committee.
3. Online panel discussion on “Management of Gynaecologic Cancers Amidst the COVID 19 Pandemic”
will be organised by AOGD Oncology Subcommittee on 15th May, 2021.
4. Public Forum on “5 tips to Stay Safe from Anaemia during Pregnancy” will be conducted by Chairperson
Multidisciplinary Committee AOGD Dr Shashi Lata Kabra on 15th May, 2021.
5. A Public Forum on “Pregnancy and Postpartum Care in COVID Era” will be organised by Safdarjung
Hospital in aegis of AOGD on 17th May, 2021.
6. A webinar on “Thyroid Disorders in Pregnancy” will be organised by AOGD Adolescent Subcommittee
on 18th May, 2021.
7. Online Group Discussion on “Mental and Social Wellbeing of Health Care Workers in COVID Era:
Challenges and Solution” is planned for 21th May, 2021 between 5-7 pm.
8. E- CME on “MTP Act Old and New” is planned on 27th May, 2021 between 4 to 6pm, by Delhi
Gynaecologist Forum, North-West, under the aegis of AOGD.
9. Virtual AOGD Monthly Clinical Meeting is planned for 28th May, 2021 by B L Kapoor Hospital.
10. Sister Shivani will give an Inspirational Talk virtually on 29th May, 2021.
11. RCOG in association with AOGD and NARCHI will organise a webinar on “Evidence Based Management
of Intrahepatic Cholestasis of Pregnancy” on 30th May, 2021.
12. “Trials and Tribulations with Hysteroscopy”, A webinar by AOGD Endoscopy Subcommittee will be held
on 4th June, 2021

Vol.21, No.1; May, 2021 27

 Induction of Labour: Monitoring and
Management of Complications
Megha Mittal1, Jyotsna Suri2
1
Assistant Professor, Obstetrics & Gynaecology, Lady Hardinge Medical College & Smt. Sucheta Kriplani Hospital
2
Professor, Obstetrics & Gynaecology, Vardhman Mahavir Medical College & Safdarjung Hospital, Delhi

The process of artificial stimulation of uterus to start significantly lower risk of caesarean delivery,
labour is known as induction of labour. Induction of maternal peripartum infection, and adverse
labour refers to techniques for stimulating uterine perinatal outcomes.4
contractions to achieve vaginal delivery prior to the b. Risks and benefits of IOL should be counselled and
spontaneous onset of contractions. Between 1990 exact success rate of IOL and alternative options
and 2018, the frequency of labour induction almost should be sought for.
tripled rising from 9.5% in 1990 to 27% (2018).1 It c. Pre induction maternal and foetal assessment-
is usually performed by administering oxytocin or reconfirming the period of gestation through
prostaglandins to the pregnant woman, or by artificially reliable methods, foetal presentation, Bishop’s
rupturing the amniotic membranes. In low and middle assessment and preinduction non stress test for
income countries the rates are generally lower, but in foetal well being should be done.
some settings, they can be as high as those observed
d. Method of IOL and exact duration of IOL- cervical
in the high income countries.2,3 Induction of labour
ripening methods (eg. Dinoprostone gel,
may increase the need for operative interference and
misoprostol) would be required for women with
certain complications like precipitate labour, uterine
unfavourable cervix (bishops score ≤ 6) but in
hyperstimulation, foetal distress, failed induction,
ripe cervix (bishop >6) oxytocin can be used as
cord accidents, and post partum haemorrhage, hence
method of induction.5
meticulous monitoring of labour is required.
During Induction and Labour
Monitoring in Induction of Labour a. Reassessment of patient - Bishop’s score should be
(IOL) assessed 6 hours after vaginal PGE2 tablet or gel
insertion and 24 hour after the controlled release
Before Induction pessary insertion or earlier if patient starts having
a. Indication of IOL should be thoroughly reviewed good uterine contraction. If oxytocin is used
and documented. Though there are no clear as method of induction the target is to achieve
cut indications of elective induction in India strong uterine contractions every 2-3 minutes or
but Meta-analysis of six cohort studies in more a uterine activity of 200-250 Montevideo units.6
than 66,000 women undergoing elective labour b. Monitoring of labour progress- The duration of
induction at 39 weeks were compared with the latent phase of labour is longer in induced
those of more than 584,000 women undergoing labour. In an observational study the total length
expectant management beyond that gestational of time from admission to delivery in women
age, elective induction was associated with a were 3- 4 hour prolonged than the patient who

CTG Trace

Category 1 Category 2 * Category 3

No Intervention Is Required Reassess the 3P's(power, Immediate Intervention
Passage and Passesnger) Arm if in labour or operative
Discontinue induction interference
Rehydrate
Left lateral position and oxygen

*If category 2 CTG trace recover continue with induction if not consider as category 3
Fig 1: Action to be taken according to the CTG Tracing during IOL

28 AOGD Bulletin
Table 1: Complications of IOL and their Management
S.No. Complications Management
1. Uterine Hypercontractibilty/ Tachysystole • Category 1 CTG- analgesics, continuous foetal heart
Incidence- 1 to 5% monitoring, reducing the syntocinon drip rate to
Defined as9-11 previous rate.
• four or more contractions in 10 minutes over a 30 • Category 2 CTG- same as category 1, discontinue the
minutes period or induction and reassess after 30 minutes.
• contractions lasting more than 2 minutes in duration • Category 3 CTG- same as CTG 2, consider terbutaline
or (250 micrograms IV/SC) or sublingual GTN .12 if foetal
• contraction of normal duration occurring within 60 compromise continued then expedite the birth
sec of each other. (operative interference)
2. Cord Accidents • Manual reposition is not recommended.
• Incidence – 0.4%13 • Minimal handling of cord outside vagina to avoid
• One of the potential risks at the time of labour vasospasm.
especially when induction done in free floating head. • Disengage the foetal head by either maternal knee
• At the time of preliminary vaginal examination the chest position or filling the bladder.
umbilical cord presentation should be looked for. • Expedite delivery – if dilated vaginal if not caesarean.
3. Failed Induction • Further attempt to prolong the induction is as per
• Though there is no general consensus and incidence clinician discretion and woman’s wishes.
for this outcome but this term is generally used • The method and timing of IOL should be chosen as
as an indication of caesarean delivery where after the bishop’s score of the patient.
induction, vaginal delivery is unlikely.
• It is defined as failure to generate regular contractions
and cervical change after at least 24 hours
of oxytocin administration, with artificial membrane
rupture as soon as feasible and safe.
• The time devoted to cervical ripening is not
included when calculating the length of induction or
diagnosing failed induction.9,10
4. Uterine Rupture • Misoprostol should not be used for cervical ripenining
• Women with scarred uterus are prone to this or induction (ACOG 2019, Level A) in women with
complication. scarred uterus
• Proper risk assessment should be done before • Clinicians should be aware that induction of labour
inducing labour in scarred uterus. using mechanical methods (amniotomy or Foley
• The risk of rupture is two times than the patients with catheter) is associated with a lower risk of scar rupture
spontaneous labour in women with scarred uterus. compared with induction using prostaglandins.
[RCOG 2015, Level D}
• In cases with suspected scar dehiscence immediately
wheel-in the patient for emergency caesarean
section.
5. Infectious Morbidity • The timing of rupture of membranes or amniotomy
• Usually associated in women with prolonged rupture should be documented properly and antimicrobials
of membranes. should be started.14,15
6. Preciptate Labour and Post Partum Hemorhhage • Supervised delivery
• Usually occurs due to prostaglandins. • Timely intervention
• Atonic and traumatic PPH is common. • Adequate blood products arrangements.
• Proper assessment and monitoring of labour during
induction is important.
7. Amniotic Fluid Embolism • The inadvertent use of prostaglandins and oxytocics
• In one retrospective series, the adjusted odds along with precipitant labour and predispose this
ratio was 1.8 (95% CI 1.2-2.7), but the absolute risk catastrophe.
difference was small (10.3 per 100,000 births with
medical induction versus 5.2 per 100,000 births
without medical induction)16
8. Hypersenstivity Reaction • Antihistaminics should be administered timely.
• Though true allergic reactions are rare but a
reported entity.

Vol.21, No.1; May, 2021 29

 had expectant management but the duration of spontaneous labour in Latin America. Bull World Health
active labour remained comparable in two.7 Organ. 2011 Sep; 89(9): 657- 65.
c. Monitoring the foetal heart- continuous 4. Grobman WA, Caughey AB. Elective induction of labor
at 39 weeks compared with expectant management:
cardiotococgraphy (CTG) monitoring of induced a meta-analysis of cohort studies. American journal of
labour is preferable. However if CTG is not obstetrics and gynecology. 2019 Oct 1;221(4):304-10.
available intermittent auscultation every 15 5. Tajik, P, vander Tuuk, K, Koopmans, C.M, Groen, H et
minutes in first stage and after every contraction al. Should Cervical Favorability Play a Role in the Decision
in second stage is recommended. for Labor Induction in Gestational Hypertension or Mild
The interpretations and management of Preeclampsia at Term? An Exploratory Analysis of the
HYPITAT Trial, Obstetric Anesthesia Digest: Dec 2013.
labour is pre-requisite in successful outcome Volume 33 - Issue 4 - p 210-212.
of induced labour. We generally use the three-
6. ACOG Committee on Practice Bulletins -- Obstetrics.
tiered classification systems for categorizing the ACOG Practice Bulletin No. 107: Induction of labor. Obstet
CTG trace into category I, II and III. Though there Gynecol 2009; 114:386. Reaffirmed 2019.
are many guidelines regarding the defining 7. Grobman WA, Caughey AB. Elective induction of labor
features of CTG trace but they all have a common at 39 weeks compared with expectant management:
agreement about the baseline heart rate, beat a meta-analysis of cohort studies. Am J Obstet Gynecol.
to beat variability and accelerations but a 2019 Oct;221(4):304-310.
disagreement about the decelerations. Santo et al 8. Santo S, Ayres‐de‐Campos D, Costa‐Santos C, Schnettler W,
in a study found that ACOG group classified 81 % Ugwumadu A, Da Graça LM, FM‐Compare Collaboration.
Agreement and accuracy using the FIGO, ACOG and
of tracings as category II, whereas the suspicious NICE cardiotocography interpretation guidelines.
classification was only 52% in FIGO group and 33% Acta obstetricia et gynecologica Scandinavica. 2017
in NICE group.8 The action to be taken during IOL Feb;96(2):166-75.
according to the CTG trace is shown in Figure 1 9. ACOG practice bulletin. Antepartum fetal surveillance.
A. Managing the complications of IOL Number 9, October 1999. Clinical management
guidelines for obstetrician-gynecologists. Int J Gynaecol
Even though IOL is largely considered a safe
Obstet. 2000;68:175-85.
procedure, it may be associated with maternal or
10. ACOG practice bulletin: dystocia and augmentation
foetal complications. The complications as well as of labour. International Journal of Gynaecology and
their management are defined in Table 1. Obstetrics. 2003;85:315-24.
11. ACOG Practice Bulletin No. 106: Intrapartum fetal
Key Points heart rate monitoring: nomenclature, interpretation,
and general management principles. Obstetrics and
• Induction of labour should be done for an gynecology. 2009 Jul;114(1):192-202.
appropriate indication with an appropriate 12. Rayburn WF. Prostaglandin E2 gel for cervical ripening and
method. induction of labor: a critical analysis. American journal of
• Strict monitoring during the procedure is obstetrics and gynecology. 1989 Mar 1;160(3):529-34.
important. 13. Kahana B, Sheiner E, Levy A, Lazer S, Mazor M. Umbilical
• Meticulous monitoring of induced labour can help cord prolapse and perinatal outcomes. International
Journal of Gynecology & Obstetrics. 2004 Feb 1;84(2):127-
in early detection of the complications so that 32.
timely interventions can be done. 14. Dare MR, Middleton P, Crowther CA, Flenady V, Varatharaju
B. Planned early birth versus expectant management
References (waiting) for prelabour rupture of membranes at term
1. Managing complication in pregnancy and childbirth: a (37 weeks or more). Cochrane database of systematic
guide for midwives and doctors. Geneva, World Health reviews. 2006(1).
Organisation, 2000 15. Preterm prelabour rupture of membranes. Green top
2. Vogel JP, Souza JP, Gülmezoglu AM. Patterns and guidelines No. 44. Oct 2010.
Outcomes of Induction of Labour in Africa and Asia: a 16. Kramer MS, Rouleau J, Baskett TF, et al. Amniotic-
secondary analysis of the WHO Global Survey on Maternal fluid embolism and medical induction of labour: a
and Neonatal Health. PLoS One. 2013; 8(6): e65612. retrospective, population-based cohort study. Lancet
3. Guerra GV, Cecatti JG, Souza JP, Faúndes A, Morais 2006; 368:1444.
SS, Gülmezoglu AM, et al. Elective induction versus

30 AOGD Bulletin
 Third Stage of Labour: Prevention and
Management of PPH
Aakriti Batra1, Achla Batra2
1
Senior Resident, 2Consultant & Professor, Department of Obstetrics and Gynaecology
Vardhman Mahavir Medical College & Safdarjung Hospital, Delhi

“Third stage is the most unforgiving stage of labour, Prevention of Postpartum

and in it there lurks more unheralded treachery than
Haemorrhage
in both the other stages combined. The normal case
can, within a minute, become abnormal and successful Anticipation, preparedness, taking prophylactic
delivery can turn swiftly to disaster.” measures, and vigilance for PPH are the cornerstones
of PPH prevention. Anticipation involves knowing
The third stage of labour commences with the the risk factors which can cause PPH (Table 1) and
completed delivery of the foetus and ends with the be prepared with blood components and expert
completed delivery of the placenta and its attached obstetrician at onset of labour.
membranes. The average duration is 5-15 minutes.
Preparedness for PPH: PPH can occur unexpectedly
The complications of third stage are- Postpartum also therefore in all cases of delivery preparedness
Haemorrhage (PPH), retained placenta, and uterine for PPH is essential. This involves-
inversion. Placenta accreta and its variants also may
1. PPH trolley in labour room which should have
manifest for the first time during the third stage.
everything required for management of bleeding
Most complications of the third stage occur in low-
patient (Table 2)
risk women; therefore protocols and management
strategies have to be in place to deal with these 2. Training of labour room staff for estimation of
problems promptly when they arise. blood loss and PPH Drill
3. Avoidance of routine episiotomy and performance
of active management of third stage of labour
PPH (AMTSL)
A blood loss of 500 ml after vaginal delivery and
1000 ml after caesarean section is taken as primary Active management of the third stage of labour
PPH. It is classified as Minor PPH when loss is <1000 reduces the risk of PPH. The components of AMSTL
cc and major when loss is >1000cc. are uterotonics at anterior shoulder delivery or
immediately after the delivery of baby, delayed
PPH can lead to serious maternal morbidities like cord clamping and controlled cord traction (CCT) to
multi organ failure, multiple blood transfusions, deliver the placenta.
hysterectomy and even death. About 25% of
maternal deaths occur because of PPH (WHO). Uterine fundus should be assessed immediately
It also results in Iron deficiency anemia (with after delivery of baby but uterine massage should
associated fatigue and newborn care difficulties) be avoided before placental delivery. Uterotonic
and prolongation of hospital stay. should be kept ready before the delivery in order to
facilitate rapid administration.

Table 1: Risk Factors for PPH

Prenatal Antenatal Intranatal
Previous caesarean Primiparity Fever
BMI>35, Age >40 year Macrosomia in baby Prolonged labour
Large uterine myoma Multiple pregnancy Operative vaginal delivery
Bleeding disorder Hydramnios Episiotomy
Grand multipaity Coagulopathy Caesarean
History of PPH Platelet <50,000/ cumm
APH
Gestational hypertension, PE
Anaemia
Placenta previa, placenta accrete spectrum

Vol.21, No.1; May, 2021 31

Table 2: Components of PPH Trolley

IV fluids- Lactated Ringer, saline I/V set, Venflon, Syringes, needles, Vials for blood collection for
Uterotonic drugs (In fridge): Oxytocin, adehisive tape haemogram, coagulation profile, blood
Carboprost, and ergometrine Foleys catheters, condoms, silk thread grouping & cross matching
Misoprostol tablets Oxygen mask Requisition forms for blood
components & investigation

Oxytocin (10 IU), administered intramuscularly and uterine exploration is only done if suspicious
after delivery of the anterior shoulder/baby, is the of incomplete placenta or membranes. Following
preferred medication and route for the prevention delivery of the placenta, the abdomen should be
of PPH in low-risk vaginal deliveries. Intravenous palpated to assess and monitor uterine tone and size.
infusion of oxytocin (20 to 40 IU in 1000 mL, Uterine massage is done if concern exists regarding
150 mL per hour) is an acceptable alternative for uterine tone. Once good, sustained uterine tone has
AMTSL. Carbetocin, 100 μg given as an IV bolus been established, the lower genital tract should be
over 1 minute, can be used instead of continuous examined using adequate lighting and appropriate
oxytocin infusion in elective Caesarean section for positioning. The cervix should also be explored after
the prevention of PPH and to decrease the need for instrumental vaginal deliveries.
therapeutic uterotonics. Any episiotomy or lacerations should be repaired.
Ergometrine 0.2 mg IM, and misoprostol 600 to The patient should be observed for blood loss by
800 μg given by the oral, sublingual, or rectal route, visual inspection and vital monitoring over the next
may be offered as alternatives in vaginal deliveries hour, with assessment of uterine tone and size at
when oxytocin is not available. Ergometrine is least every 15 minutes.
contraindicated in patients with hypertension, not Early breastfeeding should be done as it promote
routinely used. endogenous oxytocin release.
Cord blood harvesting should not delay uterotonic
administration. In fact, uterotonics may increase Estimation of Blood Loss
the amount of blood harvested due to placental
Estimation of blood loss can be visual (Figure 1) and
compression. Assessment of the placenta and
by clinical sign & symptoms
membranes for completeness should be done

Fig 1: Visual Estimation of Blood Loss

32 AOGD Bulletin
 Retained placenta or placental bits. Management
of PPH requires a team approach as, assessment,
resuscitation and treatment has to be done
simultaneously.

Minor PPH
Intravenous access should be obtained with 2 wide
bore cannulas and crystalloids (Lactated ringer
or normal saline) are started. Blood samples for
grouping cross matching, coagulation profile should
be taken. Simultaneously uterine tone is assessed,
uterine message and oxytocin drip with 20 units in
500 ml ringer started at 40 drops/min when uterus is
atonic. Bladder is catheterised and vagina and cervix
Brass V drape Kellys Pad are visualised if not done already.
Fig 2: Calibrated drape Table 4: Team Organization
The first step is calling for
Calibrated drape- These can be put under patients Check airway
help and team organization
buttocks after delivery to collect blood in calibrated and starting assessment
Start oxygen
Communication
drape or container (Figure 2). resuscitation and treatment Documentation
Clinical Assessment of Blood loss –A patient who simultaneously. The leader of Helper 1
team will assess for tone of
comes after delivery with history of PPH, clinical
uterus, injury to genital tract,
sign and symptoms can guide regarding amount of presence of retained placental
blood loss (Table 3). bits and guide the team.
Table 3: Clinical Assessment of Blood loss Bladder should be catheterised
to keep it empty and record
Blood Systolic BP Symptoms & Degree of Helper 2 Helper 3
output
volume loss (mm Hg) Signs Shock
The helper 1, at head end will Pulse Blood
500-1000 ml Normal Palpitation Compensated BP investigation
(10-15%) Tachycardia assess consciousness level,
Drugs I/V fluids
Dizziness airway and breathing and Blood
start oxygen therapy. The components
1000-1500 ml Slight fall Weakness Mild
recording of events, drugs &
(15-25%) (80-100) Tachycardia
fluid administered as well as
Sweating
communication with other
1500-2000 ml Moderate Restlessness Moderate specialities and relatives would
(25-35%) fall Pallor also be done by helper 1
(70-80) Oligurea
Helper 2 at arm end will secure
2000-3000 ml Marked fall Air hunger Severe I/V access by 2 large bore canula
(35-50%) (50-70) Collapse (14or16) and start crystalloids Leader
Anuria and give drugs as required Assessment of tone
Helper 3 at other arm will Catheterization Massage
Shock Index- The Shock Index (SI) is calculated by of uterus Management
monitor vitals and send
dividing heart rate by systolic blood pressure It gives samples for blood grouping and
of trauma /Tissue Co
ordination with team
quick assessment of degree of shock. A SI of 0.9 or crossmatching, haemogram,
above should be taken as a warning sign of shock. coagulation profile, RFT, LFT and
• Normal Non Pregnant= 0.5-0.7 electrolytes
Traumatic cause when repaired
• Pregnant woman= 0.7-0.9 or retained placental bits when
• SI <0.9- Reassurance removed will control PPH
• SI >0.9 indicates hypovolemia The cause of PPH in 80% cases
is atony and is most challenging
• SI >1.2= 30% blood loss
to treat. If uterus is found atonic
fundal massage followed by
Management of PPH bimanual massage is done and
uterotonic drugs are given
The cause of PPH can be- Atony, Trauma, DIC,

Vol.21, No.1; May, 2021 33

Blood loss is estimated and if blood loss is upto
1000cc in a non anaemic women and PPH is
controlled, there no need to transfuse blood.

Major PPH but Bleeding Controlled

If blood loss 1000-1500cc, 2 units packed cells
should be transfused. If blood loss > 1500cc, after 2
packed cells give PRBC, FFP and platelets according
to reports.

Ongoing Major PPH

This requires multidisciplinary approach, involving
senior obstetrician, anaesthesiologist and
haematologists (Table 4).
Fig 3: Uterine Tamponade Balloons
Tranexamic Acid
Tranexmic acid 1 gram IV slowly given within 3 hours
of PPH is effective in reducing bleeding especially in
traumatic PPH. It can be repeated after 30 minutes
but not more than 10mg/kg per day can be given. It
is not given if coagulopathy present. Drugs used in
PPH are listed in Table 5.
Fig 4: PPH Cannula
Table 5: Atonic PPH Drugs
Drug Initial Continuation Total Dose
Dose Dose Vaccume Retraction by PPH Cannula
Oxytocin IV: 20 u in IV:20u in 1 Not >3 litres A specially made stainless steel or plastic cannula
1 litre at 60 litre at 40 of IV fluid of 12 mm in diameter and 25 cm in length with
drops/min drops/min containing multiple holes of 4 mm diameter at the distal 12 cm
IM:10 units oxytocin of the cannula is introduced into the uterine cavity
Ergometrine IM or IV Repeat 0.2 Five doses through the vagina to reach the fundus (Figure 4).
(slow) 0.2 mg IM after (total 1.0 mg) The cannula is connected to a suction apparatus,
mg 15 minutes, if
and a negative pressure of 700 mm mercury is
required, give
0.2 IM or IV created to suck out blood. Suction is kept for 30
(slowly) every minutes. The inner surface of the uterine cavity gets
four hours strongly sucked by the cannula. All the bleeding
Misoprostol Sublingual Repeat 200- Not more vessels including arterioles and sinusoids get sucked
800 mcg 800 mcg than 1600 into the holes of the cannula, thereby mechanically
mcg closing them. The bleeding points are permanently
15-Methyl IM 250 0.25 mg 8 doses (total closed due to clot formation within 30–40 min.
PGF2α mcg every 15-90 2 mg)
minutes
Volume Replacement in PPH
When major blood loss occurs there is decrease
Intrauterine Balloon Tamponad in blood volume which has to be replenished to
If bleeding not controlled by medical management maintain cardiac output. Till blood arrives this has
then uterine cavity balloon tamponade is done to be done by replacing with crystalloids in the ratio
and operation theatre is prepared simultaneously 1:3 for each volume of blood lost. The fluid should
(figure 3). balloon can be inflated with 300-500 not be cold as hypothermia decreases dissociation
cc of fluid and has to be placed near fundus. of oxygen from haemoglobin to tissue and shivering
The vagina is packed to keep balloon in place. If can cause acidosis due to lactic acid production
bleeding controlled then balloon is left in situ for from contracting muscles. Fluid has to be given fast
6-8 hours. in boluses of 500-1000cc in 15-20 minutes, after

34 AOGD Bulletin
2.5 litre of fluids blood must be given otherwise
dilutional coagulopathy can occur

Blood Component Replacement in

PPH
When the blood loss is more than 2000cc then the
transfusion of all components of blood in the ratio
1:1:1 has to be done. FFP should be given only after
4 unit of packed cells have been given unless there is
high risk of coagulopathy as in abruption or amniotic
fluid embolism or massive blood loss has occurred.
Transfusion of 4 unit of packed cell, 4 unit FFP and
4 unit platelet rich plasma is done initially and Fig 6: Position of patient
further transfusion depend on report of coagulation
parameters and haemoglobin if bleeding stops. If Surgical Management of Atonic PPH
onging PPH, all components have to be repeated till If bleeding not controlled by these measures then
reports come. patient is taken for surgical management. The
Targets to be achieved are - Hb ≥8 gm%; PT ≥1.5; important points to be considered during surgical
APTT≥1.5; Fibrinogen ≥100gm/dl; and Platelet count management are -
>50000/microlitre Position of patient: The position of patient on table
should never be supine, it should be 30 degree
Monitoring trendelenburg with hips flexed at 15 degree to
Pulse rate, blood pressure respiratory rate, allow for visualization of perineum for assessment of
consciousness level and output should be recorded bleeding (Figure 6).
on a flow chart such as the modified obstetric early
warning system charts. Documentation of fluid Compression Sutures
balance, blood, blood products and procedures The first surgical procedure according to WHO
should be done guidelines is compression sutures but before putting
External Aortic Compression- It is a simple life the sutures compression test should be done which
saving procedure & can be used to arrest bleeding at involves exteriorising the uterus and compressing
any stage (Figure 5). Downward pressure is applied it by placing one hand on posterior side and other
over abdominal aorta through abdominal wall a on anterior side of uterus for 3-4 minutes and if
little to left of umbilicus. The other hand is used to this decreases the bleeding only then compression
feel for femoral pulse to see if it becomes feeble sutures should be applied.
during compression. This is done till patient is taken Compression sutures include the ‘B-Lynch’ suture
to operation theater or bleeding is controlled. (Figure 7), Hayman suture (Figure 8), horizontal and
vertical brace sutures and various modifications,
including Cho’s multiple square technique (Figure
9). The main aim of these compression sutures is to
control bleeding from the placental site, by apposing
the anterior and posterior uterine walls together.

Needles and Sutures Required

Needles- 70 mm round bodied hand needle or
Straight needle which should ideally be 6 cm long so
as to exceed the combined thickness of the anterior
and posterior lower segment. Sutures used are
DEXON or VICRYL number 1 or number 2 chromic
Fig 5: External Aortic Compression catgut suture.

Vol.21, No.1; May, 2021 35

A number of compression sutures have been If bleeding is not controlled by brace sutures then
described, both vertical and horizontal but one must a balloon tamponade can also be done after brace
know that in one segment of uterus both horizontal stitches. The balloon should not be inflated more
vertical sutures should not be taken as it can impede than 200 cc to prevent ischemia.
clearance of secretion and also cause tissue necrosis
by total occlusion of blood supply.

Fig 10: Sandwich Technique

Fig 7: B Lynch Suture Step Wise Devasculariation

When bleeding persists after compression sutures
or compression test is negative, systematic pelvic
devascularization is done. It includes ligation of
uterine, tubal branch of the ovarian as well as
anterior division of internal iliac arteries respectively
(Figure 11).

Fig 8: Hayman & Cervicoisthemic Suture

Fig 11: Step Wise Devasculariation

Peripartum Hysterectomy
In a hemodynamically unstable patient, readiness
for definitive management with a hysterectomy is
Fig 9: CHO Sutures

36 AOGD Bulletin
necessary in order to reduce the risk of maternal Conclusion
mortality. Subtotal or total abdominal hysterectomy PPH prevention involves predicting, anticipating and
is attempted as the last resort to save life. This preparedness to deal with PPH. Active management
might need to be considered earlier if the patient of third stage decreases the amount of blood loss in
is haemodynamically unstable. The decision to 3rd stage. Management of PPH involves team work
perform a hysterectomy should be made by the as the assessment, resuscitation and management
most senior obstetrician have to be done simultaneously. Estimation of
Subtotal hysterectomy is safer, quicker and easier to blood loss must be done both visually and by
perform than total abdominal hysterectomy, and is clinical signs and symptoms. Fluid replacement
indicated in cases in which the source of bleeding has to be done by crystalloids in ratio 1:3 (3 times
is from the upper segment. It is not useful in cases of blood loss) to maintain cardiac output. To control
of placenta praevia or when cervical or upper PPH tone, trauma, DIC and retained tissue have to
vaginal tears contribute to PPH; in such cases, a be addressed. Decision of surgical intervention must
total abdominal hysterectomy is warranted to arrest be taken timely. Monitoring, documentation and
haemorrhage. communication are very important. The golden first
hour of management of PPH is most crucial.
Selective Artery Embolisation
In a haemodynamicaly stable patient uterine or Suggested Reading
internal iliac artery embolisation can be done to 1. WHO recommendations for the prevention and
decrease bleeding at centres where this facility is treatment of postpartum haemorrhage ISBN: 978 92 4
154850 2,2012.
available, It is useful specially in cases of placenta
2. A comprehensive textbook of postpartum hemorrhage
accrete spectrum where it can be planned before
Sabaratnam Arulkumaran (ed.) Publisher: Sapiens
hand. Publishing 2012. ISBN/ASIN: 0955228271. ISBN-13:
9780955228278.

Vol.21, No.1; May, 2021 37

 Reducing Caesarean Birth: Non-clinical
Interventions
Zeba Khanam1, Pratima Mittal2
1
Senior Resident, 2Consultant & Professor, Obstetrics & Gynaecology, Vardhman Mahavir Medical College
& Safdarjung Hospital, New Delhi

Introduction and Gynaecological Society of India (FOGSI)

In recent years caesarean section has become statement 2014 denies any ideal recommended rate
an overused mode of termination of pregnancy. for caesarean section. It says labour management
Globally caesarean rates increased from 12% in 2000 should be individualized for each labouring woman
to 21% in 2015.1 In India rates rose from 8.5% to 17.2% with the expectation of a successful and safe vaginal
from 2005-06 to 2015-16. In private sector, including delivery, together with the ability to intervene with
non-profit organization rate of caesarean birth a caesarean delivery, if needed, to prevent morbidity
varies from 27.7 to 40.9%-70%.2,3 There is minimal and mortality.6
or no reduction in the neonatal and maternal Common indications of caesarean sections include
mortality with rising caesarean rates. The caesarean labour dystocia and abnormal foetal heart tracings.7
births have been associated with maternal deaths, Not all caesarean deliveries are indicated. An
anomalous placentation in subsequent pregnancies, ‘indicated caesarean delivery’ is defined as a surgical
transient neonatal respiratory distress and long procedure to deliver a viable foetus through an
hospital stays (Table 1). Besides they require larger abdominal and uterine incision, when benefits of
human resources and incur higher costs on the this procedure outweigh the risk associated with
health system. the procedure itself. An ‘unnecessary or unindicated
caesarean delivery’ is labelled when the procedure
Indicated verses Unindicated is undertaken for reasons not associated with
anticipated adverse outcomes of natural birth.
Caesarean Sections These reasons may be social convenience, peer
It is postulated that merely 10-15% of women actually group pressure, avoidance of uncertain risk of an
require caesarean delivery (ideal caesarean rate). emergency caesarean or an instrumental delivery.
Rates >15% are associated with higher maternal Fear of labour pain, rising demand for caesarean
mortality.4 However, World Health Organization sections by affluent patients, reluctance of treating
(WHO) statement 2015, emphasized on offering obstetrician to conduct a normal vaginal or an
caesarean deliveries as per an optimal patient operative vaginal delivery due to lack of training
management protocol, rather than striving to and experience, remuneration services provided
achieve a specific rate.5 The Federation of Obstetrics at private setups, lack of support from midwives

Table 1: Maternofetal Risks Associated with Caesarean and Vaginal Births

Maternal risks Foetal risks
Caesarean deliveries- Caesarean deliveries-
• Higher overall severe mortality and morbidity • Higher rates of neonatal
• Higher rates of placental abnormalities in next pregnancy (Incidence of placenta lacerations
previa increases from 1% with one prior caesarean delivery to 3% with ≥3 • Higher rates of respiratory
caesarean sections; Incidence of morbidly adherent placenta with placenta previa morbidity (without labour).
with 3 prior caesarean deliveries is 40% and >60% in ≥5 prior caesarean sections) • Increased risk of childhood and
• Higher rates of amniotic fluid embolism adult disease later in life due to
• Higher anaesthesia complication, blood loss, infection gut dysbiois, impaired immune
• Long term adverse outcomes- subfertility due to pelvic adhesions and stress response in foetus
• Prolonged hospital stay • Cognitive disorders in baby on
Vaginal deliveries- long term
• Higher rates of 3rd and 4th degree perineal tears Vaginal deliveries-
• Similar rates of urinary incontinence and postpartum depression as caesarean Risk of shoulder dystocia
section.

38 AOGD Bulletin
and fear of litigation are other reasons. Out of the caesarean section group (Group 1 and 2)-
total 6.2 million unindicated caesarean sections Labour dystocia is responsible for the maximum
conducted worldwide each year, half are performed number of caesarean deliveries being conducted in
in China and Brazil. this group.
The definition of active stage of labour and duration
Strategies for Reducing Caesarean of latent and active phase of labour has been
Section Rates evolving since the classification of labour dystocia by
Robson Ten Group Classification System (TGCS)- Freedman.9-11 Recently WHO has proposed Labour
Clinical audits at institutional and health system care guide with a novel partographic assessment of
organisation levels remains the frontline option for labour progress.12
reducing caesarean section rates. Institution specific
quality improvement initiatives may be taken Non-clinical Interventions to Reduce
based on these audits. One approach is to follow a
standardized, international accepted classification
Unnecessary Caesarean Sections
system to monitor and compare caesarean section In 2018, WHO released recommendations on
rates in a consistent and action oriented manner at non-clinical interventions to reduce unnecessary
local and international level. The WHO systematic caesarean sections. It divided targeted interventions
review and critical appraisal of available classification at three groups- the woman, health care professionals
of caesarean section concluded one such Robson and health organisation, facilities or system (Table
TGCS based on five basic characteristics of 2).13
pregnancy (parity, onset of labour, gestational age, • Other strategies for reducing caesarean section
foetal presentation and number of foetuses), which rates includes raising awareness among
fulfils best the local and international needs. The ten obstetricians and patients about labour analgesia;
groups are totally inclusive and mutually exclusive Mobilization during labour process; Teaching
and categorises each pregnant woman delivering nurses and the parturient favourable labour
irrespective of the mode of delivery.8 positions to encourage vaginal deliveries; Writing
Robson group 1, 2 and 5 contribute to two-third of cardiotocographic examination reports in the
the overall caesarean section rates. Among them medical records and later auditing them by a
group 5 comprises 61 % of all Caesarean sections. medical record committee; Creating realistic labour
induction protocols individualized according
• Reducing caesarean rates in repeat caesarean
to institutions; Rigorous audit of caesarean
section group (Group 5)- The best way is preventing
sections; Providing uniform remuneration for
primary (first) caesarean section and encouraging
both caesarean and vaginal deliveries; Mandatory
VBAC (Vaginal Birth After Caesarean section).
second opinions; and Expanding role of midwives.14
• Reducing caesarean section rates in primary
Table 2: Recommendations by international organisations for reducing Caesarean rates
ACOG recommendations for the safe WHO recommendations WHO recommendations
prevention of primary caesarean Intrapartum care for a non-clinical interventions
delivery, 20141 positive childbirth experience, to reduce unnecessary
201811 caesarean sections, 201813
First and second stage of labour: First stage of labour- Interventions targeted at women-
• A prolonged latent phase (>20 hrs • Latent first stage is characterized Health education for women through
nullipara; >14 hrs multipara)- Not an by painful uterine contractions and childbirth training workshops,
indication of Caesarean delivery variable changes of the cervix, nurse-led applied relaxation training
• Slow but progressive first stage • Associated with some degree of programme, psychological couple-
of labour – Not an indication for effacement and slower progression based prevention programme and
Caesarean section. of dilatation up to 5 cm. psychoeducation.
• Cervical dilation of 6 cm as threshold • The active first stage is characterized No specific form of intervention
of active first stage of labour. by regular painful uterine (pamphlets, videos, role play,
• Active first stage of labour arrest contractions, a substantial degree of education) is considered superior.
defined at ≥ 6cm of cervical dilatation cervical effacement and more rapid
with ruptured membranes and failure cervical dilatation from 5 cm until
to progress despite 4 h of adequate full dilatation.

Vol.21, No.1; May, 2021 39

 uterine contractions or 6 h of oxytocin • A standard duration of the latent Interventions targeted at health
administration with inadequate first stage has not been established care professionals-
contraction and no cervical change- and can vary widely. Duration of • Implementation of evidence-
Caesarean section recommended active first stage does not extend based clinical practice guidelines
• No specific minimum duration of beyond 12 h in primipara and 10 h in combined with structured,
second stage of labour for operative multipara. mandatory second opinion for
vaginal delivery. • Epidural analgesia is recommended caesarean section indication is
• Second stage arrest of descent for healthy pregnant women recommended to reduce caesarean
defined only after 2 h of pushing requesting pain relief during births in settings with adequate
in multipara and 3 h of pushing labour. Parenteral opioids (fentanyl, resources and senior clinicians
in nullipara with reassuring diamorphine and pethidine) are able to provide mandatory second
maternofoetal condition other recommended options. opinion for caesarean section
(longer duration may apply in Relaxation techniques (progressive indication.
malpresentation and epidural muscle relaxation, breathing, • Implementation of evidence-
analgesia)- An indication for music, mindfulness) and manual based clinical practice guidelines,
Caesarean section. techniques (massage or application caesarean section audits and
• Operative vaginal delivery by an of warm packs) are recommended timely feedback to health-care
experienced physician is an acceptable for pain relief. professionals are recommended to
alternative to caesarean section. • Mobility and an upright position reduce caesarean births.
• Training in operative vaginal during labour in women at low risk is Interventions targeted at health
deliveries to be advocated. recommended. organisations, facilities or systems-
• Manual rotation of foetal head may Second stage of labour- • Collaborative midwifery-obstetrician
be considered before operative • The second stage is the period of model of care (a model of staffing
vaginal deliveries. time between full cervical dilatation based on care provided primarily
FHR monitoring and birth of the baby, during which by midwives, with 24-hour back-up
• Amnioinfusion may be done for the woman has an involuntary urge from an obstetrician who provides
repetitive variable foetal deceleration. to bear down, due to expulsive in-house labour and delivery
• Scalp stimulation of assessing acid- uterine contractions. coverage without other competing
base status of foetus with abnormal • Duration of the second stage varies clinical duties) is recommended only
or indeterminate heart patterns. from one woman to another. It in the context of rigorous research.
Labour induction usually lasts 3 hr in primipara and 2 This model primarily addresses
• Inductions should be done at 41 hr in nullipara. intrapartum caesarean sections.
weeks. Before that depending on • For women without/ with epidural • Financial strategies (i.e. insurance
maternofoetal condition. analgesia, adoption of birth position reforms equalizing physician
• Use cervical ripening method in as liked by woman is recommended. fees for vaginal births and
unfavourable cervix caesarean sections) for health-
• Failed induction of labour in latent care professionals or health-care
phase defined as ≥ 24 h of latent phase organizations are recommended
and oxytocin administered for at least only in the context of rigorous
12-18 h after membrane rupture- research.
indication of caesarean section
Document foetal presentation at the Fetal heart rate monitoring
start of 36 weeks to allow for the scope Intermittent auscultation of the foetal
of external cephalic version in breech heart rate with either
presentations and transverse lie. a Doppler ultrasound device or Pinard
Fetal macrosomia- Fetal weight ≥ 5 foetal stethoscope is
kg without maternal diabetes and ≥ recommended for healthy pregnant
4.5 kg with diabetes – An indication of women in labour
caesarean section.
Counsel mothers against excessive
weight gain in pregnancy
Twins- Vaginal delivery should be
offered in twins with first twin in
cephalic presentation.
Individual organisations and
government bodies to work together
and make policies to reduce caesarean
rates.

40 AOGD Bulletin
Conclusion 7. Barber E, Lundsberg L, Belanger K, Pettker C, Funai E, Illuzzi
J. Indications Contributing to the Increasing Cesarean
Clinical audits at institutional and health system Delivery Rate. Obstetrics & Gynecology. 2011;118(1):29-
organisation level remains the frontline option 38.
for reducing caesarean section rates. TGCS should 8. Robson Classification: Implementation Manual. Geneva:
be used to audit and monitor caesarean sections World Health Organization; 2017. Licence: CC BY-NC-SA
on main contributor population. Appropriate 3.0 IGO.
interventions and resources may then be directed to 9. FRIEDMAN E. The graphic analysis of labor. Am J Obstet
reduce caesarean rates. Gynecol. 1954 Dec;68(6):1568-75.
10. Zhang J, Landy HJ, Branch DW, et al. Contemporary
patterns of spontaneous labor with normal neonatal
References outcomes: Consortium on safe labor. Obstet Gynecol
1. Caughey AB, et al. American College of Obstetricians 2010;116:1281–1287.
and Gynecologists (College), Society for Maternal-Fetal 11. WHO recommenations: intrapartum care for a
Medicine, Safe prevention of the primary cesarean positive childbirth experience. Geneva: World Health
delivery. Am J Obstet Gynecol 2014;210:179–93. Organization; 2018.
2. Truven Health Analytics. The cost of having a baby in 12. Vogel JP, Comrie-Thomson L, Pingray V, Gadama L,
the United States, 2013. Available: http:// transform. Galadanci H, Goudar S, et al. Usability, acceptability, and
childbirth connection. org/ wp- content/ uploads/ 2013/ feasibility of the World Health Organization Labour Care
01/ Cost- of- Having- a Baby- Executive-Summary. pdf Guide: A mixed-methods, multicountry evaluation. Birth.
3. Molina G, Weiser TG, Lipsitz SR, et al. Relationship 2020 Nov 22.
between cesarean delivery rate and maternal and 13. WHO recommendations non-clinical interventions to
neonatal mortality. JAMA 2015;314:2263–70. reduce unnecessary caesarean sections. Geneva: World
4. Betran AP, Merialdi M, Lauer JA et al. Rates of cesarean Health Organization; 2018.
section: analysis of global, regional and national 14. Bhartia A, Sen Gupta Dhar R, Bhartia S. Reducing caesarean
estimates. Paediatric Perinat Epidemiol 2007;21:98-113. section rate in an urban hospital serving women
5. World Health Organization. WHO Statement on Caesarean attending privately in India – a quality improvement
Section Rates. Geneva: World Health Organization; 2015. initiative. BMC Pregnancy and Childbirth. 2020;20(1):1-7.
6. Caughey A. Can We Safely Reduce Primary Cesareans
with Greater Patience?. Birth. 2014;41(3):217-219.

Vol.21, No.1; May, 2021 41

 Simplified Bishop’s Score for Prediction
of Successful Induction of Labour
in Nulliparous Women
Suchandana Dasgupta1, Rekha Bharti2, Pratima Mittal2, Jyotsna Suri2
Sumitra Bachani3, Divya Pandey3
1
Fellow National Board, 2Professor, 3Associate Professor
Obstetrics & Gynaecology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi

Abstract obstetrics. In 1964, Edward Bishop established a

Objective: To compare simplified Bishop’s score pelvic scoring system for elective induction of labour.
with original Bishop’s score for prediction of labour The pelvic scoring system is known as Bishop’s score
induction outcome in nulliparous women. Material and it basically guides for requirement of cervical
and Methods: After informed consent 300 women ripening before induction of labour.1 It is the most
undergoing induction of labour in labour ward of widely acceptable and performed pre-induction
a tertiary care centre were included in the study. scoring and can be assessed by digital examination
Pelvic examination was done and Bishop’s score at the time of induction.
was calculated. Simplified Bishop’s score using Bishop’s score comprises of five parameters, cervical
cervical dilation, effacement and head station was dilation, effacement, position, consistency and
also noted. Women were induced according to the station of head. The total score is 0-13 (Table 1). A
existing institutional protocol and followed for mode score of 8 or more has the same chance of vaginal
of delivery and induction delivery interval. Receiver delivery subsequent to labour induction as in
operating characteristic curve was used to find spontaneous labour, whereas a score of 6 or less
out cut off point of original and simplified Bishop’s signifies unfavourable cervix which needs cervical
Score to predict vaginal delivery. Result: Out of 300 priming when induction is indicated. Later, many
women, 214 (71.33%) had normal vaginal delivery, 9 modifications of this scoring were done, of them
(3%) had operative vaginal delivery and 77 (25.67%) modified bishop’s score was introduced by Calder
had caesarean delivery. The cut off obtained by AA et al in 1974 in which the cervical effacement was
receiver operating characteristic curve was >2 for replaced by cervical length.2 Another modification
original bishop’s score and >1 for simplified bishop’s was done by Laughon SK et al in 2011, he use a
score for prediction of successful induction in simplified bishop’s score using three parameters
terms of vaginal delivery. The sensitivity, specificity, (cervical dilation, effacement and station of head)
positive predictive value and negative predictive which were most significant in predicting vaginal
value of original and simplified bishop’s score for birth.3 They found that a score of 5 is equivalent to
prediction of vaginal delivery were, 78.48%, 63.64%, the score of 8 in original Bishop’s score in predicting
86.2%, 50.5% and 90.58%, 66.23%, 88.6% and 70.8% vaginal birth. Ivras J et al added parity as a predictive
respectively. Conclusion: Simplified bishop’s score parameter and also tried to simplify the Bishop’s
has higher diagnostic accuracy for prediction of score. They found that effacement and station are
vaginal delivery in nulliparous women undergoing the most significant parameters predicting success
induction of labour. of labour induction.4
Keywords: induction of labour, successful IOL, Although till now the original Bishop’s score is widely
bishop’s score, simplified bishop’s score, induction used, it is cumbersome to do it in a busy labour
delivery interval ward and also all the parameters are subjective
having high inter-observer variation. Our attempt
Introduction is to study simplified score suggested by Laughon
SK et al using the most significant parameters i.e.
Induction of labour is done when continuation of
dilation, effacement and station for predicting the
pregnancy poses threat either to the mother or the
success of labour induction and also to compare its
baby and vaginal delivery is not contraindicated.
predictability with the original Bishop’s score.3
It is one of the most common procedures done in

42 AOGD Bulletin
Table 1: Bishop’s score number and percentage (%). The presentation of the
Parameters Score continuous variables was done as mean ± SD and
0 1 2 3 median values. The data normality was checked by
Dilation closed 1-2 3-4 >5 using Kolmogorov-Smirnov test. The cases in which
(cm) the data was not normal, we used non parametric
Effacement 0-30 40-50 60-70 >80 tests. The following statistical tests were applied for
(%) the results: The association of the induction to delivery
Station -3 -2 -1,0 +1,+2.+3 intervals with Dilatation, Effacement, Original and
Position Posterior Mid- Anterior - modified Bishop’s score were analysed using Mann-
position Whitney Test and Station, Position, Consistency were
Consistency Firm Medium Soft - analysed using Kruskal Wallis test. The association
*Simplified Bishop’s score- dilatation, effacement and head station of the variables: Dilatation, Effacement, Station,
Position, Consistency, Original and modified Bishop
Materials and Method Scores which were qualitative in nature with mode of
delivery were analysed using Chi-Square test. Receiver
It was an observational study conducted on 300 term
operating characteristic curve was used to find out
nulliparous women undergoing IOL in the Department
cut off point of original and modified Bishop Scores
of Obstetrics and Gynaecology, Vardhman Mahavir
to predict vaginal delivery. Sensitivity, specificity, PPV
Medical College and Safdarjung Hospital, New Delhi,
and NPV was calculated. DeLong et al test was used
India. Nulliparous women, admitted for induction
to compare AUC of original and modified Bishop’s
of labour were eligible to participate in the study.
score. Logistic regression was used to predict vaginal
Women with APH, foetal macrosomia, foetal growth
delivery. For statistical significance, p value of less
restriction, preterm rupture of membranes, previous
than 0.05 was considered as significant.
uterine surgery and with favourable Bishop’s score
(>6) were excluded from the study. In all patients
digital vaginal examination was done, cervical Results
parameters included in bishop’s score were assessed Most women were in the age group of 21-30 years
and total score calculated. Simplified bishop’s (83%) with late term gestation i.e. 39-40+6 weeks
score explained by Laughon SK et al taking three
parameters dilatation, effacement and station, Table 2: Distribution of parameters of Bishop's score in study
was also calculated. After assessment of above subjects
mentioned parameters induction of labour using Parameters of No of observations Percentage
dinoprostone (PGE2) gel was done. Assessment after Bishop score (n=300) (%)
the first dose of dinoprostone gel was done after 6 Dilatation
hours and a second dose was administered based 0{Closed} 65 21.67
upon the Bishop’s score. Maximum two doses of gel 1{1-2 cm} 235 78.33
were used for priming of cervix followed by induction Effacement
or augmentation of labour with oxytocin according 0{0-30%} 185 61.67
to the cervical favourability and uterine contractions. 1{40-50%} 115 38.33
Failed induction was defined as failure to enter active
Station
stage of labour (cervical dilation ≥4cm) with regular
0{-3} 97 32.33
uterine contractions after 2 doses of dinoprostone
1{-2} 119 39.67
gel and 6-12 hours of oxytocin administration after
ARM.5 These women were followed for mode of 2{-1} 84 28.00
delivery and induction to delivery interval. Position
0{Posterior} 208 69.33
Statistical Analysis 1{Mid position} 84 28.00
2{Anterior} 8 2.67
The data entry was done in the Microsoft EXCEL
spreadsheet and the final analysis was done with Consistency
the use of Statistical Package for Social Sciences 0{Firm} 173 57.67
(SPSS) software version 21.0. The presentation of 1{Medium} 112 37.33
the Categorical variables was done in the form of 2{Soft} 15 5.00

Vol.21, No.1; May, 2021 43

(52%). Almost half of the study population had had operative vaginal delivery and 77 (25.67%) had
normal BMI (45.34%). The most common indication caesarean delivery. Caesarean section were done
for IOL was postdatism (43.34%) followed by for non-reassuring foetal heart rate with or without
hypertensive disorders (25%). Out of 300 women, meconium stained liquor (37.66%), arrest of labour
214 (71.33%) had normal vaginal delivery, 9 (3%) (5.19%) and failed induction (57.14%). Most babies

Table 3: Receiver operating characteristic curve of original and modified Bishop score to predict vaginal delivery
Vaginal delivery Original Bishop score Simplified Bishop score
Area under the ROC curve (AUC) 0.755 0.857
Standard Error 0.0299 0.0232
95% Confidence interval 0.703 to 0.803 0.813 to 0.895
P value <0.0001 <0.0001
Cut off >2 >1
Sensitivity(95% CI) 78.48% (72.5 - 83.7%) 90.58% (86.0 - 94.1%)
Specificity(95% CI) 63.64% (51.9 - 74.3%) 66.23% (54.6 - 76.6%)
PPV(95% CI) 86.2% (80.7 - 90.6%) 88.6% (83.7 - 92.4%)
NPV(95% CI) 50.5% (40.2 - 60.8%) 70.8% (58.9 - 81.0%)
Diagnostic accuracy 74.67% 84.33%
P value comparing AUC 0.0001

Table 4: Association of Bishop’s Score Parameters with Vaginal Delivery and Induction to Delivery Interval
Parameters LSCS Vaginal delivery P value Induction to delivery P value
(n=77) (n=223) interval(hours)
Dilatation
0 35 (53.85%) 30 (46.15%) <.0001* 18.67 (12.417-22) 0.048#
1 42 (17.87%) 193 (82.13%) 15.65 (11.15-20.817)
Effacement
0 59 (31.89%) 126 (68.11%) 0.002* 17.53 (11.7-21.833) 0.021#
1 18 (15.65%) 97 (84.35%) 14.5 (11.075-19.042)
Station
0 60 (61.86%) 37 (38.14%) <.0001* 16.83 (12-20.5) 0.919$
1 14 (11.76%) 105 (88.24%) 16.42 (10.933-21.167)
2 3 (3.57%) 81 (96.43%) 16.12 (11.65-21.504)
Position
0 40 (19.23%) 168 (80.77%) 0.006* 15.6 (11.242-20.896) 0.143$
1 34 (40.48%) 50 (59.52%) 16.94 (11.587-21.562)
2 3 (37.50%) 5 (62.50%) 22.04 (16.333-28.417)
Consistency
0 29 (16.76%) 144 (83.24%) <.0001* 16.53 (11.75-21.333) 0.221$
1 40 (35.71%) 72 (64.29%) 15.29 (9.458-20.842)
2 8 (53.33%) 7 (46.67%) 17.67 (12.65-19.75)
Original Bishop score
<=2 49 (50.52%) 48 (49.48%) <.0001* 17.67 (12.417-21.9) 0.091#
>2 28 (13.79%) 175 (86.21%) 15.5 (11.15-20.742)
Simplified Bishop score
<=1 51 (70.83%) 21 (29.17%) <.0001* 18.02 (12.312-21.183) 0.228#
>1 26 (11.40%) 202 (88.60%) 15.8 (11.158-20.975)
* # $
- Chi-square test, - Mann-Whitney test, -Kruskal Wallis test

44 AOGD Bulletin
had normal birth weight (77.33%) and rest were Various variations of the Bishop’s score have been
small for gestation (SGA) babies (22.67%). created in an attempt to simplify the score with
The distribution of different parameters of Bishop’s similar or higher predictive ability.3,4,6-10 In our study
score is shown in Table 2. Cut off for prediction of we evaluated simplified Bishop’s score and found
successful induction in terms of vaginal delivery by it to have higher accuracy in prediction of vaginal
Receiver operating characteristic curve was >2 for birth following IOL.
original Bishop’s score and >1 for simplified Bishop’s A total of 300 nulliparous women undergoing cervical
score, Figure 1. Diagnostic accuracy for simplified priming before labour induction were included in the
Bishop’s score as compared to original Bishop’s score study. Original and simplified Bishop’s scores were
was high and standard error was less, Table 3. Cervical calculated, vaginal delivery (either normal delivery
dilation and effacement had significant association or operative vaginal delivery) was considered as the
with induction to delivery interval, p< 0.05, Table 4. primary outcome for successful induction of labour.
The variance was calculated after removing one All the five parameters of original Bishop’s score were
or more parameters with regression model. It assessed individually for association with mode of
showed least variance (51.53%) when effacement, delivery and also induction to delivery interval. The
consistency and position were removed, Table 5. simplified and the original Bishop’s score were also
evaluated for the same. In our study group dilation,
station and consistency were the most significant
parameters (p<0.0001) followed by effacement (p
0.002) and position of the cervix (p 0.006). Lyndrup J
et al also reported foetal head station to be the most
significant parameter associated with success of IOL
(p<0.05) followed by cervical dilatation.7 Ivras J et al
found fetal station, cervical effacement, and parity
to be the only factors associated with the success of
induction. It is also reported that consistency and
position are not useful in predicting success of IOL.3,4
In our study, we found higher sensitivity, specificity,
positive predictive value (PPV) and negative
predictive value (NPV) of simplified Bishop’s score
as compared to original Bishop’s score for prediction
of vaginal delivery, 78.48%, 63.64%, 86.2%, 50.5%
and 90.58%, 66.23%, 88.6%, 70.8%, respectively.
Laughon SK et al who proposed this simplified
Fig 1: Receiver operating characteristic curve of original and
Bishop’s score found similar or better PPV (87.7%
modified Bishop score to predict vaginal delivery
compared with 87.0%), NPV (31.3% compared with
29.8%), positive likelihood ratio (2.34 compared
Discussion with 2.19), and correct classification rate (51.0%
Bishop’s score has been used for assessment of compared with 47.3%) of simplified compared with
cervical favourability before induction of labour. the original Bishop score.3
Table 5: Evaluating Regression Model with Outcome of Vaginal Delivery
Number of variable removed Variable removed Proportion of explained variance
0 None were removed 54.61%
Consistency 54.27%
1
Position 53.80%
Consistency + Position 53.34%
2 Position + Effacement 51.99%
Consistency + Effacement 52.08%
Consistency + Position+
3 51.53%
Effacement

Vol.21, No.1; May, 2021 45

To find out the importance of each parameter of Conclusion
original Bishop’s score, we used regression model Simplified bishop’s score has lesser parameters
to calculate amount of variance after removing one to be assessed, is easy to calculate and has higher
or more parameters. In our study cervical position accuracy for prediction of induction of labour than
was found to be the least significant parameter for original bishop’s score.
prediction of vaginal delivery. The variance was
decreased when position was removed individually
(53.80%) and in combination with effacement References
(51.99%) and consistency (53.34%) as compared to 1. Wormer KC, Williford AE. Bishop Score. [Updated 2019 Jan
7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
when no parameter was removed (54.61%). Also Publishing; 2019 Jan-. Available from: https://www.ncbi.
the variance was least (51.53%) when effacement, nlm.nih.gov/books/NBK470368/ Last accessed on April
consistency and position were removed suggesting 10, 2021.
dilation and station being the most important 2. Calder AA, Embrey MP, Hillier K. Extra-amniotic
parameters of Bishop’s score, Table 5. Similar findings prostaglandin E2 for the induction of labour at term. J
are supported by other authors in their respective Obstet Gynaecol Br Commonw. 1974;81(1):39-46.
studies.3,6 3. Laughon SK, Zhang J, Troendle J, Sun L, Reddy UM. Using a
simplified Bishop score to predict vaginal delivery. Obstet
Individual parameters of Bishop’s score were also Gynecol. 2011;117(4):805-811.
evaluated for association with induction to delivery 4. Ivars J, Garabedian C, Devos P, Therby D, Carlier S,
interval, and only cervical dilatation and effacement Deruelle P, Subtil D. Simplified Bishop score including
were found to be significantly associated with parity predicts successful induction of labor. Eur J Obstet
induction to delivery interval, p < 0.05 (Table 4). For Gynecol Reprod Biol. 2016;203:309-314.
calculated cut off of simplified bishop’s score of >1 5. Induction of labor (NICE clinical guideline 70) Available
and original bishop’s score of >2, the mean induction from https://www.rcog.org.uk/en/guidelines-research-
to delivery interval were 15.8 hours and 15.5 hours, services/guidelines/induction-of-labor/ Last accessed on
April 10, 2021.
respectively. Reis FM et al demonstrated dilatation
6. Harrison RF, Flynn M, Craft I. Assessment of factors
(v2 = 16.29, P < .0001) and effacement (v2 = 20.83, P constituting an “inducibility profile”. Obstet Gynecol.
< .0001) to be significantly associated with delivery 1977;49(3):270-274.
within 24 hours. However, they did not find cervical 7. Lyndrup J, Legarth J, Weber T, Nickelsen C, Guldbaek
position (v2 = 3.47, P = 0.10), consistence (v2 = 3.73, E. Predictive value of pelvic scores for induction of
P = 0.2), and head station (v2 = 1.34, P = 0.2) to be labor by local PGE2. Eur J Obstet Gynecol Reprod Biol.
useful in prediction of vaginal delivery after labour 1992;47(1):17-23.
induction. 8. Reis FM, Gervasi MT, Florio P, Bracalente G, Fadalti M,
Severi FM, Petraglia F. Prediction of successful induction of
As cervical consistency and position of cervix are labor at term: role of clinical history, digital examination,
not found to be useful parameters in predicting ultrasound assessment of the cervix, and fetal fibronectin
outcome of labour induction in nulliparous women, assay. Am J Obstet Gynecol. 2003 Nov;189(5):1361-7.
therefore the simplified Bishop’s score suggested 9. Lange AP, Secher NJ, Westergaard JG, Skovgård I. Prelabor
by Laughon SK et al may be used for assessment of evaluation of inducibility. Obstet Gynecol. 1982 Aug;
cervix favourability before IOL. 60(2):137-47.
10. Dhall K, Mittal SC, Kumar A. Evaluation of preinduction
The main strength of study is the large sample size scoring systems. Aust N Z J Obstet Gynaecol. 1987
of 300 homogenous population including only term Nov;27(4):309-11.
nulliparous women. The limitation of the study was
that primary outcome of successful IOL was vaginal Corresponding Author
Suchandana Dasgupta
delivery and not the failure to enter active stage of
FNB fellow, VMMC & Safdarjung Hospital
labour as one third of caesarean sections were done
New Delhi
for foetal distress. Email: suchandana.dasgupta@gmail.com

46 AOGD Bulletin
Correlation of Digital Vaginal Examination with
Transabdominal Ultrasound to Assess Foetal
Head Position Prior to Operative Vaginal and
Caesarean Delivery
Manisha Verma1, Niharika Guleria2, Sumitra Bachani3
Pratima Mittal4, Jyotsna Suri4, Rekha Bharti4
1
Postgraduate Resident, 2Senior Resident, 3Associate Professor, 4Professor
Obstetrics & Gynaecology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi

Abstract is delivered from the uterus. Position of foetus

Objective: To compare transabdominal ultrasound refers to the relationship of foetal presenting part
(TAS) with digital vaginal examination (DVE) for to the maternal pelvis as foetal occiput in cephalic
determination of foetal head position (FHP) during presentation. Intrapartum foetal head position (FHP)
active labour prior to operative vaginal delivery assessment can be used to predict the course of
(OVD) and caesarean sections (CS). Material and labour.1 Traditionally this is performed by palpation of
Methods: This was a prospective observational study sagittal suture, and anterior & posterior fontanelle on
at Vardhman Mahavir Medical College and Safdarjung digital vaginal examination (DVE).2 The main reasons
Hospital. Low-risk pregnant women in active labour of misinterpretation by this method are presence of
with singleton foetus in vertex presentation were tense bag of membrane, large caput succedaneum,
enrolled in the study. DVE and TAS were done for the asynclitism of foetal head and moulding. Other
assessment of FHP prior to OVD and CS and agreement disadvantage of DVE is that it is subjective so,
of FHP via DVE and TAS was recorded. Inter-rater inaccurate, painful, intrusive and associated with
agreement kappa (k) was used to find out the strength risk of infections. Inaccurate assessment as in case
of agreement between FHP by DVE and TAS. A p of occipito-posterior position if early rupture of
value of <0.05 was considered statistically significant. membranes is done it can make long anterior rotation
Results: Amongst 335 women, 302 (90.15%) delivered of foetal head difficult, resulting in prolonged labour
vaginally, 12 (3.58%) underwent OVD, and 21 (6.27%) and higher rates of operative delivery along with
had CS. TAS could determine FHP in all (100%) women adverse maternal and neonatal outcomes.3
who underwent OVD. There was good concordance With the advent of transabdominal ultrasound (TAS),
between DVE and TAS for determining FHP in second more precise assessment of FHP in pelvis during
stage of labour, Kappa= 0.633; p value= <0.0001 in active labour is possible. It is less invasive, associated
women undergoing OVD. There was fair correlation with better outcomes for vaginal delivery, decreased
between DVE and TAS in second stage of labour for caesarean section rates and reduced risk of ascending
determining FHP, Kappa= 0.558; P value= <0.0001 infections.4 It may be of great value in certain clinical
in women undergoing CS. Conclusion: A higher situations such as prior to instrumental delivery to
percentage of the occiput-transverse and occiput- improve the accuracy of vaccum cup placement.5
posterior positions can be misdiagnosed on DVE. TAS Error in assessment of FHP can result in a deflexed
can be a useful adjunct to correctly determine the FHP
and an asynclitic head attitude leading to failure of
prior to vacuum application as well as before CS to
vacuum delivery. Failure of instrumental delivery
avoid both unnecessary caesarean section and delay
in turn followed by caesarean section is associated
in caesarean.
with an increased decision‐to‐delivery interval and
Keywords: Foetal head position, Digital vaginal further increased risk of maternal and foetal trauma.
examination, Transabdominal ultrasound, Normal Studies have generally used TAS, as by this route
vaginal delivery, Operative vaginal delivery, both midline structures as well as occiput positions
Caesarean section (anterior and posterior) could be defined in 94%,
although it may be technically difficult with a deeply
Introduction engaged foetal head in the second stage of labour.6
Labour is defined as the process by which the foetus In current study TAS was used for determining FHP

Vol.21, No.1; May, 2021 47

as it is easily accessible in labour room, skills can be foetal spine as landmark and defining the occiput
learnt easily and it helps to determine the position as the denominator. TAS findings were considered
of spine and thus the foetal occiput. as the gold standard. It was expressed in the form
of 12-hour clock system such that the examiner was
Material and Methods always facing the perineum. By TAS, the OA (occiput-
anterior) position was defined to be from >9:30 to
This was a prospective observational study conducted
<2:30 clock hours, the left occiput transverse (LOT)
in Department of Obstetrics and Gynaecology at
position from 2:30 to 3:30 clock hours, the right
Vardhman Mahavir Medical College over a period of 18
occiput transverse (ROT) position from 8:30 to 9:30
months post ethical clearance. Nulliparous pregnant
clock hours, and the OP (occiput-posterior) position
women with term singleton pregnancy in the active
from >3:30 to <8:30 clock hours (Fig. 1).
phase of the first stage of labour (cervical dilatation
4–6 cm) with cephalic presentation were enrolled
in the study after informed consent. Digital vaginal
examination was carried out by the labour ward
resident for the assessment of cervical status, station
of head, membrane status, and any cephalopelvic
disproportion. The FHP (foetal head position) was
noted by the resident and this was followed by TAS
(transabdominal ultrasonography) which was done
within 10 minutes of DVE (digital vaginal examination).
Women prepared for emergency caesarean
section in the first stage of labour, pregnancy with
intrauterine death, women with medical emergencies
necessitating immediate delivery, previous cervical Fig 1: Position of the foetal head on transabdominal
surgery (cone biopsy and cervical cerclage), foetal sonography
macrosomia (baby weight ≥ 4 kg), and all other The operator first determined the location of the
nonvertex presentations in labour were excluded from foetal spine with the ultrasound probe placed
the study. All ultrasonographic assessments were done longitudinally on the mother’s abdomen. If the
with Toshiba’s model SSA640 A with 3–5 Hz probe. cervical spine was seen at the midline, then the
The person performing the ultrasound examination foetus was in the direct OA position (Fig. 2). If the
was blinded to the findings of DVE. Compliance cervical spine was seen by tilting the probe more
of Preconception Prenatal Diagnostic Techniques than 45° from midline, then the foetus was in the
(PCPNDT) Act was strictly adhered. right occiput anterior (ROA) or left occiput anterior
On DVE, the FHP was determined based on the (LOA) position. If the cervical spine was only seen by
position of the occiput and posterior fontanel. TAS was putting the probe near either left or right anterior
performed using 3–5 Hz probe of two-dimensional superior iliac spine, then the foetus was determined
(2D) ultrasound. The FHP was determined using the to be in the LOT or ROT position, respectively. If the

Fig 2: Foetal head position on transabdominal sonography with respect to foetal spine

48 AOGD Bulletin
cervical spine could not be seen, then the ultrasound body mass index (BMI) of 23.25 ± 11.85 kg/ m2. The
probe was rotated to orientate transversely to the mean gestational age of women was 39.07 ± 0.79
maternal spine and the operator would identify the weeks (37–42 weeks). Period of gestation was 39–39
foetal orbits. Depending on the orientation of the + 6 in 54.39% of women. Most of the babies [236
foetal orbits, the FHP was classified as direct OP, left (70.45%)] weighed between 2.5 and 3.5 kg, and 20.3%
occiput posterior (LOP), or right occiput posterior babies were of low birth weight. Amongst 335 women,
(ROP) position accordingly (Fig. 2). Both examinations 302 (90.15%) had a normal vaginal delivery, 12 (3.58%)
were done in the active first stage of labour (cervical underwent operative vaginal delivery, and 21 (6.27%)
dilatation 4–6 cm) and the beginning of the second had second stage caesarean section (Table 1).
stage of labour (full dilatation) in the same women. DVE was able to correctly diagnose FHP in 7/10 (70%)
In few cases, the FHP could not be determined in the women with OA position.DVE could not diagnose the
second stage of labour, due to deeply engaged head. solitary OP position which was delivered by forceps
application. TAS however could determine FHP in all
Statistical Analysis (100%) women who underwent OVD. The absolute
Categorical variables were presented as numbers agreement between DVE & TAS in OVD was 66.67%
and percentages, and continuous variables were (Table 2). There was good concordance between
presented as mean ± SD and median. Qualitative DVE and TAS for determining FHP in second stage of
variables were correlated using Chi-square test. labour, Kappa= 0.633; P value= <0.0001 in women
Inter-rater κ agreement was used to find out the undergoing operative vaginal delivery. (Table 3)
strength of agreement between the FHP by DVE and Amongst women who had caesarean section
USG. A p value of <0.05 was considered statistically (CS), DVE was able to correctly diagnose FHP
significant. The data were entered in MS Excel in 83.33%(5/6) women with OA position and in
spreadsheet, and the analysis was done using SPSS 33.33%(1/3) with OP position. While TAS correctly
version 21.0. K value interpretation was taken as identified 85.7% (18/21) FHP prior to second stage
poor (<0.20), fair (0.21-0.4), moderate (0.41-0.6), caesarean, there were 14.29%(3) observations in
good (0.61-0.8) and very good (0.81-1.00) which the FHP could not be determined by TAS.
This was due to deep seated foetal head in maternal
Results pelvis or obstructive view of foetal occiput due to
A total of 335 women were enrolled in the study and maternal pubic bones.(Table 4). There was absolute
followed up by DVE and TAS to determine the FHP in agreement of 47.61% between DVE and TAS prior
the active first stage (cervical dilatation 4–6 cm) and to second stage caesarean section. There was fair
in the early second stage of labour. The mean age of correlation between DVE and TAS in second stage of
women participating in the study was 22.81 ± 2.91 labour for determining FHP, Kappa= 0.558; P value=
years. Maximum number of women (60.0%) had mean <0.0001(Table 5)

Table 1: Labour outcomes with relation to foetal head position

OA LOA ROA ROT LOT ROP LOP OP UD TOTAL
Vaginal 139 116 30 0 0 2 1 5 9 302
(95.2%) (95.08%) (90.9%) (0.00%) (0.00%) (66.6%) (50.0) (71.4%) (75.0%) (90.1%)
Operative 2 5 3 1 0 1 0 0 0 12
vaginal (1.37%) (4.1%) (9.09%) (14.2%) (0.00%) (33.3%) (0.00%) (0.00%) (0.00%) (3.58%)
Caesarean 5 1 0 6 3 0 1 2 3 21
(3.42%) (0.82%) (0.00%) (85.7%) (100.0%) (0.00%) (50.0%) (28.5%) (25.0%) (6.27%)

Table 2: Agreement between foetal head position in vaginal examination and ultrasonography in “operative vaginal delivery”
Actual no. Diagnosed by TAS Absolute agreement with DVE
(Number/ %) (Number/ %)
Occiput-anterior position 10(83.33%) 7(70.0%)
Occiput-transverse position 1(8.33%) 1(100.0%)
Occiput-posterior position 1(8.33%) 0(0.00%)
Total 12(100.00%) 8(66.67%)

Vol.21, No.1; May, 2021 49

Table 3: Correlation of foetal head position on vaginal examination and ultrasonography in “operative vaginal delivery”
FHP IN 2ND STAGE BY USG (N=12) Total
LOA OA ROA ROP ROT
FHP LOA 3 (25.00%) 1 (8.33%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 4 (33.33%)
in 2nd OA 1 (8.33%) 1 (8.33%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 2 (16.67%)
Stage by
ROA 0 (0.00%) 0 (0.00%) 3 (25.00%) 0 (0.00%) 0 (0.00%) 3 (25.00%)
DVE
ROT 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (8.33%) 1 (8.33%) 2 (16.67%)
UNDETERMINED 1 (8.33%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (8.33%)
Total 5 (41.67%) 2 (16.67%) 3 (25.00%) 1 (8.33%) 1 (8.33%) 12 (100.00%)

Table 4: Agreement between foetal head position in vaginal examination and ultrasonography in “caesarean section”
Actual no. Diagnosed by TAS Absolute agreement with DVE
(Number/ %) (Number/ %)
Occiput-anterior position 6(28.57%) 5(83.33%)
Occiput-transverse position 9(42.85%) 4(44.44%)
Occiput-posterior position 3(14.28%) 1(33.33%)
Undetermined 3(14.28%) 0(0.00%)
Total 21(100.00%) 10(47.61%)

Table 5: Correlation of foetal head position on vaginal examination and ultrasonography in “caesarean section”
FHP IN 2ND STAGE BY USG Total
LOA LOP LOT OA OP ROT UNDETERMINED?
FHP LOA 1 0 0 0 (0.00%) 0 0 0 (0.00%) 1
in 2nd (4.76%) (0.00%) (0.00%) (0.00%) (0.00%) (4.76%)
Stage LOP 0 0 1 0 (0.00%) 0 0 0 (0.00%) 1
by (0.00%) (0.00%) (4.76%) (0.00%) (0.00%) (4.76%)
DVE LOT 0 1 2 0 (0.00%) 0 0 0 (0.00%) 3
(0.00%) (4.76%) (9.52%) (0.00%) (0.00%) (14.29%)
OA 0 0 0 4 0 0 0 (0.00%) 4
(0.00%) (0.00%) (0.00%) (19.05%) (0.00%) (0.00%) (19.05%)
OP 0 0 0 0 (0.00%) 1 0 3 (14.29%) 4
(0.00%) (0.00%) (0.00%) (4.76%) (0.00%) (19.05%)
ROA 0 0 0 0 (0.00%) 0 2 0 (0.00%) 2
(0.00%) (0.00%) (0.00%) (0.00%) (9.52%) (9.52%)
ROP 0 0 0 0 (0.00%) 1 1 0 (0.00%) 2
(0.00%) (0.00%) (0.00%) (4.76%) (4.76%) (9.52%)
ROT 0 0 0 0 (0.00%) 0 2 0 (0.00%) 2
(0.00%) (0.00%) (0.00%) (0.00%) (9.52%) (9.52%)
UNDETERMINED 0 0 0 1 (4.76%) 0 1 0 (0.00%) 2
(0.00%) (0.00%) (0.00%) (0.00%) (4.76%) (9.52%)
Total 1 1 3 5 2 6 3 (14.29%) 21
(4.76%) (4.76%) (14.29%) (23.81%) (9.52%) (28.57%) (100.00%)

Discussion 94.37% cases of OA (occiput-anterior) and 66% of

Accurate intrapartum assessment of FHP is OP (occiput posterior) positions. In a similar study,
considered important for the management of both Gardberg et al reported OA as the most common
normal and abnormal labours as this influences the positions to be delivered vaginally and OP positions
obstetric outcomes such as management of labour to be more commonly delivered by OVD or CS.7 In
dystocia, choice of instruments for assisted delivery, another article by the authors of current study,
success of vaginal delivery and fetomaternal the FHP by DVE significantly correlated with TAS in
complication.3 In present study, 90.15% women had anterior positions (p<0.0001) and kappa showed
normal vaginal delivery, 3.58% had OVD and 6.27% moderate concordance (0.606). In 72 (22.98%)
underwent CS. Vaginal delivery was favourable for women DVE differed by >45º with respect to TAS.8

50 AOGD Bulletin
The rate of error was found to be 50-76% with failed, it was 4.5 times more likely that a deflexing
vaginal examination when ultrasound examination application of the vacuum cup had been performed,
findings were taken as gold standard in studies by which more commonly occurs with occiput-lateral or
Akmal et al and Sherer et al. posterior position.15 Vacca and Kreiser examined the
Sherer et al studied 112 patients and reported outcome of 244 vacuum extractions and reported
agreement in 40% of cases (p=0.044) and kappa was that incorrect application and failure is associated
fairly concordant (0.25) in second stage of labour with neonatal injury in the form of subdural
between DVE and TAS. When vaginal examinations or cerebral, intraventricular and subarachnoid
recorded within ±45º of the USG assessments were haemorrhage.16 Therefore, early diagnosis will help
considered as consistent, it increased the agreement the obstetrician to provide women with additional
to 68% however kappa was fairly concordant (0.30).9 information about the timely need for OVD. Kappa
Akmal et al studied 64 patients immediately before showed good concordance (0.633) between DVE
OVD and found that the difference was >45º in 19% and USG in instrumental delivery. In the current
of cases between the two modalities.10 Zara et al study ultrasound was able to correctly diagnose
studied 34 patients and reported absolute agreement and facilitate instrumental delivery in OA and OT
between DVE and TAS in 27(54%) of cases (kappa positions.
0.073) and agreement with ±45º allowance was OP is the most common malposition at term with an
in 40 (80%) of cases (kappa=0.728).11 Hence digital incidence of 2-10% cases in labour. In 90% cases it
examinations are reliable for anterior positions in rotates anteriorly, while the remaining 10% should
second stage of labour, however ultrasound should be accurately diagnosed for they may account for
be used as an adjunct for confirmation in occiput second stage. CS.3 In the present study, caesarean
posterior and transverse positions as these can be sections were done in 21(6.26%) women mainly
misdiagnosed on vaginal examination. Dupuis et al for arrest of descent of head apart from foetal
reported that they were unable to locate the FHP in indication. Women undergoing CS in first stage were
second stage of labour by DVE in 7 out of 110 women, excluded from the study to maintain uniformity in
similar to the findings of current study.12 Hence TAS both stages of labour. DVE was able to determine
is useful in such conditions with an advantage to FHP in second stage of labour before CS in 5(83.33%)
provide an opportunity to objectively assess the cases in OA positions and 4 cases (44.44%) in OT
FHP as well as being non intrusive and comfortable positions. Agreement between DVE and TAS was
for the labouring woman.13 seen in one (33.33%) woman with OP positions.
Correct determination of FHP in second stage of Akmal et al studied 601 women and reported the
labour is particularly useful before instrumental incidence of caesarean in OP position in 19% and
delivery because errors in assessment may result occiput transverse and anterior position in 11%.17
in deflexed and asynclitic head attitudes and TAS was undetermined in 3(14.28%) observations in
consequent failure of vaccum delivery.5 In the present which the foetal head was deep seated in maternal
study, 12(3.58%) women underwent OVD (vaccum or pelvis or view of foetal occiput was obstructed due
forceps assisted). DVE was able to determine correct to maternal pubic bones.
FHP in 100% observations in ROT and ROA in second
stage of labour. DVE had agreement with TAS during Conclusion
second stage of labour in 7(70%) observations in A higher percentage of the foetal occiput-transverse
OA positions. There was no agreement between and occiput-posterior positions are misdiagnosed on
DVE and TAS in OP positions (kappa=0.633). Akmal digital vaginal examination (DVE). Transabdominal
et al reported 75% agreement in determining FHP ultrasonography (TAS) compared to DVE can be a
by DVE and TAS prior to instrumental delivery and useful adjunct to correctly determine the FHP prior
the accuracy of digital examination was higher in OA to instrumental delivery and to facilitate delivery of
positions (83%) than it was for OT and OP positions the foetal head in second stage caesarean section.
(54%) as was in current study.14 In current study
there was no case of failed instrumental delivery References
and vaccum cup displacement. Mola et al. examined
1. Senecal J, Xiong X, Fraser WE. Effect of fetal position on
the outcome of 59 trials of instrumental deliveries second-stage duration and labour outcome. Obstet
and reported that in the 12 cases in which the trial Gynecol 2005;105:763–72.

Vol.21, No.1; May, 2021 51

2. Shetty J, Aahir V, Pandey D, et al. Fetal Head Position 11. Lok ZLZ, Chor MCM. Reliability of digital vaginal
during the First Stage of: Comparison between Vaginal examination for fetal head position determination: A
Examination and Transabdominal Ultrasound. ISRN prospective observational study. Edorium J Gynecol
Obstet Gynecol 2014;314:617. Obstet. 2015;1:5–9
3. Cheng YW, Shaffer BL, Caughey AB. Associated factors 12. Dupuis O, Ruimark S, Corinne D, et al. Fetal head
and outcomes of persistent occiput posterior position: a position during the second stage of labor: comparison
retrospective cohort study from 1976 to 2001. J Matern of digital vaginal examination and transabdominal
Fetal Neonatal Med 2006;19:563–8. ultrasonographic examination. Eur J Obstet Gynecol
4. Verhoeven CJ, Rückert ME, Opmeer BC, et al. Reprod Biol 2005;123(2):193–7.
Ultrasonographic fetal head position to predict mode of 13. Zahalka N, Sadan O, Malinger G, et al. Comparison of
delivery: a systematic review and bivariate meta-analysis. transvaginal sonography with digital examination and
Ultrasound Obstet Gynecol 2012;40(1):9-13. transabdominal sonography for the determination of
5. Johanson RB, Heycock E, Carter J, et al. Maternal and child fetal head position in the second stage of labor. Am J
health after assisted vaginal delivery: five-year follow up Obstet Gyencol 2005;193:381–86.
of a randomized controlled study comparing forceps and 14. Akmal S, Kametas N, Tsoi E, et al. Comparison of
ventouse. Br J Obstet Gynaecol 1999;106:544–9. transvaginal digital examination with intrapartum
6. Wong GY, Mok YM, Wong SF. Transabdominal ultrasound sonography to determine fetal head position before
assessment of the fetal head and the accuracy of vacuum instrumental delivery. Ultrasound Obstet Gynecol
cup application. Int J Gynaecol Obstet 2007;98(2):120–3 2003;21(5):437–40.
7. Gardberg M, Laakkonen E, Sälevaara M. Intrapartum 15. Mola GD, Amoa AB, Edilyong J. Factors associated with
sonography and persistent occiput posterior position: a success or failure in trials of vacuum extraction. Aust N Z
study of 408 deliveries. Obstet Gynecol 1998;91:746–9. J Obstet Gynaecol 2002; 42: 35–39.
8. Mittal P, Verma M, Bachani S, et al. Correlation of Digital 16. Vacca A. Vacuum-assisted delivery: an analysis of traction
Vaginal Examination with Transabdominal Ultrasound to force and maternal and neonatal outcomes. Aust N Z J
Assess Fetal Head Position during Active Labor. J South Obstet Gynaecol 2006;46:124–7.
Asian Feder Obst Gynae 2019;11(6):375–380. 17. Akmal S, Kametas N, Tsoi E, et al. Ultrasonographic occiput
9. Sherer DM, Miodovnik M, Bradley KS, et al. Intrapartum position in early labour in the prediction of Caesarean
fetal head position II: comparison between transvaginal section. Br J Obstet Gynaecol 2004;111(6):532-6.
digital examination and transabdominal ultrasound
Corresponding Author
assessment during the second stage of labor. Ultrasound
Obstet Gynecol 2002;19(3):264–8. Niharika Guleria
Senior Resident, VMMC & Safdarjung Hospital
10. Akmal S, Tsoi E, Kametas N, et al. Intrapartum sonography
New Delhi
to determine fetal head position. J Matern Fetal Neonatal
Med 2002;12(3):172–7.
Email: niharikasethi26@gmail.com.

52 AOGD Bulletin
 Journal Scan
Sheeba Marwah1, Saumya Prasad2
1
Associate Professor, 2Assistant Professor
Obstetrics & Gynaecology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi

Continued Versus Discontinued Conclusions: In a setting where monitoring of

the fetal condition and the uterine contractions
Oxytocin Stimulation in the Active
can be guaranteed, routine discontinuation of
Phase of Labour (CONDISOX): Double oxytocin stimulation may lead to a small increase in
Blind Randomised Controlled Trial caesarean section rate but a significantly reduced
Sidsel Boie, Julie Glavind, Niels Uldbjerg risk of uterine hyperstimulation and abnormal fetal
Philip J Steer, Pinar Bor heart rate patterns.
BMJ 2021;372:n716. (Published 14 April 2021)
Tranexamic Acid for the Prevention of
Objective: To determine whether discontinuing
oxytocin stimulation in the active phase of induced
Blood Loss after Cesarean Delivery
labour is associated with lower caesarean section Loïc Sentilhes, Marie V. Sénat, Maëla Le Lous,
rates. Norbert Winer, Patrick Rozenberg, et al
N Engl J Med 2021; 384:1623-1634 (April 29, 2021)
Design: International multicentre, double blind,
randomised controlled trial. Background: Prophylactic administration of
Setting: Nine hospitals in Denmark and one in the tranexamic acid has been associated with reduced
Netherlands between 8 April 2016 and 30 June 2020. postpartum blood loss after cesarean delivery in
several small trials, but evidence of its benefit in this
Participants: 1200 women stimulated with
clinical context remains inconclusive.
intravenous oxytocin infusion during the latent
phase of induced labour. Methods: In a multicenter, double - blind,
randomized, controlled trial, we assigned women
Intervention: Women were randomly assigned to
undergoing cesarean delivery before or during
have their oxytocin stimulation discontinued or
labor at 34 or more gestational weeks to receive an
continued in the active phase of labour.
intravenously administered prophylactic uterotonic
Main Outcome Measure: Delivery by caesarean agent and either tranexamic acid (1 g) or placebo.
section. The primary outcome was postpartum hemorrhage,
Results: A total of 607 women were assigned to defined as a calculated estimated blood loss greater
discontinuation and 593 to continuation of the than 1000 ml or receipt of a red-cell transfusion
oxytocin infusion. The rates of caesarean section within 2 days after delivery. Secondary outcomes
were 16.6% (n=101) in the discontinued group included gravimetrically estimated blood loss,
and 14.2% (n=84) in the continued group (relative provider-assessed clinically significant postpartum
risk 1.17, 95% confidence interval 0.90 to 1.53). hemorrhage, use of additional uterotonic agents,
In 94 parous women with no previous caesarean and postpartum blood transfusion.
section, the caesarean section rate was 7.5% Results: Of the 4551 women who underwent
(11/147) in the discontinued group and 0.6% (1/155) randomization, 4431 underwent cesarean delivery,
in the continued group (relative risk 11.6, 1.15 to 4153 (93.7%) of whom had primary outcome data
88.7). Discontinuation was associated with longer available. The primary outcome occurred in 556 of
duration of labour (median from randomisation to 2086 women (26.7%) in the tranexamic acid group
delivery 282 v 201 min; P<0.001), a reduced risk of and in 653 of 2067 (31.6%) in the placebo group
hyperstimulation (20/546 (3.7%) v %12.9) 541/70); (adjusted risk ratio, 0.84; 95% confidence interval
P<0.001), and a reduced risk of fetal heart rate [CI], 0.75 to 0.94; P=0.003). There were no significant
abnormalities (%27.9) 548/153) v %40.8) 537/219); between-group differences in mean gravimetrically
P<0.001) but rates of other adverse maternal and estimated blood loss or in the percentage of
neonatal outcomes were similar between groups. women with provider-assessed clinically significant

Vol.21, No.1; May, 2021 53

postpartum hemorrhage, use of additional Research Group in Obstetrics and Gynecology
uterotonic agents, or postpartum blood transfusion. (GROG) between 2012 and 2015. We recruited women
Thromboembolic events in the 3 months after with labor induced for medical reasons, a Bishop
delivery occurred in 0.4% of women (8 of 2049) who score ≤ 5 at ≥ 36 weeks, and a cephalic-presenting
received tranexamic acid and in 0.1% of women (2 singleton pregnancy with no prior cesarean delivery.
of 2056) who received placebo (adjusted risk ratio, Women were randomly allocated to receive either
4.01; 95% CI, 0.85 to 18.92; P=0.08). vaginal misoprostol at 4-hour intervals (25 μg) or
Conclusions: Among women who underwent a 10-mg slow-release dinoprostone pessary. The
cesarean delivery and received prophylactic primary outcome was the total cesarean delivery
uterotonic agents, tranexamic acid treatment rate. Noninferiority was defined as a difference in
resulted in a significantly lower incidence of the cesarean delivery rates between the groups of
calculated estimated blood loss greater than 1000 no more than 5%. Secondary outcomes included
ml or red-cell transfusion by day 2 than placebo, but neonatal and maternal morbidity, vaginal delivery
it did not result in a lower incidence of hemorrhage- < 24 hours after starting the induction process, and
related secondary clinical outcomes. maternal satisfaction.
Results: The study included 1674 randomized
Induction of Labor at Term with women. The per-protocol analysis included 790 in
each group. The total cesarean delivery rate in the
Vaginal Misoprostol or a PGE2 Pessary: misoprostol group was 22.1% (n=175) and in the
a Noninferiority RCT dinoprostone group, 19.9% (n=157), for a difference
Adrien Gaudineau, Marie-Victoire Senat, Virginie between the groups of 2.2% (with an upper-bound
Ehlinger, Patrick Rozenberg, Christophe Ayssiere 95% confidence limit of 5.6%), P=.092. Results in the
American Journal of Obstetrics and Gynecology, intention-to-treat analysis were similar. Neonatal
Available online 19 April 2021: In Press and maternal morbidity were similar between
DOI: https://doi.org/10.1016/j.ajog.2021.04.226 groups. Vaginal delivery within 24 hours was
significantly higher in the misoprostol group (59.3%
Background: Induction of labor is among the vs 45.7%, P<.001) as was maternal satisfaction,
most common procedures for pregnant women. assessed in the postpartum period by a visual analog
Only a few randomized clinical trials (RCT) with scale: mean score: 7.1 (SD 2.4) vs 5.8 (3.1), P<.001.
relatively small samples have compared misoprostol Conclusion: The noninferiority of 25-μg vaginal
to dinoprostone. Although their efficacy appears misoprostol every four hours to the dinoprostone
similar, their safety profiles have not been adequately pessary for CD rates after IOL at term could not be
evaluated and economic data are sparse. demonstrated, although the confidence limit of
Objective: To test the noninferiority of vaginal the difference barely exceeded the noninferiority
misoprostol (PGE1) (25 μg) to a slow-release margin. Nonetheless, given the small difference
dinoprostone (PGE2) pessary (10 μg) for induction between these cesarean rates and the similarity of
of labor with an unfavorable cervix at term. neonatal and maternal morbidity rates in this large
Study Design: Open-label multicenter randomized study, the clinical risk-benefit ratio justifies the use
noninferiority trial at 4 university hospitals of the of both drugs.

54 AOGD Bulletin
Cross Word Puzzle
Niharika Guleria
Senior Resident, Obstetrics & Gynaecology, Vardhman Mahavir Medical College & Safdarjung Hospital, Delhi
1

2
Down
3
1. Percentage incidence of morbid
adherent placenta in placenta
4
previa with previous 3 caesarean
5 6 secƟon
2. TocolyƟc drug that can be used to
7 manage uterine tachysystole
4. Uterotonic contraindicated in
8 9
hypertension
10
5. Procedure found useful for
the management of repeƟƟve
11
variable deceleraƟons
12 6. Bishop score assessed aŌer how
many hours of PGE2 gel inserƟon
9. PaƩern of increased variability
>25 BPM lasƟng > 30 mins on CTG
known as
Across
3. First graphical analysis of labour given by professor
7. WOMAN trial endorses use of this drug to reduce mortality in post part haemorrhage (PPH)
8. 2 reassuring + 1 non reassuring feature on cardiotocograph (CTG) trace categorised as
10. Drug used for paƟent controlled analgesia
11. Type of verƟcal compression suture used for PPH
12. Robson group number accounƟng for maximum cases of caesarean secƟon

Pictorial Quiz
Divya Pandey
Associate Professor, Obstetrics & Gynaecology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi
(Questions: Refer to picture on page 56)
Ques 1: What is the appropriate plan of action at c. Occipeto-posterior position with late deceleration
6:00hrs for the parturient mother as per the LCG d. Occipeto-posterior position/ Late deceleration
shown? with Caput (3+)/ Moulding (3+) /Meconium (3+)
a. Offer companion / Pain Relief/ Augment uterine
Ques 3: What is the diagnosis and appropriate
contractions.
management at 14:00hrs as per the LCG shown?
b. Offer companion/ Pain Relief.
a. Arrest of active phase of labour stop oxytocin /
c. Offer companion/ Pain relief/ correct hydration/ watch for progress of labour
Augment uterine contractions.
b. Arest of active phase of labour with fetal distress
d. Offer companion/ pain relief/ correct hydration/ in–utero fetal resuscitation followed by routine
Augment uterine contractions / arrange monitoring
blood/ careful labour monitoring in view of
c. Arrest of active phase of labour with fetal distress
occipetoposterior position.
stop oxytocin, plan for operative vaginal
Ques 2: Describe fetal parameters at 14:00hrs as per delivery
the LCG shown? d. Arrest of active phase of labour with features
a. Late deceleration of Obstructed labour with fetal distress stop
b. Normal fetal parameters oxytocin- prepare for Em LSCS

Vol.21, No.1; May, 2021 55

 Pictorial Quiz

Mail the answers to editorsaogd2021@gmail.com. The correct answers and names of the three
winners will be announced in the next issue.

56 AOGD Bulletin
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