Use of oxytocin
and misoprostol
for induction or
augmentation of
labor
in low-resource
settings
A Report of a Worki...
Background
 International agencies, NGO projects and national
health programs are promoting the expanded
availability ...
Background
 The literature and anecdotal information
suggest induction and augmentation are
taking place in low resour...
A few examples:
 W Africa: Demi Demi - an observed practice of giving 5IU
oxytocin IM in each buttock to begin or speed...
Objectives of the Expert Meeting
1. Summarize the literature review and working
paper.
2. Discussion of content.
3. Ma...
Summary of working paper: Data sources
for the review:
1. Compilation of international obstetric
practice guidelines;
...
Literature Review Summary
Databases searched: PubMed; Embase; CINAHL Plus; Scopus; Cochrane database
Databases searched:...
Current Recommendations
 Misoprostol
25ug vaginally every four hours until delivery
or 50ug orally every four hours un...
National induction rates in HRS
Country Reference year Induction Rate
(in %)
Sweden 2001-2002 33.2
Australia 2006 36.7...
Rising trends in induction in HRS
0 5 10 15 20 30 40
Induction Rate (in %)
1988 1992 1996 2000 2004 2008
Reference Yr ...
Outcome of CS with elective induction vs.
spontaneous labor. Odds Ratios and 95% confidence
intervals.
0 0.5 1 1.5 2 2....
Induction and augmentation rates from 7 LRS
countries (source: AMSTL study)
0.5
8.3
3.2
17.1
22.6
25.5
10.5
37.9 ...
Hospital specific rates of induction in LRS
from the literature.
Author/year Country Data collec-tion
year
Rate of ind...
Hospital specific rates of elective
induction in LRS
Author Reference
year
Country Rate (in %)
Oboro V, Isawumi
A, e...
Uterine Rupture and induction in LRS
Author Reference
year
Country % of uterine
ruptures
associated with
induction
...
Neonatal Outcomes in LRS
 Most cases of ruptured uterus also result in
perinatal death.
 Dujardin et al: increased ri...
Non-pharmacological methods
Mechanical dilators:
Cochrane review shows
less risk than oxytocin or
misoprostol
Strippi...
Availability
Oxytocin Misoprostol
Outcome of working group:
 The group found the issue to be of public
health importance and that we should move
forward...
Next Steps
 Define/quantify the public health problem in
terms of maternal and perinatal
mortaltiy/morbidity.
 Prior...
Priorities
Research Priority: gathering empirical data to describe the
magnitude of the problem in public, private and h...
Thank you
Popph ipresentation
of 23

Popph ipresentation

jhh
Published on: Mar 4, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Popph ipresentation

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

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