CASE REFLECTION

Medical Abortion

William Ray Cassidy

08/268114/KU/12814

Instructor:
Prof. dr. Djaswadi Dasuki, MPH, Ph.D, SpOG(K)

Department of Obstetric and Gynecology

Faculty of Medicine Gadjah Mada University
RSUP Dr Sardjito
2013
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Case
A 36 years old woman (G2P1A0) came to ER in RSUP Dr Sardjito with
complaints of early amniotic membrane rupture. She was referred from a women and
child hospital with EGA 20 weeks. The patient has felt some contractions since evening.
Examination results revealed imminent abortion. The patient agreed to terminate the
pregnancy and received misoprostol 400 micrograms / 6 hours orally. The fetus and
placenta were expulsed few hours afterwards, but USG showed signs of incomplete
abortion. A D&C was then planned for the patient.
How do we manage patients with prolonged latent phase? Are there any correlations
between the previous history of Cesarian Section and the current vaginal delivery
attempt? When can we decide to induce labor and/or ripen the cervix?

Clinical Problem
Childbirth is the period from the onset of regular uterine contractions until
expulsion of the placenta. The onset of latent labor, as defined by Friedman (1972), is
the point at which the mother perceives regular contractions. The latent phase for most
women ends at between 3 and 5 cm of dilatation. This threshold may be clinically
useful, for it defines cervical dilatation limits beyond which active labor can be
expected.
NICE (2007) recommend the following definition of latent phase a period of
time, not necessarily continuous, when there are painful contractions and there is some
cervical change, including cervical effacement and dilatation up to 4cm and the onset of
active labour when there are regular painful contractions and there is progressive
cervical dilatation from 4cm.
Friedman and Sachtleben (1963) defined a prolonged latent phase as being
greater than 20 hours in the nullipara and 14 hours in the multipara. These are the 95th
percentiles. Factors that affect duration of the latent phase include excessive sedation or
epidural analgesia; unfavorable cervical condition, that is, thick, uneffaced, or undilated;
and false labor.
The incidence of prolonged latent phase in spontaneously laboring women
should be 4 to 6 percent, if duration of latent phase follows a normal distribution.
Prolonged latent phase is responsible for 30 percent of labor abnormalities in nulliparas
and over 50 percent of such abnormalities in multiparous women. A prolonged latent
phase can often be a discouraging and exhausting experience and women clearly need
good psychological support (Simkin and Ancheta 2000).
The rate of cesarean delivery in the United States rose from 20.7% in 1996 to
31.1% in 2006.A major reason for this increase is the decline in the rate of attempted
vaginal birth after cesarean delivery. Elective cesarean delivery may be scheduled to
accommodate patient and physician convenience, and there is a risk that it may be

performed earlier than is appropriate. Because approximately 40% of the 1.3 million
cesarean deliveries performed annually in the United States are repeat procedures and
the number of cesarean deliveries continues to rise, the timing of elective cesarean
delivery has increasingly important public health implications.
As compared with infants born vaginally, those born by cesarean section are at
increased risk for adverse respiratory outcomes, especially when delivery occurs before
the onset of labor. This increased risk persists even in infants who are delivered by
cesarean section at full term (i.e., at or beyond 37 completed weeks of gestation).

Figure showing normal dilatation curve in nulliparous labour.

Labor progress curve showing Friedmans curve.

Strategies and Evidence

Diagnosis
In this case, the vaginal examination result showed dilated cervix with diameter
around 2 cm for more than 14 hours (in multipara patient), which means it is in
prolonged latent phase and not fully ripe for labor. Thus, we need to intervene in
order to ripen the cervix for the success of inducing labor.

The condition of the cervix influences the success of inducing labor. For this
reason, a cervical examination is essential before labor induction is initiated. In 1964,
Bishop developed a scoring system to evaluate multiparous women for elective
induction at term. The scoring system is based on properties of the cervix that may be
assessed clinically at the time of pelvic examination such as dilatation, effacement,
consistency, and position as well as the station of the fetal presenting part.
The higher the Bishop score, the more ripe or favorable the cervix is for
labor induction.

Management
Over the past few years, there has been an increasing awareness that if the cervix
is unfavorable, a successful vaginal birth is less likely. The Bishop score helps delineate
patients who would be most likely to achieve a successful induction. The duration of
labor is inversely correlated with the Bishop score; a score that exceeds 8 describes the
patient most likely to achieve a successful vaginal birth. Bishop scores of less than 6
usually require that a cervical ripening method be used before other methods.
Nonpharmacologic approaches to cervical ripening and labor induction have
included herbal compounds, castor oil, hot baths, enemas, sexual intercourse, breast
stimulation, acupuncture, acupressure, transcutaneous nerve stimulation, and
mechanical and surgical modalities. Of these nonpharmacologic methods, only the
mechanical and surgical methods have proven efficacy for cervical ripening or induction
of labor.
Pharmacologic agents available for cervical ripening and labor induction include
prostaglandins, misoprostol, mifepristone, and relaxin. When the Bishop score is
favorable, the preferred pharmacologic agent is oxytocin. (Am Fam Physician
2003;67:2123-8.)
Castor Oil , Hot Baths , And Enemas
Castor oil, hot baths, and enemas also have been recommended for cervical
ripening or labor induction. The mechanisms of action for these methods are unknown.
Sexual Intercourse
Sexual intercourse is commonly recommended for promoting labor initiation.
Sexual relations usually involve stimulation of the breasts and nipples, which can
promote the release of oxytocin.With penetration, the lower uterine segment is
stimulated. This stimulation results in a local release of prostaglandins. Female orgasms
have been shown to include uterine contractions, and human semen contains
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prostaglandins, which are responsible for cervical ripening.

Mechanical Modalities
All mechanical modalities share a similar mechanism of actionnamely, some
form of local pressure that stimulates the release of prostaglandins.1 The risks
associated with these methods include infection (endometritis and neonatal sepsis have
been associated with natural osmotic dilators), bleeding,membrane rupture, and
placental disruption. Hygroscopic dilators absorb endocervical and local tissue fluids,
causing the device to expand within the endocervix and providing controlled
mechanical pressure.
Balloon devices provide mechanical pressure directly on the cervix as the balloon is
filled. A Foley catheter (26 Fr) or specifically designed balloon devices can be used.
The addition of extra-amnionic saline infusion (EASI), shown in Figure 221,
has been reported to significantly improve the Bishop score and decrease induction-todelivery times when compared with that by (1) 50- g intravaginal misoprostol tablets
(Vengalil and colleagues, 1998), (2) 0.5 mg of intracervical prostaglandin E2 (Goldman
and Wigton, 1999; Hemlin and Mller, 1998; Sciscione and associates, 1999), or (3) 50g oral misoprostol.

Technique for Placement of Balloon Dilators

The catheter is introduced into the endocervix by direct visualization or blindly by
locating the cervix with the examining fingers and guiding the catheter over the
hand and fingers through the endocervix and into the potential space between the
amniotic membrane and the lower uterine segment.
The balloon reservoir is inflated with 30 to 50 mL of normal saline. The balloon is

retracted so that it rests on the internal os.

Additional steps that may be taken:
Apply pressure by adding weights to the catheter end. Constant pressure:
attach 1 L of intravenous fluids to the
catheter end and suspend it from the end of the bed.
Intermittent pressure: gently tug on the catheter end two to four times per
hour.
Saline infusion:
Inflate catheter with 40 mL of sterile water or saline. Infuse sterile saline at a
rate of 40 mL per hour using an
infusion pump.
Remove six hours later or at the time of spontaneous expulsion or rupture
of membranes (whichever occurs first).
Prostaglandin E2 infusion
Oxytocin
As pregnancy progresses, the number of oxytocin receptors in the uterus
increases (by 100-fold at 32 weeks and by 300-fold at the onset of labor). Oxytocin
activates the phospholipase C-inositol pathway and increases intracellular calcium
levels, stimulating contractions in myometrial smooth muscle.23 Oxytocin is the
preferred pharmacologic agent for inducing labor when the cervix is favorable or ripe.
Discussion
There are some points that is still need to be answered regarding this case,
although now it is clear that the patients cervix is not favorable hence a medical
intervention is necessary. First, what kind of cervical ripening method that is best for
this patient? Second, should we really continue with vaginal delivery?
In the study that was performed by Kashanian et al. Foley catheter with different
balloon volumes were compared to oxytocin for cervical ripening and labor induction.
They concluded that Foley catheter is a safe and suitable method for patients with an
unfavorable cervix, and might reduce the duration of labor and increase the number of
deliveries within 24 h; moreover, the larger balloon volume might improve these effects.
Fekrat et al. studied three methods of cervical ripening and labor induction with vaginal
misoprostol and Foley catheter and a combination of these two methods. The duration
between induction of labor and delivery was significantly lower in misoprostol group.
They resulted that the combination of these two methods didnt have more efficacy on
cervical ripening.
In WHO recommendations for induction of labor, it is stated that compared with
prostaglandins, the balloon catheter was associated with a lower risk of uterine
hyperstimulation with fetal heart rate changes (seven trials, 823 participants, RR 0.51,
95% CI 0.300.86) and the risk of caesarean section with the two methods was similar
(19 trials, 2050 participants, RR 1.01, 95% CI 0.881.17). With regard to other priority

outcomes, the results for the prostaglandins versus the balloon catheter comparison were
statistically non-significant. Compared with oxytocin, the balloon catheter was
associated with a lower risk of caesarean section (two trials, 125 participants, RR 0.43,
95% CI 0.220.83). Balloon catheter is recommended for induction of labour.
(Moderate-quality evidence. Strong recommendation).The combination of balloon
catheter plus oxytocin is recommended as an alternative method when prostaglandins
(including misoprostol) are not available or are contraindicated.(Low-quality evidence.
Weak recommendation.)
This patient has a history of Cesarian Section four years ago. A vaginal delivery
after C-Section does possess its own risks and complications. Such complications
include uterine rupture, which is uncommon but serious and may result in hysterectomy,
urologic injury, a need for blood transfusion, maternal death, and perinatal
complications, including neurologic impairment and death. For women with one prior
cesarean delivery, the risk of uterine rupture is higher among those whose labor is
induced than among those with repeated cesarean delivery without labor. Labor induced
with a prostaglandin confers the highest risk. (N Engl J Med 2001;345:3-8.)

Conclusion
Prolonged latent phase in pregnancy requires immediate intervention from
attending physician (in this case ob-gyn doctor or resident). However, it is best if
induction or cervical ripening attempt is done in facility where Cesarian Section can be
performed. Many methods of induction or cervical ripening available for this kind of
patient, including mechanical method which was done. Women with previous history of
Cesarian Section should at least avoid vaginal delivery if possible due to risk of uterine
rupture, especially those with prostaglandin analogue induction, making its use not
preferable in this case. Patients with this condition should be monitored with utmost
care.

Reference
Obstetrics : Normal and Problem Pregnancies, 5th edition. 2007, Churchill Livingstone.
Williams Obstetrics 22nd edition. 2007, McGraw-Hill.
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WHO Recommendations for Induction of Labour, 2011.

Greene, MF. Vaginal Birth after Cesarean Revisited. N Engl J Med 2004; 351;25.
Lydon-Rochelle, et al. Risk Of Uterine Rupture During Labor Among Women With A
Prior Cesarean Delivery. N Engl J Med, Vol. 345, No. 1
Roudsari, et al. Comparison of Vaginal Misoprostol with Foley Catheter for Cervical
Ripening and Induction of Labor. Iranian Journal of Pharmaceutical Research
(2011), 10 (1): 149-154
Landon, et al. Maternal and Perinatal Outcomes Associated with a Trial of Labor after
Prior Cesarean Delivery. n engl j med 351;25
Tenore, JL. Methods for Cervical Ripening and Induction of Labor. Am Fam Physician
2003;67:2123-8