https://doi.org/10.15218/ejnm.2021.05 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Indications of Labor Induction at Delivery Room of Maternity Teaching Hospital in Erbil city ABSTRACT INTRODUCTION Induction of labour means stimulation of contractions before the birth starts spon- taneously, with or without ruptured membranes. When the cervix is uneffaced and closed, labour induction often begins with the ripening of the cervix, a process that generally uses prostaglandins to open and soften the cervix[1]. The posi- tion and consistency of the cervix are not necessary to predicting successful labour induction by oxytocin and amnioto- my [2]. Induction is indicated when the benefits to the mother or fetus outweigh the benefits of continuing the pregnancy. The most common indications include oli- gohydramnios, pre-labour rupture of the membranes, high blood pressure during pregnancy, severe fetal growth restriction, Background and objectives: Induction of labour means stimulation of contractions before the birth starts spontaneously, with or without ruptured membranes. The most common indications include oligohydramnios, pre-labour rupture of the membranes, high blood pressure during pregnancy, severe fetal growth restriction, post-term pregnancy, and var- ious maternal medical conditions such as chronic hypertension and diabetes. The aim of the study was to find out the different indications of labour and associated obstetrical factors in a local tertiary hospital. Methods: A cross-sectional study was conducted among 120 parturient women who attended a delivery room in the Maternity Teaching Hospital in Erbil City from the period of 2nd June to 2nd October 2020. After reviewing the literature, a questionnaire was pre- pared to obtain socio-demographic data, data related to reproductive characteristic and data related to the indications for labour induction. The data were analyzed using descrip- tive and inferential statistical approaches. Results: The study included 120 patients with the highest percentage of the patients (49.1%) were 16 to 23 years old and more than half of the sample (51.6%) had a post- term pregnancy, gestational hypertension and pre-eclampsia (15%). There were highly significant statistical differences between parity, gestational age and indication of labour induction, and significant differences between gravidity and antenatal care visits and indi- cations for labour induction. Conclusions: The majority of the sample had a post-term pregnancy of 40 and 42 weeks as an indication for induction of labour followed by gestational hypertension and pre- eclampsia, oligohydramnios and pre-labour rupture of membrane. There was a statistical- ly significant difference between the antenatal care visit and parity with the induction of labour. Keywords: Indication of labour induction; Post-term pregnancy; Oligohydramnios Bewar Husamaldeen Noori ; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: bewar.husamaldeen@gmail.com) Awaz Aziz Saeed ; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 41 Erbil Journal of Nursing & Midwifery Received: 06/11/2020 Accepted: 01/02/2021 Published: 30/05/2021 mailto:bewar.husamaldeen@gmail.come https://doi.org/10.15218/ejnm.2021.05 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article various maternal medical conditions such as chronic hypertension and diabetes [3] . and post-term pregnancy, particularly be- tween 40 and 42 weeks [4]. There are po- tential medical advantages of scheduled induction of full-term delivery, such as re- duced stillbirth and further fetal growth, leading to macrosomia and its consequenc- es. According to some studies, the risk of Cesarean section (CS) is lower among women whose labour was induced than among those expectantly managed in term and post-term pregnancies with the bene- fits to the fetus and no increased risk of maternal death [5]. Induction of labour, regardless of the method used, is associat- ed with a higher risk of postpartum haem- orrhage [6], failed induction of labour [7], increased risk of CS [8], uterine hyperstim- ulation [9], increased risk of cord prolapse [10] and increased risk of uterine rupture [11].Labour induction is the most common interventional procedure in obstetrics. It is applied in 20% to 25% of all pregnancies [12]. The indication of labour induction affects the risk of CS. Specifically, the in- duction of labour for fetal indications greatly increases its risk in nullipa- rous women[13]. Induction of labour for gestational diabetes mellitus, post-term, hypertensive disorders in pregnancy and macrosomia is associated with a higher risk for CS, while induction of labour for intrau- terine growth restriction and previous fast labour carries a lower risk for CS [14]. Ac- cording to the reports of patients who were hospitalized in the Maternity Teach- ing Hospital in Erbil City, the number of women inducing labour is increasing daily. This is a problematic and risky process that has a negative impact on the health of the mother and the infant. This study aimed to find out the different indications for labour induction and associated socio- demographic and obstetrical factors. A quantitative, cross-sectional descriptive study was conducted on 120 parturient women in the Maternity Teaching Hospital in Erbil City (MTH) from the period of 2nd June to 2nd October 2020. The sample size was determined by using the following for- mula [15]: n=N/ (1+Ne2) n=140/1+140(0.05)2 n=103 n= the sample size N=the size of the population (based on MTH report of admissions of the parturient women for the induction of labour every month (35 cases), so the estimated popu- lation for four months was 140 patients) e= the alpha- error of 0.05 Accordingly, the estimated sample size was 103 women but the study included 120 patients. The researcher obtained the per- mission of the Ethics Committee at the Col- lege of Nursing. (Number 92), Hawler Med- ical University in Erbil and the official ap- proval from the Erbil General Directorate of Health. A non-probability purposive sampling method of parturient women was done and the data were gathered through a direct interview and observation by using the questionnaire. The question- naire was prepared for collecting data after reviewing the literature. The pilot study was conducted on 15 patients who were selected purposively from the MTH from 20 April to 31 May 2020. The pilot study was useful to determine the reliability, clarity, acceptability of the tool. The results were checked to determine reliability by calculating Cronbach’s alpha (0.81). Socio- demographic data of patients included age, educational level, residency, occupa- tion, socio-economic state, smoking, pas- sive smoking, and the Body Mass Index be- fore pregnancy and after pregnancy (< 18.5 underweight, 18.5-25 normal weight, 25- 42 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2021.05 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article infertility zero (no years of infertility) and 91.7% of women attended the antenatal care visits (59.2% of women attended 1-5 visits). Based on the parity, para 1-4 repre- sented the highest proportion (52.5%), and 81.7% of the sample were the gravida 1- 4. 53.3% of cases were at a gestational age of 41-42 weeks. 29.9 overweight, 30-35 obesity, and > 35 morbid obesity). Data related to reproduc- tive characteristic included the history of infertility, antenatal care visits, parity (0 - nulliparous, 1-primiparous, 2-4 – multipa- rous, and ≥ 5 - grand multipara), gravidity (1- primigravida, 2-4 -multigravida, and ≥ 5 - grand multigravida) and gestational age. The data related to the indication of labour induction included post-term pregnancy, decreased fetal movement, pre-labour rup- ture of membranes, gestational hyperten- sion plus pre-eclampsia, gestational diabe- tes, oligohydramnios, vaginal bleeding, and chorioamnionitis. Data were analyzed using the Statistical Package for Social Sciences (SPSS, version 21), by using descriptive (frequency and percentage) and inferential (One-Way ANOVA test) statistical ap- proaches. Table 1 shows the socio-demographic char- acteristics of the study sample. the highest percentage of the women (49.1%) were within the age range of 16 to 23 years of age. Regarding the educational level and the place of living, 26.6% were primary school graduates and 45% lived in a rural area. In terms of occupation, 97.5% were housewives, and about three quarters (76.7%) were not satisfied with their socio- economic status. The Body Mass Index (BMI) data measured before pregnancy showed that 36.7% of women had normal weight, but this percentage decreased to 11.7% after pregnancy. Assessment of the smoking status indicated that the majority (96.7%) were non-smokers, but about half (50.8%) of the participants were exposed to secondary smoking. Table 2 shows the distribution of the reproductive data of the study sample, in which more than three- quarters of the sample (78.3%) had no his- tory of infertility. 78.3% had the years of 43 Erbil Journal of Nursing & Midwifery RESULTS Table 1: Distribution of the Demographic Data of the Study Sample (No.: 120). The Characteristics Subgroups Induced labor f. % Age Groups (Years) 16 – 23 59 (49.1) 24 – 31 33 (27.5) 32 – 39 26 (21.7) 40 Years and more 2 (1.7) Mean ± S.D. 1.76 ± 0.850 Education Level Illiterate 28 (23.3) Able to Read and Write 17 (14.2) Primary School 32 (26.6) Secondary School 26 (21.7) College or Insti- tute 17 (14.2) Residence Urban 35 (29.2) Suburban 31 (25.8) Rural 54 (45) Occupation Government Employee 1 (0.8) Student 2 (1.7) House wife 117 (97.5) Socio-economic Status Satisfy 28 (23.3) None Satisfy 92 (76.7) BMI Before Preg- nancy Under Weight 1 (0.8) Normal Weight 44 (36.7) Over Weight 45 (37.5) Obesity 27 (22.5) Morbid Obesity 3 (2.5) BMI After Preg- nancy Under Weight 0 (0) Normal Weight 14 (11.7) Over Weight 41 (34.2) Obesity 40 (33.3) Morbid Obesity 25 (20.8) Smoking Yes 4 (3.3) No 116 (96.7) Secondary Smok- ing Yes 59 (49.2) No 61 (50.8) Grand Mean: 2.59, BMI: Body Mass Index, f.: fre- quency, No.: Number, %: percentage. https://doi.org/10.15218/ejnm.2021.05 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Table 3 shows the distribution of the indi- cations for induction of labour data, which shows that 51.6% of the sample had post- term pregnancy followed by gestational hypertension + pre-eclampsia (15%) and oligohydramnios (13.4%). 44 Erbil Journal of Nursing & Midwifery Table 2: Distribution of the Reproductive Data of the Study Sample (No.: 120). The Characteristics Subgroups Induced labor f. % History of Infertility Yes 26 (21.7) No 94 (78.3) Years of Infertility 0 94 (78.3) 1-3 Years 23 (19.2) 4-6 Years 3 (2.5) Antenatal Care Visit (Follow-up) Yes 110 (91.7) No 10 (8.3) No. of Visits 0 10 (8.3) 1-5 Visits 71 (59.2) 6-10Visits 39 (32.5) Number of Para 0 51 (42.5) 1 25 (20.8) 2-4 38 (31.8) 5 and more 6 (4.9) Number of Gravida 1 47 (39.2) 2-4 51 (42.6) 5 and more 22 (18.2) Gestational Age 37-38weeks 31 (25.8) 39-40weeks 25 (20.8) 41-42weeks 64 (53.3) BMI: Body Mass Index, f.: frequency, No.: Number, %: percentage. Table3: Distribution of the Indications of labor Induction of the Study Sample (No.: 120). Indications of Induction F % Postdate Pregnancy 62 (51.6) Decrease Fetal Movement 3 (2.6) Pre-labor Rupture of Membrane 10 (8.4) Gestational Hypertension + Preeclampsia 18 (15) Gestational Diabetes 7 (5.3) Oligohydramnios 16 (13.4) Vaginal Bleeding 4 (3.4) Total 120 (100) f.: frequency, %: percentage. Table 4 shows the difference between the reproductive characteristics and the indi- cations for labour induction. There were non-significant differences between the history of infertility at p-value = 0.956, years of infertility at p-value = 0.938, and the number of antenatal care visits at p- value = 0.254 and the indication for labour induction. There were significant differ- ences between antenatal care visits at p- value = 0.038 and gravidity at p-value = 0.01 and an indication of labour induction. There were highly significant statistical differences between parity at p-value < 0.001, gestational age at p-value < 0.001 and an indication for labour induction. https://doi.org/10.15218/ejnm.2021.05 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article 45 Erbil Journal of Nursing & Midwifery Table4: difference between Reproductive Characteristics and Indications of Induction by One-Way ANOVA test (n=120). Reproductive Characteristics Indications of Induction Mean S. D. F. value p-value History of Infertility Postdate Pregnancy 1.79 0.410 0.257 0.956 Decrease Fetal Movement 2.00 0.000 Pre-labor Rupture of Membrane 1.80 0.422 Gestational Hypertension + Preeclampsia 1.72 0.461 Gestational Diabetes 1.86 0.378 Oligohydramnios 1.75 0.447 Vaginal Bleeding 1.75 0.500 Years of Infertility Postdate Pregnancy 1.03 0.178 0.295 0.938 Decrease Fetal Movement 1.00 0.000 Pre-labor Rupture of Membrane ‎0011‎ 0.422 Gestational Hypertension + Preeclampsia 1.06 0.236 Gestational Diabetes 1.00 0.000 Oligohydramnios 1.00 0.000 Vaginal Bleeding 1.00 0.000 Antenatal Care Visits Postdate Pregnancy 1.05 0.216 2.322 0.038 Decrease Fetal Movement 1.33 0.577 Pre-labor Rupture of Membrane 1.10 0.316 Gestational Hypertension + Preeclampsia 1.06 0.236 Gestational Diabetes 1.14 0.378 Oligohydramnios 1.06 0.250 Vaginal Bleeding 1.50 0.577 No. of Visits Postdate Pregnancy 1.53 0.646 1.320 0.254 Decrease Fetal Movement 1.67 1.155 Pre-labor Rupture of Membrane 1.70 0.675 Gestational Hypertension + Preeclampsia 2.00 0.840 Gestational Diabetes 1.71 0.756 Oligohydramnios 1.56 0.629 Vaginal Bleeding 1.25 0.500 Para Postdate Pregnancy 1.11 0.319 4.699 < 0.001 *** Decrease Fetal Movement 2.00 0.000 Pre-labor Rupture of Membrane 1.00 0.000 Gestational Hypertension + Preeclampsia 1.17 0.383 Gestational Diabetes 1.14 0.378 Oligohydramnios 1.06 0.250 Vaginal Bleeding 1.00 0.000 Gravida Postdate Pregnancy 1.18 0.385 3.545 0.01 ** Decrease Fetal Movement 2.33 0.577 Pre-labor Rupture of Membrane 1.10 0.316 Gestational Hypertension + Preeclampsia 1.22 0.428 Gestational Diabetes 1.29 0.756 Oligohydramnios 1.13 0.342 Vaginal Bleeding 1.00 0.000 Gestational age Postdate Pregnancy 2.98 0.127 78.783 < 0.001 *** Decrease Fetal Movement 1.33 0.577 Pre-labor Rupture of Membrane 1.80 0.789 Gestational Hypertension + Preeclampsia 1.44 0.616 Gestational Diabetes 1.43 0.535 Oligohydramnios 1.44 0.512 Vaginal Bleeding 1.75 0.500 Grand Mean: 2.98, d.f.: 239, ANOVA: analysis of variance, f.: frequency, F. value: Fisher test, ***: high sig- nificant, No.: Number, S.D.: Standard deviation, ≤: less than and equal to, %: percentage, +: plus. https://doi.org/10.15218/ejnm.2021.05 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article In the current study about half of the sam- ple (49.1%) between 16–23 years old, which agrees with the results of a previous study done in Oromia [16]. However, it is in disagreement with the results of the previ- ous study, which was done in Eastern Ne- pal. [17]. Most of the women in the current study were primary school graduates, which is similar to the result of the previ- ous study done by Lawani et al. [18]. Con- cerning the occupation, housewives repre- sented the largest group, which contrasts with the study conducted in Brazil [19]. Be- fore the pregnancy, the majority of this study participants were overweight, which disagrees with the study done by Dundar et al. [20].The present study’s findings showed that the highest percentage of pa- tients were overweight at term and are supported by other studies [20]. But they contradict the study conducted in Saudi Arabia [21]. Based on the parity, the result of the present study showed that 1-4 para represented the highest proportion, which is similar to the results of the previous study [22]. In terms of gravidity, the 1-4 gravida group of the study sample made up more than a third of the sample, which agrees with the previous study [22]. Re- garding the gestational age, the result of the present study showed that the 41-42 weeks gestational age was present in the highest percentage of cases, which disa- grees with the result of the study done in Sweden [23].The most common indication for the induction of labour was the post- term pregnancy, which is similar to the pre- vious study conducted in Tanzania [24], but different from the report by Lueth et al., which identified the pre-labour rupture of membranes as the most common indica- tion, followed by the post-term pregnancy [25]. The second most common indication in this study was gestational hypertension + pre-eclampsia followed by oligohydram- nios and the pre-labour rupture of the membranes. There was a statistically sig- nificant difference between the antenatal clinic follow-up and the induction of la- bour, which agrees with earlier studies that demonstrated similar results [16]. The data also showed a highly significant differ- ence between parity and all indications for labour induction. This finding is similar to a study conducted in Turkey [26]. Further- more, the results indicated that there was a statistically significant difference be- tween gravidity and the indications for la- bour induction similarly to the reported study done in Ethiopia [25]. The present study revealed that gestational age was one of the factors that yielded a highly sig- nificant difference with the indication of labour induction. A previous study also in- dicated that gestational age makes a sig- nificant difference in labour induction [27]. This study shows that the highest propor- tion of the sample had post-term pregnan- cy as an indication for the induction of la- bour followed by gestational hypertension + pre-eclampsia, oligohydramnios and pre- labour rupture of the membranes. There was a statistically significant difference be- tween antenatal care visits and gravidity with the induction of labour. The research- er recommends doing further research on a larger sample size. Further research is needed to determine the risk factors for indications of labour induction. This work has no potential conflicts of in- terest, whether of financial or other na- ture. 46 Erbil Journal of Nursing & Midwifery DISCUSSION CONCLUSION AND RECOMMENDATIONS CONFLICTS OF INTEREST https://doi.org/10.15218/ejnm.2021.05 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article 2013 Jan 25;8(1):e54858. 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