Comparison of outcomes of Foley's induced labors with different sonographic floater densities in fore-water

Abstract

Background: Onset of spontaneous labor occurs on completion of fetal functional maturity at amniotic fluid optical density (AFOD) 0.98 ± 0.27 (mean ± SD). All three events occurring together at any time from 35 weeks to 42 weeks indicate the individualized term for each fetus. No failures of induction of labor were reported when labors induced at AFOD 0.98 ± 0.27. As AFOD estimation needs invasive amniocentesis, we tried to induce women with liquor with mature AFOD by observing the sonographic appearances of fore-water by transvaginal sonography.
Methods: In this comparative study, three groups of gestational age and parity matched uncomplicated singleton term pregnant women, underwent fore-water trans-vaginal sonography before induction of labor with Foley's catheter. Sonographic images were divided into three grades based on floating particle densities. Each group consisted of 20 women with each grade of sonographic images. Uncentrifuged fresh AF samples collected at amniotomy were used for AFOD measurement with colorimeter at 650 nm in all groups. After Foley's expulsion, labor was augmented with vaginal misoprostol. The mean AFOD values, Foley's insertion expulsion intervals, Foley's insertion delivery intervals (FIDI), T misoprostol required, and neonatal respiratory distress were recorded in each group and compared.
Results: In groups 1, 2, and 3, the mean AFOD was found to be 0.29 ± 0.09, 0.68 ± 0.14, and 1.15 ± 0.20, respectively. Mean Foley's insertion expulsion intervals were 10.57 ± 3.76 h, 5.83 ± 2.24 h, and 4.08 ± 0.86 h, respectively. Mean FIDI were 20.00 ± 6.20 h, 11.22 ± 4.20 h, and 8.95 ± 2.98 h, respectively. The mean numbers of T misoprostol required in each group was 3 ± 1, 2 ± 1, and 2 ± 1, respectively. Significant differences were observed in all outcomes between groups (P < 0.05) favouring inductions with Grade 3 sonographic images.
Conclusion: Labor induction with Grade 3 sonographic images of fore-water was successful in all women with shorter FIDI, and with better perinatal outcomes.

Full text

33
© 2020 Tropical Journal of Obstetrics and Gynaecology | Published by Wolters Kluwer - Medknow
 Dr. Samartha Ram Hemmanur,
Department of Obstetrics and Gynecology, Sandhya Ram Maternity
Hospital, Katampazhipuram, Palakkad, Kerala ‑ 678 633, India.
E‑mail: drsamartharam@gmail.com
Original Article
ABSTRACT
Background: Onset of spontaneous labor occurs on completion of fetal functional maturity at amniotic uid optical
density (AFOD) 0.98 ± 0.27 (mean ± SD). All three events occurring together at any time from 35 weeks to 42 weeks
indicate the individualized term for each fetus. No failures of induction of labor were reported when labors induced at AFOD
0.98 ± 0.27. As AFOD estimation needs invasive amniocentesis, we tried to induce women with liquor with mature AFOD
by observing the sonographic appearances of fore‑water by transvaginal sonography.
Methods: In this comparative study, three groups of gestational age and parity matched uncomplicated singleton term
pregnant women, underwent fore‑water trans‑vaginal sonography before induction of labor with Foley’s catheter. Sonographic
images were divided into three grades based on oating particle densities. Each group consisted of 20 women with each
grade of sonographic images. Uncentrifuged fresh AF samples collected at amniotomy were used for AFOD measurement
with colorimeter at 650 nm in all groups. After Foley’s expulsion, labor was augmented with vaginal misoprostol. The mean
AFOD values, Foley’s insertion expulsion intervals, Foley’s insertion delivery intervals (FIDI), T misoprostol required, and
neonatal respiratory distress were recorded in each group and compared.
Results: In groups 1, 2, and 3, the mean AFOD was found to be 0.29 ± 0.09, 0.68 ± 0.14, and 1.15 ± 0.20, respectively. Mean
Foley’s insertion expulsion intervals were 10.57 ± 3.76 h, 5.83 ± 2.24 h, and 4.08 ± 0.86 h, respectively. Mean FIDI were
20.00 ± 6.20 h, 11.22 ± 4.20 h, and 8.95 ± 2.98 h, respectively. The mean numbers of T misoprostol required in each group
was 3 ± 1, 2 ± 1, and 2 ± 1, respectively. Signicant differences were observed in all outcomes between groups (P < 0.05)
favouring inductions with Grade 3 sonographic images.
Conclusion: Labor induction with Grade 3 sonographic images of fore‑water was successful in all women with shorter FIDI,
and with better perinatal outcomes.
Key words: Amniotic uid optical density; Foley’s induction of labor; fore‑water scanning; transvaginal ultrasonography.
to 43 weeks. The AFOD value at completion of fetal functional
maturity was found to be 0.98 ± 0.27 (mean ± SD), and
Comparison of outcomes of Foley’s induced labors with
dierent sonographic oater densities in fore‑water
12
Department of Obstetrics and Gynecology, Sandhyaram Maternity Hospital, Katampazhi Puram, Palakkad District, Kerala, 1Consultant
Obstetrician and Gynecologist, Divya Hospital Palladam Road, Tirupur, Tamil Nadu, 2Consultant Obstetrician and Gynecologist,
Sankar Laparoscopy and Infertility Center, Chirala, Andhra Pradesh, India
This is an open access journal, and arcles are distributed under the terms of the Creave
Commons Aribuon‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix,
tweak, and build upon the work non‑commercially, as long as appropriate credit is given and
the new creaons are licensed under the idencal terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Hemmanur SR, Illa SS, Krishna HR. Comparison
of outcomes of Foley’s induced labors with different sonographic oater
densities in fore‑water. Trop J Obstet Gynaecol 2020;37:33‑7.
Received: 22‑12‑2019 Revised: 25‑03‑2020
Accepted: 01‑04‑2020 Published Online: 14‑08‑2020
Introduction
Samartharam et al. reported the concept of the individualized
term for each fetus based on amniotic fluid optical
density (AFOD).[1] Babies attain completion of functional
maturity at different gestational ages ranging from 35 weeks
Access this article online
Website:
www.tjogonline.com
Quick Response Code
DOI:
10.4103/TJOG.TJOG_111_19
Videos Available on: www.tjogonline.com
labors
[Downloaded free from http://www.tjogonline.com on Tuesday, August 18, 2020, IP: 181.164.132.190]

Hemmanur, et al.: Comparison of outcomes of Foley’s induced labors with dierent sonographic oater densities in fore‑water
34 Tropical Journal of Obstetrics and Gynaecology / Volume 37 / Issue 1 / January-April 2020
at this AFOD value the spontaneous labor occurs. Babies
bornwith AFOD value ≤0.40 are functionally premature
and develop varying degrees of respiratory distress,
irrespective of gestational age, and birth weight.[2-5] Raising
levels of amniotic fluid lecithin during the third trimester
induces progressive and rapid detachment of vernix from
the fetal skin surface. The detached vernix clumps get
mixed with amniotic fluid, resulting in a rapid surge like a
change of color in liquor before the onset of spontaneous
labor.[2,6] The color of amniotic fluid, to start with looks
watery, then changes to milky, buttermilk like, and then
become curd-like.[7] The color and turbidity of AF can be
measured in terms of optical density (AFOD) at 650 nm by
a laboratory colorimeter.[1] It was reported, labors induced
at mature AFOD values (0.98 ± 0.27, mean ± SD) result in
optimally mature babies, shorter induction delivery intervals,
no induction failures, less labor pain, and no neonatal
respiratory distress (NRD).[8]
Deciding the day of delivery at term is an unsolved dilemma in
obstetrics. The ideal objective of any obstetrician is to deliver
the baby at optimal functional maturity, i.e. the baby should
be neither premature nor postmature. This can be achieved by
AFOD-guided induction of labors.[8] AFOD estimation before
induction of labor needs invasive amniocentesis which is
not acceptable.
In the first part of this study, we tried to find a correlation
between the density of floating vernix clumps in fore water by
transvaginal sonography and the AFOD. In the second part of
this study, we attempted to compare the outcomes of Foley’s
induced labors between 3 different grades of sonographic
image groups of fore-water.
Methods
In this comparative study, gestational age and parity matched
uncomplicated singleton term pregnant women, underwent
fore water transvaginal sonography, before induction of labor
with Foley’s catheter insertion. Sonographic images were
divided into 3 grades based on the floating vernix clump
density. Three groups were made with 20 women in each
group with each grade of sonographic images of fore-water.
Uncentrifuged fresh AF samples collected at amniotomy were
used for AFOD measurement with colorimeter at 650 nm in
all women of three groups. After Foley’s Cather expulsion,
labor was augmented with vaginal T. Misoprostol 25 mcg at
an interval of four hours. The AFOD values, Bishop scores at
induction, Foley’s insertion expulsion intervals (FIEI), Foleys
insertion delivery intervals (FIDI), and requirement of T.
misoprostol were recorded in each woman of all three groups.
Babies that developed neonatal respiratory distress (NRD),
and the babies that required NICU admission, were also
recorded in each group. The outcomes of these variables
were statistically compared between groups.
Exclusion criteria
Women who underwent cesarean sections were excluded
from the study.
Fore‑water scanning by transvaginal sonography
After emptying the bladder, the woman lie-down on a foot
end elevated table (around 30°) in the lithotomy position. The
woman was advised to relax for 5 min. Presenting part was
gently pushed above with fingers to create a better fore-water
pocket. Fore-water scanning was done with transvaginal
sonography. While scanning, the position of the presenting
part can be adjusted by pushing the presenting part above
with fingers per abdominally. Very gentle manipulation of
the presenting part with TV probe can also be done to get
better images [Figures 1--3].
Grading of sonographic images
• Grade 1: Hypoechoic fore-water with very few or no
echogenic floating vernix clumps [Figure 1 and Video 1].
https://youtu.be/Zh5oZynGx-o
• Grade2: Fore-water with moderate echogenic floating
vernix clumps [Figure 2 and Video 2]. https://youtu.be/
SdwtqhbFPf8
• Grade 3: Fore‑water with heavy echogenic floating
vernix clumps, irregular shaped cloud-like big vernix
clumps [Figure 3 and Video 3], and also swarming fish
like movement of vernix clumps (Swarming fish sign)
can be seen. https://youtu.be/_iWs5zOEZZY
Method of Foley’s catheter induction
Foley’s catheter of 22 F size was inserted through cervix
under strict aseptic precautions, and the bulb was inflated
up to 60–70 mL with distilled water.
AF sample collection at amniotomy
When Foley’s catheters got expelled, cervices had more than
4 cm dilatation. Woman in the lithotomy position, under
the good source of light, Sims speculum was applied and
membrane visualized. AF sample was drawn using 2.5 cm
long 23 G needle fitted with 2 mL disposable syringe. The
membrane was pierced when the uterus was not acting to
avoid splashing of liquor.
Method of measuring AFOD
The colorimeter was set at 650 nm wavelength. The test tube
containing distilled water (control solution) was inserted
into the cuvette holder of the machine and the “0” reading
was adjusted. Later, this control test tube was removed
[Downloaded free from http://www.tjogonline.com on Tuesday, August 18, 2020, IP: 181.164.132.190]

Hemmanur, et al.: Comparison of outcomes of Foley’s induced labors with dierent sonographic oater densities in fore‑water
35
Tropical Journal of Obstetrics and Gynaecology / Volume 37 / Issue 1 / January-April 2020
enter button, the AFOD value can be read directly from the
display screen of the machine.
(AFOD Estimation with Colorimeter https://youtu.be/
vfQhzRKeCI0)
Neonatal respiratory distress (NRD) dened
Respiratory grunting, labored breathing, intercostal
recession, and transient tachypnea within 1 h after birth was
considered as NRD
Informed and written consent was obtained from all subjects
who participated in this study. This study confined to the
standards of Declarations of Helsinki.
Statistical analysis
Statistical software, MS Excel, SPSS version 22 (IBM SPSS
Statistics, Somers NY, USA) was used to analyze the data.
Categorical data were represented in the form of frequencies
and proportions. Chi-square test or Fischer’s exact test (for
2 × 2 tables only) was used as a test of significance for
qualitative data [Table 1]. Continuous data were represented
as mean and standard deviation. ANOVA was used as a test of
significance to identify the mean difference between more than
two quantitative variables [Table 1]. P value (the probability
that the result is true) of < 0.05 was considered as statistically
significant after assuming all the rules of statistical tests.
Results
In groups 1, 2, and 3, the mean ± SD values of AFOD was
found to be 0.29 ± 0.09, 0.68 ± 0.14, and 1.15 ± 0.20,
respectively (P < 0.001).
In groups 1, 2 and 3, the mean ± SD values of B.
Score at induction were 5 ± 1, 7 ± 1, and 7 ± 1,
respectively (P < 0.001).
The mean ± SD values of Foley’s insertion expulsion intervals
were 10.57 ± 3.76 h, 5.83 ± 2.24 h, and 4.08 ± 0.867.0 h,
respectively (P < 0.001).
The mean ± SD values of FIDI were 20.00 ± 6.20 h,
11.22 ± 4.21 h, and 8.95 ± 2.98 h, respectively (P < 0.001).
The mean ± SD values of T misoprostol required in
each group were 3 ± 1, 2 ± 1, and 2 ± 1 (P < 0.001),
respectively [Table 2].
The percentage of babies that developed NRD in group 1,
2, and 3 were 45%, 15%, and 0%, respectively (P < 0.001).
The percentage of babies that were admitted to NICU in
Figure 1: (Original): Grade 1 sonographic images of fore‑water (AFOD 0.45).
AF samples with dierent AFOD values and their corresponding sonographic
images are shown
Figure 2: (Original): Grade 2 sonographic images of fore‑water (AFOD values
between 0.45–0.85). AF samples with dierent AFOD values and their
corresponding sonographic images
Figure 3: (Original): Grade 3 sonographic images of fore‑water (AFOD values
0.86). AF samples with dierent AFOD values and their corresponding
sonographic images are shown
from the cuvette holder, and the test tube containing a fresh
uncentrifuged AF sample was inserted. With the press of the
[Downloaded free from http://www.tjogonline.com on Tuesday, August 18, 2020, IP: 181.164.132.190]

Hemmanur, et al.: Comparison of outcomes of Foley’s induced labors with dierent sonographic oater densities in fore‑water
36 Tropical Journal of Obstetrics and Gynaecology / Volume 37 / Issue 1 / January-April 2020
group 1, 2, and 3 were 50%, 20%, and 10% (P < 0.001),
respectively [Table 1].
Significant differences were observed in all outcomes
between groups favouring inductions with Grade 3
sonographic images.
Discussion
Skin is the last organ to mature, and the completion of
skin maturation is denoted by shedding of vernix from the
fetal skin surface into the amniotic fluid.[7,9] This adding of
vernix clumps into AF is responsible for the color of AF. This
process of vernix shedding and color change in liquor starts
occurring 8 to 10 days before the onset of spontaneous
labor.[2] Human amniotic fluid cells (vernix cells) produce
prolabor cytokines like IL6, IL8, IL1beta, and EGF which can
trigger the expression and production of uterine activation
proteins (UAPs) and prostaglandins.[10,11] These are the
events that occur before the onset of spontaneous labor. The
color and turbidity of AF can be measured in terms of optical
density (AFOD) at 650 nm by a laboratory colorimeter.[1]
The onset of spontaneous labor occurs on completion of fetal
functional maturity at AFOD value 0.98 ± 0.27 (mean ± SD). All
these three events occurring together at any time from
35 weeks to 42 weeks indicate the individualized term
for each fetus. There are early maturing fetuses that attain
completion of functional maturity as early as 35–36 weeks,
and there are late maturing fetuses that attain completion
of maturity as late as 41–42 weeks.[2-5]
This concept of “individualized term for each fetus” is
having a very significant impact on clinical obstetrics.
A baby destined to mature by 42 weeks, if delivered at
40 weeks, this baby will be functionally premature and
develop NRD, and also suffer the problems of adaptation.
On the other hand, a baby who attained completion of
maturity by 35 weeks, and for some reason if the labor
does not start, and if delivered at 39 weeks, this baby will
be functionally posted mature, dysmature, and sometimes
IUFD may also occur.[2] This could be one of the reasons for
unexplained IUFDs.
Shorter induction delivery intervals and optimally mature
babies with best perinatal outcomes were reported when labors
were induced at AFOD value of 0.98 ± 0.27 (mean ± SD).[8]
We need invasive amniocentesis to pick up the women at
these mature AFOD values.
In the first part of this study, to avoid invasive amniocentesis
for AFOD estimation, we tried to quantify the density of
vernix floaters in amniotic fluid by scanning the bag
of fore-waters by TV sonography. We divided these
sonography images into three grades. The range of AFOD
values for each grade of images was found [Figures 1-3].
In the second part of this study, we evaluated the outcomes
of Foley’s induced labors with three different grades of
sonographic images.
Very favorable Bishop Scores at induction, lowest Foleys
insertion expulsion intervals, lowest Foley insertion delivery
intervals, and very less T misoprostol required, were observed
in grade 3 sonography image group when compared to
Grade 1 and 2 groups [Table 2]. Moreover, the number
of babies that developed NRD, and the NICU admissions
needed were the least in the grade 3 sonographic image
Table 2 (Original): Comparison of labor outcome measures between groups
Variable Group 1 n: 20 AFOD <0.45
n: 20, (Mean±SD)
Group 2 n: 20 AFOD 0.45 to 0.85
(Mean±SD)
Group 3 n: 20 AFOD >0.86
(Mean±SD)
Sig P
ANOVA
GA (age at induction) 38.51±0.82 38.66±1.44 39.4±1.04 0.035
Para 2±1 2±1 2±1 0.914
B. Score at induction 5±1 7±1 7±1 <0.001
Foley’s insertion‑ expulsion intervals 10.57±3.76 5.83±2.24 4.08±0.86 <0.001
Foley’s insertion‑ Delivery intervals 20.00±6.20 11.22±4.20 8.95±2.98 <0.001
AFOD at ARM 0.29±0.09 0.68±0.14 1.15±0.20 <0.001
No of T. miso used 3±1 2±1 2±1 <0.001
Table 1 (Original): Comparison of neonatal outcome measures between groups
Variable Yes/ No Group 1 AFOD <0.45 Group 2 AFOD 0.45 to 0.85 Group 3 AFOD >0.86 Sig P
Count n% Count n% Count n% Chi-square
NRD Absent 11 55 17 85 20 100 <0.012
Present 9 45 3 15 0 0
NICU Admission No 10 50 16 80 18 90 <0.001
Yes 10 50 420 210
[Downloaded free from http://www.tjogonline.com on Tuesday, August 18, 2020, IP: 181.164.132.190]

Hemmanur, et al.: Comparison of outcomes of Foley’s induced labors with dierent sonographic oater densities in fore‑water
37
Tropical Journal of Obstetrics and Gynaecology / Volume 37 / Issue 1 / January-April 2020
group [Table 1]. These results show, that the preparations
for the onset of spontaneous labor were in a well-advanced
stage in grade 3 sonographic image group when compared to
grade 1 and 2 groups. This study showed the best perinatal
outcomes by triggering labors with Grade 3 sonographic
images.
Fore-water scanning by TV sonography, before induction
of labor, helps to assess the functional maturity status of
the fetus. With lower sonography grades, inductions can
be postponed. In the case of obstetric need, antenatal
steroids can be given to hasten the fetal functional
maturity.
Conclusion
Elective Foley induction of labor with grade 3 sonographic
images of fore-water helps to program labor at a
convenient hour, helps to deliver babies at optimal
maturity, avoids induction failures, and also helps to prevent
iatrogenic prematurity and its related complications.[8] As this
is a non-invasive method, this can be readily accepted and
practiced by all obstetricians. Further studies are needed to
confirm our observations with a larger sample size.
Acknowledgment
We, authors sincerely acknowledge the support given by
the staff of the Obstetrics and Gynecology Department of
Sandhyaram Hospital, Katampazhipuram in conducting this
study.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient (s)
has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in
the journal. The patients understand that their names
and initials will not be published and due efforts will be
made to conceal their identity, but anonymity cannot be
guaranteed.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
References
1. Samartha Ram H, Sandhya Ram S, Shankar Ram HS. Amniotic uid
optical density at spontaneous onset of labour and it’s correlation with
gestational age, birth weight, functional maturity and vernix caseosa
of new born. Calicut Med J 2009;7:2009. Available from: https://
drive. google.com/le/d/1_KiQAJ_2-leDAMd6-JWTjIeLWbQLDXpv/
view?usp=sharing.youtu.be/75Aak7CiN6A youtu.be/wwBStQL2RR8.
2. Samartha Ram H, Sandhya Ram D. Individualized term for each foetus:
From surge in amniotic uid optical density (AFOD). Available from:
http://ispub.com/IJGO/18/1/14784. [Last accessed on 2018 Jun 11].
youtu.be/6SPfR9VbbCc.
3. Samartha Ram H, Shankar Ram HS, Sandhya Ram S, Hanuman RK.
Correlation between amniotic fluid optical density (AFOD) and
functional maturity status of the new-born at caesarean delivery in GDM.
IOSR J Dent Med Sci 2014;13:1-5.
4. Klimek R. ‘The use in obstetrics of quantum theory as well as modern
technology to decrease the morbidity and mortality of new-borns and
mothers during iatrogenic induced delivery’. Neuroendocrinol Lett
2001;22:5-8.
5. Klimek M. Prediction of the birth term and course of the labour. Ob/
Gyn Department, Jagiellonian University, Kopernika, Cracow, Poland,
23, 31-501. Available from: http://www.cyfronet.krakow.pl/~mmklimek/
marek_re.html. [Last accessed on 2018 Jun 12].
6. Narendran V, Randall WR, William LP, Steven BH. Interaction between
pulmonary surfactant and vernix: A potential mechanism for induction
of amniotic uid turbidity. J Pediatric Res 2000;48:120-4.
7. Zabkar JH. Evaluation of foetal maturity by amnioscopy. J Perinat Med
1975;3:145-53.
8. Samartha Ram H, Samyuktha IS, Nagasree V. Outcomes of
induction of labour with mature and premature amniotic uid optical
density (AFOD): A preliminary case control study. Trop J Obstet
Gynaecol 2019;36:206-11.
9. Agorastos T, Vlassis G, Zournatzi B, Papaloukas A. Foetal lung maturity
and skin maturity: 2 distinct concepts and the clinical signicance of
their differences. Z Geburtshilfe Perinatol 1983;187:146-50.
10. Mazzucchelli I, Avanzini MA, Ciardelli L, Pagani S, Greco R, Belloni C,
et al. Human amniotic uid cells are able to produce IL -6 and IL- 8.
Am J Reprod Immunol 2004;5:198-203.
11. Christiaens I, Zaragoza DB, Guilbert L, Robertson SA, Mitchell BF,
Olson DM. Inammatory processes in preterm and term parturition.
J Reprod Immunol 2008;79:50-7.
[Downloaded free from http://www.tjogonline.com on Tuesday, August 18, 2020, IP: 181.164.132.190]