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ADDIS ABABA UNIVERSITY

FACULTY OF MEDICINE
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
September 2001

INDUCTION AND AUGMENTATION OF LABOR

I. DEFINITIONS
An induction of labor is the process by which medical or surgical means are used to initi-
ate and maintain labor any time after the 28th week of gestation.
** Induction is done when the benefits of delivery to the fetus or the mother exceed the
benefits of continuing the pregnancy. It could be either as:
 Planned (elective)
 Emergency
An active labor refers to the occurrence of regular contractions, cervical dilatation 3 cm
or more and cervical length 1 cm or less.
An adequate contraction consists of 3-5 strong contractions in 10 min. each lasting for
45-60 sec.

II. INDICATIONS
The following are the indications for induction of labor. However when to induce with a
given indication is determined by the protocol prepared for each indication per se.

A. Obstetrical
1. Hypertensive Disorders of Pregnancy including eclampsia
2. Post term pregnancy
3. Intra-uterine Fetal death (IUFD)
4. Unexplained Recurrent Intrauterine Fetal Death near term
5. Monsters
6. Polyhydramnious
7. Premature Rupture of Membranes (PROM)
8. Rh-Isoimmunization
9. Intra-uterine Growth Retardation (IUGR)
10. Placental Abruption and minor degree anterior placenta praevia
11. Chorioamnionitis

B. Maternal Medical Disorders aggravated by Pregnancy

1. Chronic renal disease
2. Chronic hypertension
3. Severe cardiac disease
4. Diabetes mellitus
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III. CONTRAINDICATIONS
In general any condition that is contraindication for spontaneous labor and vaginal deliv-
ery should be a contraindication for induction of labor. Contraindications may include
but are not limited to the following;
 ABSOLUTE
1. Gross cephalo-pelvic disproportion (CPD)
2. Transverse and oblique lie
3. Footling breech
4. Upper segment Uterine scar
5. Active or culture proven genital herpes (with intact membranes or rupture of
membranes of less than 6hrs duration)
6. Extensive genital wart
7. Invasive cervical Ca.
8. Pelvic tumor obstructing the birth canal
9. Placenta praevia (major degree)
10. Acute fetal distress
11. Two or more previous lower uterine segment cesarean scar

 RELATIVE
12. Grande multiparity
13. Bad obstetric history
14. Twin pregnancy
15. Prematurity
16. Macrosomia
17. One previous lower segment c/s
IV. RISKS AND COMPLICATIONS OF INDUCTION

A. MATERNAL
1. Failed induction
2. Unforeseen CPD leading to obstructed labor
3. Uterine hyper stimulation/titanic contractions
4. Sepsis
5. Placental abruption
6. Water intoxication
7. Amniotic fluid embolism
8. PPH
9. Uterine rupture
B. FETAL
1. Iatrogenic prematurity
2. Fetal asphyxia
3. Cord prolapse
4. Fetal hemorrhage from vasa previa
5. Fetal pneumonia
6. Neonatal jaundice

V. BISHOP’S PELVIC SCORING SYSTEM

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Table 1. Bishop’s pelvic scoring system

Score Dilatation Effacement Station* Consistency Position
0 Closed 0-30% -3 Firm Posterior
1 1-2cm 40-50% -2 Medium Mid posi -
tion
2 3-4cm 60-70% -1to +1 Soft Anterior
3 ≥5cm ≥80% +2 - -
Score ≤ 4: unfavorable
Score 5-8: intermediate
Score 9: favorable
*Station reflects a -3 to +3 scale.

VI. CONDITIONS THAT SHOULD BE FULFILLED BEFORE INDUCTION

 Document the indication.

 Make sure that there are no contraindications.
 Do pelvic scoring (Bishop) and if unfavorable, consider cervical ripening. Methods in-
clude;

1. Pharmacological: prostaglandins
PGE2:
3 mg vaginal tab; 1 tab to be inserted in the posterior fornix of the vagina, 12 hrs be-
fore induction is started, every 6 hours, till the cervix becomes favorable (maximum
of four doses). 2.5 mg intravaginal gel; to be applied on the upper vaginal canal mu-
cus membrane 12 hrs before induction is started, every 6 hourly, till the cervix be-
comes favorable (maximum of four doses). 0.5 mg intracervical gel; to be applied in
the cervical canal 12 hrs before induction is started, every 6 hourly, till the cervix be-
comes favorable (maximum of three doses).
 Patient is expected to remain recumbent for at least 30 min.
 An observation period ranging from 30 min. to 2 hrs. is required
 Effects of prostaglandin E2 maybe exaggerated with oxytocin, so in-
duction with oxytocin should be delayed for 6 hrs.
 Doses should only be repeated if Bishop score change is no more
than 3.
 In case of hyper stimulation, intravenous/subcutaneous terbutaline,
250 μg or magnesium sulfate (2-6 g in 10-20% dilution) maybe used
for uterine relaxation.
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2. Ballooned catheters: 16 or 18 gauge Foley catheter.

- Assess the baseline Bishop Score the evening prior to induction.
- After thoroughly cleaning the vagina and the cervix, a size 16 or 18 Foley
catheter is introduced through the cervix above the internal os using aseptic
technique either digitally or with the aid of a speculum. The balloon is then
inflated with 30-50 ml of sterile saline and pulled gently to the level of the in-
ternal os, where it is left for 12 hrs or until spontaneous expulsion occurs. Ap-
ply traction on the catheter or infuse 1ml/min of normal saline extra-amniotic
(maximum of 1lit) to accelerate the ripening process.
- In the condom catheter method, the catheter is covered with two condoms (ex-
tra precaution to avoid rupture) from the proximal end to about 8-10 cm to-
wards the distal end. After inserting the condom-catheter into the cervix, it is
filled with 0.9% N/S (800-1000 ml) and the distal part of the catheter is tied
with a bandage connected to a 1-2 kg weight hanging at the edge of the bed.
- Ascertain availability of labor ward staff and also the capacity to do emergency
cesarean section.
- Get informed consent from the patient.

VI. DETAILS OF THE INDUCTION PROCEDURE

1. All inductions, except emergency inductions, should be started at 8 a.m.
2. Check indication and Bishop score.
3. Explain the procedure to the patient.
4. Light sedation the previous night of induction.
5. Encourage the mother to empty her rectum or give enema at 6:00 a.m. on the day of
induction.
6. Light fluid diet or NPO in the morning.
7. Monitor maternal v/s, uterine activity and FHB according to the protocol for the man-
agement of labor.
8. Check recent hematocrit and other basic investigations, if not available order a new
one.
9. Place a No.18 venous canula.
10. Start oxytocin drip and label the bottle.
11. Artificial rupture of the membranes (ARM)
 Early amniotomy according to the case; consult with chief-on-call before per-
forming amniotomy.
 Follow strict asepsis and use antiseptics
 Check for vasa praevia, cord presentation and prolapse before and after ARM
 Listen to the fetal heart rate
 Document the time of ARM, color and amount of amniotic fluid, and also if
there is any bleeding
12. Oxytocin infusion dosage
 Aim to maintain the lowest possible dosage consistent with regular uterine
contraction
 Use 0.9% N/S or R/L for infusion solution
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 Increase the drop rate every 30 min. until 3-5 contractions are achieved in 10
min. each lasting 40-60 sec.
 Dosage is the same for primi-and multi gravidae.

I) For pregnancies before term:

1. Add 2 iu of oxytocin to 1000 ml of 0.9% N/S
2. Start at 2 mu/min., increasing q 30 min. by 2 mu/min up to 8 mu/min; then in-
crease by 4 mu/min up to a maximum of 32 mu/min.

II) For pregnancies at term:

 Add 2 iu of oxytocin to 1000 ml of 0.9% N/S
 Start at a rate of 1 mu/min., increasing the rate at 1 mu/min. up to 8 mu/min.;
then 2-4 mu/min up to a maximum dose of 32 mu/min.

Drops/min. Oxytocin mu/min.

10 1
20 2
30 3
40 4
50 5
60 6
70 7
80 8
If no adequate contraction, add 2 iu in the same bag and, start with,
50 10
60 12
80 16
If no adequate contraction, add 2 iu in the same bag and, start with,
50 20
60 24
70 28
80 32

After initiation of oxytocin infusion,

 Follow maternal v/s and input/output
 Follow progress of labor
 No need to increase the dose of oxytocin once adequate contractions are achieved
 If patient in not in established labor after 6 hrs of oxytocin administration, consult the
senior in charge
*A failed induction is diagnosed when there has been no cervical change or descent of
the presenting part after 6-8 hours of labor, or contractions of 3 in 10 min. or 1 every 3
min. has not been achieved.

 Start antibiotic treatment if membranes are ruptured for more than 8 hrs
 After the labor has entered the active phase, plan to deliver within 8-12 hrs
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 Continue the oxytocin infusion for 1 hr post partum

 If the patient develops tetanic type of uterine contraction, stop the oxytocin drip.

AUGMENTATION OF LABOR
Definition: Correction of dystocia due to inefficient uterine contractions (power) by the
use of oxytocin.

INDICATION
Poor progress of labor due to inefficient uterine contractions.
CONTRAINDICATIONS
1. Breech presentation
2. CPD
3. Malpositions
4. Invasive cervical ca.
5. Active genital herpes infection
6. Outlet and mid-pelvis contracture
7. Non-reassuring FHB pattern
8. Fetal macrosomia

CONDITIONS TO BE FULFILLED
 Proper evaluation of the patient and the fetus (to rule out contraindications)
 Maternal rehydration, positioning
 The capacity to do emergency c/s
 Get an informed consent

Procedure;
1. Do ARM aseptically if membrane is intact
2. Start oxytocin infusion
 Add 1 IU of oxytocin to 1000 ml of R/L and label the bottle.
 Start with 0.5 mu/min. for multipara and 1 mu/min. for primigravida.
 The rate of increment should be 1 mu/min. q 30 min. up to maximum dose of 20
mu/min.
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Drops/min. Oxytocin mU/min.

10 0.5
20 1
40 2
60 3
80 4

If no adequate contraction, add 1 iu of oxytocin to the same bag and start with,
60 6
70 7
80 8

If no adequate contraction, add 1 iu of oxytocin to the same bag and start with,
50 10
60 12
70 14
80 16
If no good progress, add 1 IU of oxytocin to the same bag and start with,
50 20

During augmentation, monitor;

1. Progress of labor, FHB pattern, maternal status q 10 min.
2. No need to increase the dose after adequate contraction has been reached.
3. Give antibiotics when membrane has ruptured for more than 8 hrs.
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naecol 1999; 64:35-41.
3. Gon SJ, Sawhney H, Gopalan, S. Oxytocin induction of labor: a comparison of 20-
and 60-min. dose increment levels. Int J Obstet Gynaecol 1995; 48:31-36.
4. ACOG technical bulletin. Induction of Labor. Int J Obstet Gynaecol 1996; 53: 65-72
5. ACOG technical bulletin. Dystocia and the Augmentation of Labor. Int J Obstet Gy-
naecol 1996; 53:
6. Tekle-Ab Mekbib. 1994. Ethiop Med J 32:107-113
7. Williams Obstetrics, 20th edition.
8. Gabbe.1996