INDUCTION OF
LABOUR
OTARA A
Outline
• Definition
• Indication
• Counseling
• Assessment
• Cervical ripening
• ARM and oxytocin
• Monitoring
• Analgesia
Definition
• Induction of labour is artificial initiation of
labour
• Induction agents are substances used in
induction of labour
Indications
• Maternal diseases
Maternal diabetes mellitus
Pre-eclampsia/eclampsia and other hypertensive
disorders
Rh –ve/Iso-immunization
DVT
• Pre-labor (premature) rupture of
membranes/Chorioamnionitis
• Intrauterine fetal growth restriction
• Fetal demise
• Prolonged pregnancy/Post-term pregnancy,
• Maternal choice
Contraindication
• Previous penetrative uterine surgery
• Fetal malpresentation, malposition
• Foetal weight greater than 4000g
• Contracted pelvis
• Active genital herpes infection
• Placenta or vasa previa
Contraindication
• Special considerations
• Multiple gestation
• Some maternal cardiac conditions
• Grand multiparity
• Breech presentation
• Abnormal fetal heart rate patterns
• Severe hypertension
Counseling
• Patients should be counselled on
– Indication for induction and risk if not done
– Alternatives to induction
– Possible complications
– Assessment before induction
– Procedure of induction
– Analgesia during labour
• Allow to discus with partner or guardian
• Assure decision will be respected
REQUIREMENTS FOR
INDUCTION
• Assessments of gestational age
• fetal size and presentation
• clinical pelvimetry
• cervical examination
• personnel, available and familiar with the
process and its potential complications
• Uterine activity and fetal heart rate
monitoring
Possible complications
• Failure of induction
• Cord prolapse
• Ruptured uterus
• Hyperstimulation
• Foetal distress
Assessment
• Confirm
– Indication
– Maturity
– Contraindication
– Cervical readiness (Bishop score)
Maturity confirmation
• LNMP: Most reliable if
recorded/Regular/No contraception x 6/12
• Quickening
• PDT
• Early obstetric scan (before 16weeks)
• Early obstetric examination
Cervical readiness (Bishop
Score)
Factor 0 1 2 3
Dilation 1- 3- >5
Closed 2cm 4cm
Length >4cm 3-4cm 1-2cm <1cm
Consist Firm Medium Soft
ency
Position Posterior Central Anterior
Descent -3 or -2 or -1,0 or +1,+2 or
4/5up 3/5up 2/5up 1/5up
Cervical readiness
• If score is more than 6, the cervix is ready
for induction
• In score is equal to or less than 6, ripening
needed before induction of labour
METHODS OF INDUCTION OF
LABOUR
• MECHANICAL
• Stripping of membranes
• Amniotomy/ARM
• Insertion of balloon catheters above the cervical os
(with or without extra-amniotic saline infusion)
• Introduction of hygroscopic dilators into the
endocervix
• MEDICAL
– Oxytocin
– locally applied hormones ( relaxin, mifepristone)
– prostaglandin compounds
Methods of cervical ripening
• Prostaglandin E2 (Prostin 3mg pessary,
gel or slow release pessary)
• Misoprostol (25µg)
– Insert every 6-8hour to a maximum of 3 doses
– Stop if cervix ripe or labour starts
– If oxytocin must be used, it should not be
used in less than 6hours since last
prostaglandin dose
– Advice to remain in bed for at least an hour
PROSTAGLANDINS
• Prostaglandins were first discovered
and isolated from human semen in the
1930s by Ulf von Euler of Sweden.
Thinking they had come from the
prostate gland, he named them
prostaglandins. It has since been
determined that they exist and are
synthesized in virtually every cell of the
body
PROSTAGLANDIN
SYNTHESIS
PROSTAGLANDIN TYPES
• PGE2-Prostin E2 vaginal tablets and
vaginal gel contain the active ingredient
dinoprostone, a naturally occurring female
hormone.
• PGF2-dinoprost tromethamine
a synthetic analogue of the naturally
occurring prostaglandin F2 alpha.
• PGEI
Contraindications of PG
• Abnormally strong uterine contractions in
a previous pregnancy
• History of asthma
• History of epilepsy
• Glaucoma or history of raised pressure in
the eye
• Decreased heart, liver or kidney function
Induction process
• Artificial rupture of membranes
• Oxytocin drip
Artificial rupture of
membranes
• Check foetal heart rate before the
procedure
• Check for cord presentation
• Rupture membranes with Kockers
forceps, amni-hook or amni-cot
• Control flow of liquor between fingers
Artificial rupture of
membranes
• Note colour of liquor
• Check for cord prolapse
• Check FHR after flow ceases
• Advise woman to remain in bed
till contractions are established
Oxytocin administration
• Start with 2.5/5IU in 500ml of NS or 5%
dextrose.
• Start with 10 drops per minute(dpm) and
increase by 10drops ½ hourly till 60dpm or
3 contractions every 10minutes lasting
more than 40seconds
• If adequate contractions are not achieved
by 60dpm, increase oxytocin to 5IU in
500ml and start at 30dpm
Oxytocin administration
• If 3 moderate contractions are not
achieved by 60dpm, increase oxytocin to
10IU and start drip at 30dpm
• If adequate contractions are not achieved
by 60dpm, induction is considered to have
failed
• Maintain the dose of oxytocin at which
adequate contractions achieved
Monitoring
• Monitoring should be done during:
– Cervical ripening
– ARM
– Oxytocin induction
– Labour
Monitoring during cervical
ripening
• Monitor PR, FHR and contraction ½
hourly
• Cervical status 6hourly if not in
labour or no regular contractions are
felt
• If abnormal foetal heart rate occurs,
manage as patient with foetal
compromise
• Monitor ARM as earlier indicated
Monitoring during oxytocin
induction
• Continous electronic monitoring where
available
• Monitor FHR ½ hourly by auscultation
awaiting onset of labour is also adequate
• Start monitoring with a partogram once
labour is established
Analgesia during labour
• Counseling as already noted
– Pain expectation
– Available methods for pain relief
• Analgesics available
– Opiates
– Inhalational analgesics
– Rubbing the back and breathing
– Epidural
THE END