INDUCTION AND

AUGMENTATION OF
LABOUR
BY
DR M.A. LAMINA
CONSULTANT/SENIOR
LECTURER, OBGYN.
 DEFINITION
• Induction of labour is an artificial means
of stimulating uterine contractions after
28weeks (24wks) of pregnancy with the
aim of achieving vaginal delivery.
• Augmentation of labour is the
administration of oxytocics with the aim of
increasing the strength and frequency of
uterine contractions (in a woman who is
already in labour)
• The reason for interrupting/terminating
pregnancy must be viewed seriously and
this decision should be taken when the
risks of continuation of pregnancy
outweighs the risks of intervention i.e. at a
point that the intrauterine environment is
(hostile) no longer conducive to fetal
survival.
 INDICATIONS
• 1. Hypertension in pregnancy
• 2. Prolonged pregnancy
• 3. Intrauterine growth restriction
• 4. Rhesus isoimmunisation
• 5. Diabetes mellitus
• 6. Intrauterine death
• 7. Congenital abnormalities of the fetus
• 8. Spontaneous prelabour rupture of
membranes
• 9. Antepartum haemorrhage
 CONTRAINDICATIONS
ABSOLUTE
• 1. Contracted pelvis
• 2. Two previous lower segment Caesarean
sections
• 3. Previous Classical Caesarean section
• 4. Major placental praevia
• 5. Breech presentation
• 6. Transverse lie
• 7. Previous vesico-vaginal fistula repair
• 8. Previous pelvic floor repair
• 9. If there is an indication for caesarean section
 RELATIVE
• 1. Previous lower segment Caesarean
section (non-recurrent reason)
• 2. Grandmultiparity
• 3. Multiple pregnancy
 Prerequisites for induction of
labour
1. Clear indication must exist. Social reasons
no longer tenable.
2. The patient must be counseled
adequately about the benefits and risks
of the situation
3. Adequate medical and nursing personnel
- a senior registrar
- a nurse to a patient
 Prerequisites (contd)

• 4. The pelvis must be adequate

• 5. The presentation must be cephalic
• 6. Cervix must be ripe
 Investigations
• Prepare the patient as if going for
caesarean section
• a). Counseling on indication, procedure &
complications
• b). PCV, grouping & X-matching for blood (1
-2 pints)
• C). Serum electrolytes, urea & creatinine
• D). Urinalysis
 METHODS OF INDUCTION OF
LABOUR
A. SURGICAL
- Amniotomy otherwise known as
Artificial Rupture of Membranes (ARM)
- Usually done when there is cervical
dilatation.
- Release of liquor amnii results in
reduction in the length of uterine muscle
fibres so that the forces of uterine
contraction increase- Starling’s law.
 B. MEDICAL
• Oxytocin infusion
• Use of Prostaglandins and its analogues
 LOGICAL APPROACH TO
INDUCTION OF LABOUR
• The two most fundamental phenomena of
human parturition are contractility of the
myometrium and dilatation of the cervix.
• The changes which take place within the
cervical stroma to facilitate its
effacement and dilatation are designed to
occur in concert with the development of
rhythmic myometrial contractions of labour
If powerful contractions develop or are
provoked artificially when the cervix
remains rigid and unyielding, the labour will
inevitably be more protracted and will
carry increased risk of complications for
both the mother and fetus. Therefore for
induction of labour to be effective, it is
not sufficient simply to stimulate
contractility of the myometrium.
• The induction method must endeavour as
far as possible to replicate the events of
normal parturition. In addition to
generating myometrial contractility, it
must induce the changes of cervical
ripening if these have not yet occurred
naturally.
 ASSESSMENT OF CERVICAL
RIPENESS
• All women undergoing induction should be
assessed vaginally for the degree of
favourability of cervix by using the
Bishop’s score. The greater the score the
easier it should be to intiate labour. Of all
the parameters in the Bishop’s score, the
dilatation of the cervix and the station of
the presenting part are the most
important.
 MODIFIED BISHOP’S
SCORE
• Parameter/score 0 1 2 3
• Dilatation of Cx(cm) 0 1-2 3-4 ≥5
• Consist. Of Cx Firm Med Soft -
• Length of Cx(cm) >2 2-1 1-0.5 <0.5
Effacement (%) <40 40-60 60-80 >80
• Position of Cx Post Cent Ant -
• Statn of pres part -3 -2 -1or0
Below
(cm above isch spine)
 Interpretation of Bishop’s
score
• Favourable score ≥ 7
• Intermediate score 5 or 6
• Unfavourable ≤ 4

• If the cervix is not ripe, then you need to

ripen the cervix
 METHODS OF CERVICAL
RIPENING
• 1. Prostaglandin E2 gel (1mg).
• 2. Use of cervical Foley’s catheter
• 3. Use of Laminaria tent
• 4. Prostaglandin analogue e.g. misoprostol 25
-50mcg.
• The methods of induction of labour after
37 weeks most commonly include use of
prostaglandin tablet or its analogue in form
of gel or pessaries and ARM with or
without oxytocin. The methods used
depends upon the Bishop’s score and the
indication for induction.
• In our own centre, the cervix is ripened
with misoprostol tablet 25-50mcg passed
into the posterior fornix or a Foley’s
catheter that is passed into the uterine
cavity and ballooned with 40-50mls of aqua.
This is usually passed in the evening
preceding the morning of induction of labour.
It takes about 6-12 hours for the catheter
to be expelled or cervix to be ripe.
• After expulsion of the catheter, the
patient is transferred to the labour ward
and medical induction of labour using
oxytocin infusion is begun at 6.00am and
amniotomy done as well.
• Amniotomy is convenient when cervical
dilatation is 3-4cm or greater.
• The method of administration of oxytocin
infusion is that of Anderson and Turnbull
(1968)
The regimen used at our centre:
• Oxytocin concentration: 2-5 units in 500
mls of IVF
• Rate: 1st 30mins – 15 drops/min
2nd 30mins – 30 drops/min
3rd 30mins – 45 drops/min
4th 30mins – 60 drops/min
OR until a contraction frequency of 3-4 in
10 mins is achieved.
• The concentration of oxytocin infusion is
doubled after getting to 60 drops/min
without achieving desired contraction
frequency. The commencement rate after
doubling the concentration is 30 drops/min.
• The fetomaternal vital signs should be
monitored closely. The use of
cardiotocograph and electronic fetal
monitor is mandatory where such facilities
are available
• In some other centres (where CTG is not
available), the Pinard’s stethoscope is
used to auscultate for fetal heart rate
every 15mins.
• It should be remembered that in general,
induction of labour is being performed
because there is perceived risk.
 ADMINISTRATION USING
INFUSION PUMP
• Add 5U of oxytocin to 500ml Ringer’s solution
(1mU/min=6ml/hr)
• Label IV bag and infusion pump with
concentration of oxytocin
• Attach oxytocin line via infusion pump
• Begin oxytocin infusion at 2 mU/min.
• Increase oxytocin dose gradually every 30-40min
until adequate contraction pattern is obtained (1
contraction every 3min. Lasting 45sec.) OR until
20mU/min is reached.
 Administration with inf.
pump.(contd.)
• THEN decrease the dose by 1mU/min
every 30-40min. unless contraction
pattern becomes inadequate.
• Maintain IV fluids to maximum total fluid
rate of 125ml/hr
 ASSESSMENT
• Assess a 20min. CTG prior to
administration of oxytocin and 2hr post-
CTG
• Assess FHR & contraction pattern every
15mins.
• Assess 1-2hrs & prn: BP, pulse, resp. rate,
pain tolerance
• Assess every 4hrs (temp., input & output)
 Monitoring for signs of:
Uterine
hyperstimulation/Uterine
rupture Water intoxication
• Tachysystole <60sec bt • Headache
contractions, ton • Nausea & vomiting
e >20mmHg
• Confusion
• Abdominal rigidity & pain • Urine output (<30ml/hr)
• Hypotension-tachycardia • Hypotension
• Vaginal bleeding • Tachycardia or cardiac
arrhythmias
 COMPLICATIONS OF
INDUCTION OF LABOUR
• 1. Failed induction
- intrapartum haemorrhage
- fetal distress
- unsuspected CPD
---C/S
• 2. Hyperstimulation- fetal asphyxia-C/S
A contraction frequency >5 in 10min
---stop oxitocin infusion
---lie on lateral side
---give oxygen
---extreme cases, use of Halothane
• 3. Uterine rupture especially in multiparae
• 4. Postpartum haemorrhage
-continue oxitocin infusion for at least 1hr
after
delivery to prevent 10 PPH.
• 5. Intrauterine infection of fetus if delivery is
delayed after amniotomy.
• 6. Cord prolapse after amniotomy, particularly if
the amniotic fluid is increased or there is a
poorly fitting presenting part.
• 7. Fluid overload
• 8. Neonatal hyperbilirubinaemia
 THANK YOU FOR
LISTENING

GOD BLESS
YOU ALL