INDUCTION OF

LABOUR

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 Definition
• It’s an obstetrical intervention which involves
the initiation of uterine contractions (labour)
artificially or prior it’s spontaneous onset.
Indications
• Prolonged pregnancy because after 42 weeks
there is danger of placental insufficiency.
• Spontaneous rupture of membranes, after 36
weeks gestation and labour does not commence
within 12 hours, danger of intra uterine
infection is very high.
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• Rhesus iso-immunisation, accompanied by high titre
results at term.
• Diabetes mellitus, h/o intrauterine death occuring at 40
wks.
• Genital herpes, where labour is usually induced after 38
weeks gestation if disease is in remission
• Previous precipitate labour which tends to recur so
induction is indicated at 38 weeks for safe delivery.
• Social reasons, hence maternal request though not
common.
• Intrauterine death and spontaneous onset of labour
doesn’t occur shortly after.
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• Mild- moderate Preeclampsia at term, where both
mother and baby are in danger of, eclampsia and
placental insufficiency respectively.
• Signs of intrauterine growth retardation at
term ,which can be detected by abdominal
examination or serial ultrasound scan.
• When the health of the mother or the foetus
would be endangered if the pregnancy continues.
• Mild placental abruption & placenta preavia type 1
at 40 weeks.
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 Contraindication
Refers to factors that would prevent
spontaneous delivery.
Grouped into 2:
Absolute
• Cephalopelvic disproportion
• Malpresentation , due to prolonged labour.
• Foetal compromise, that is, if the foetus can not
stand the uterine contractions due to
prematurity or placenta insufficiency.
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• Placenta praevia type 2 posteriorly located,
through to type 4.
• Grandemultiparality, because of the poor tone
of the uterine muscles
Relative
• Previous uterine scar, though controversial.
• High and floating fetal head, due to possibility
of cord prolapse
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• Active genital herpes.
• Psychological factors, for example, if the mother is
against induction, her decision should be respected
• Unreliable estimated date of delivery ,in absence of
other means of confirming maturity .
Favourable factors
• 38 or more weeks of gestation.
• Cervical readiness , assessed through a scoring
system referred to as Bishop’s score.

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 ct
Where 3/5ths of the head or less is
palpable above the
pelvic brim
 Therefore, a total score of 8 and above
is highly successful.
The Bishop Score is an objective method
of assessing whether the cervix is
favourable for induction of labour.
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 Methods
I . MEDICAL
 Drugs (pharmaceutical preparation) alone are
used and the amniotic sac remains intact.
They include:-
• Prostaglandin E2 (PGE2)
 Intravaginal prostaglandin E2 are in the form
of pessaries (2.5mg), vaginal tablets (3-6mg)
or gel (2.5-5mg) e.g Dinoprostone.
It prepares the cervix and initiates uterine
contractions. 10
• Misoprostol ( Cytotec) or PGE1
 Normally packed in form of a tablet of 200 mcg.
 Recommended dose is 50 mcg, inserted to the
posterior fornix per vaginal.
 Membranes should be intact.
Adv , High success rate. Disadv, Very rapid labour
leading to negative psychological impact
• Synitocinon /Oxytocin /Pitocin
 Packed at doses of 5 and 10 units per mililitre.
 Recommended dose for primigravida is 5 units &

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 ct
multiparous 2.5 units in ½ L of 5% or 10% dextrose
commenced at 10 dpm.
 Drops are increased every ½ hrly with 10 dpm up to
a maximum of 60 dpm or till 3 moderate contractions
are achieved.
NB : Stop drops increase on attaining 3 moderate
contractions
 Evacuant enema may be necessary prior to
synitocinon drip.

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 11. SURGICAL
 Characterised by various mechanical measures, namely:
• Bulb induction for multiparous:
 A sterile catheter is inserted through the cervix , such that
the tip and ballon are within the lower uterine segment.
 Inflate ballon with 60 ml of fluid & continues adding by
10 ml hourly to a maximum of 60 ml.
 Simultaneously keep the catheter on traction against the
cervix by sticking it on the thigh.
 This continues until the bulb falls off which indicates 6 cm.

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• Sweep of the membranes:
Possible from a dilatation of at least 3 cm.
After a vaginal examination, the index &
2nd finger sweeps through the cervical os
to detach foetal membranes from the
decidua.
The action facilitates release of natural
prostaglandin.

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• Amniotomy / ARM:
 Carried out safely when presenting part has
engaged and well applied to the cervix.
COMBINED METHOD
• Mostly in terms of either cytotec, or syntocinon
drip and artificial rupture of membranes in
established labour.
• Alternatively, membranes sweep, in pre-labour
rupture and synitocinon drip.
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 Specific Management
• Discuss with the client either prenatally or just
before the procedure, regarding:
 Indications , Expectation and Possible outcome.
• The DR prescribes the induction method after
assessment, to include Bishop’s score.
• Depending on the institutional policy, the
procedure is best started in the morning, though
ripening of the cervix can be done at any time.

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 ct
First Stage
• Closely monitor maternal ,fetal conditions as well as
progress of labour.
• Initially, contractions are absent for sometimes, so
encourage relaxation.
• As they commence gradually, discourage
overreaction to prevent premature bearing down.
• Offer free oral fluids and observe aseptic technique
with invasive procedure to prevent introduction of
micro-organisms.
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 ct
• For sudden onset of strong uterine contractions,
common in cytotec use, closely monitor FHS &
maternal pulse every ¼ hourly initially, for possibility
of fetal hypoxia and maternal distress respectively.
• Encourage regular bladder emptying to facilitate
descent.
• For synitocinon drip, always assess the uterine tone
( no. of contractions as well as their strength) before
increasing the drops.
• As membranes rupture note the colour of liquor for
signs of fetal [Link] meconium stained, grade
correctly and take appropriate action. 18
 ct
• Keep the DR informed of progress.
• Maintain a fluid balance chart because of the
synitocinon’s antidiuretic effect.
• Monitor maternal reaction to pain and
administer the most appropriate method of
relief.
• Keep her company, inform of the progress and
reassure as necessary.
• Maintain partograph, interpret correctly and
intervene promptly.
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 ct
Second Stage
• Occurs as usual, though if the stage becomes
prolonged, due to perhaps poor maternal
effort, instruments are used to aid delivery.
 Be ready to resuscitate the baby.
Third Stage
• Conducted normally, but closely monitor for
PPH and intervene. Therefore continue with
synitocinon drip for at least 1(one) hour.
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 ct
Fourth Stage
• Continues as usual, however, closely monitor
state of the uterus due to possibility of
relaxation hence PPH.
Puerperal care:- As in spontaneous delivery.
Complications
• Uterine rupture, associated with use of cytotec
when membranes are either ruptured or leaking,
leading to high mortality rate to both.
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 ct
• Tetanic and tumultuous contractions, which can
result in abruptio placenta.
• Severe birth injury due to rapid expulsion of the
baby.
• Hyperstimulation of the uterus , mostly due to
misuse of oxytocin, leading to fetal hypoxia.
• Water intoxication, in prolonged use of synitocinon
because of its slight antidiuretic effect.
• Amniotic fluid embolism, due to atonia of the
uterus , immediately after 2nd stage , hence
defective clotting mechanism.
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 ct
• Postpartum haemorrhage, following
prolonged use of synitocinon because of
uterine atony.
• Transient vasodilatation and hypotension
resulting from peripheral vasodilatation due to
fast administration of an intravenous bolus of
synitocinon.
• Cord prolapse following amniotomy in a high
head.
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 contd
• Puerperal sepsis, due to prolonged period of
ruptured membranes in absence of
prophylaxis or poor aseptic technique during
invasive procedures.
• Psychological trauma, perhaps due to
unsuccessful induction hence C/S, or due to
sudden onset of unbearable uterine
contractions. So develops poor outlook to
future deliveries.
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NB: Augmentation of labour refers to use of
artificial methods to strengthen uterine
contractions during the active phase.

END

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 REFERENCE MATERIALS
 Marshall, J.E. and Raynor, M.D. (2020) Myles Textbook
for Midwives. 17th ed. London: Elsevier.
 Bennet R and Brown L: Textbook for Midwives. Great Britain.
English language book; Publisher; 11th edition.
 Marshall, Jayne E., Raynor, Maureen D., Myles, Margaret
F.. (2014). Myles textbook for midwives (16th). Oxford ; Malden,
MA: Churchill Livingstone.
National guidelines for Quality obstetrics and
perinatal care