Induction Of Labour

Sbusiso Chiliza
(2pm-3pm)
Outline
• Definition
• Advantages and risks
• Indications for induction
• Contra-indications for induction
• Modified Bishop score
• Methods of induction
• Complications
Induction of Labour
Induction of labour is the initiation of labour with the purpose of
effecting a vaginal delivery before spontaneous labour begins.
Advantages
• Prevention of serious maternal complications such as renal failure in
pre-eclampsia
• Prevention of intrauterine death e.g. in placental insufficiency, post
dates or diabetes mellitus
Risks
• Fetal immaturity with hyaline membrane disease, jaundice, etc.
• Prolonged labour with its complications
• More instrumental deliveries
• More caesarean sections, mainly due to failed induction
• Uterine rupture, particularly in multigravidae
• Complications due to the method of induction used
Indications
• Maternal indications
• Fetal indications
Maternal indications
• Hypertension, pre-eclampsia
• Pre-term rupture of membranes
• Premature rupture of membranes after 34 weeks
• Chorio-amnionitis
• Maternal medical problems exacerbated by pregnancy, such as DM
• Logistic factors(distance from hospital)
Fetal indications
• Suspected fetal jeopardy(severe growth restriction, iso-immunization)
• Postdate pregnancy
• Fetal demise
Contraindications for induction of
labour
• Previous caesarean section or myomectomy
• Previous uterine rupture
• Active genital herpes infection
• Obstetrical indication for C/Section
• Invasive cervical cancer
• Fetal distress on CTG
Cervical ripening
• Onset of labour-there must be cervical and myometrial changes. Prior
to labour, the cervix becomes shortens(effacement) and the
endocervical canal widens (dilation). These changes are collectively
known as the ripening of the cervix.
• A ripe cervix facilitates labour and influences the prospects of a
successful vaginal delivery.
• Bishop’s score – assesses the cervical status clinically
Modified Bishop score
• The modified Bishop score is used to clinically assess the Cervical
status
• The cervical status is the determinant of ease of induction
• A score of 9 or more indicates a mature cervix and the chances of
successful vaginal delivery following induction are then similar to
those of a patient going into spontaneous labour.
• A score of 7 or 8 indicates that induction will probably be successful.
Induction
• If the maternal or fetal risks of continuing pregnancy are considered
to outweigh the risks of delivery , the pregnancy should be
interrupted
• If there are no contraindications to induction and vaginal route of
induction is preferred, then labour will have to be induced.
• A decision of the most appropriate method of induction will have to
be made
Prior to induction
• A thorough assessment of the mother and the fetus
• Maternal assessment must include medical and obstetric history and
examination and assessment of the cervix
• Counsel the mother regarding HIV testing since this will influence the
method of induction
• The indications for induction and the options available should be fully
discussed with the patient.
• Any method decided upon should be explained, as well as possible side
effects and complications.
• Neonatal facilities for managing premature babies must be available and the
neonatal unit’s staff alerted
• Required staff and facilities must be available for adequate monitoring
and also for emergency c/section if induction fails.
• A CTG should be performed before and after administration of the
induction agent
Methods of induction of labour
• Pharmacological medication
 Prostaglandins, either dinoprostone(E2) or Misoprostol(E1)
 Oxytocin

• Surgical Induction
 Artificial rupture of membranes(Amniotomy)

• Mechanical Induction
 Intrauterine catheter
 Membrane stripping(stretch and sweep)
 Hydroscopic Dilators
• Modified Bishop score of 9 and more:
Prostaglandins
Oxytocin(if spontaneous contraction occur)
Artificial rupture of membranes
Prostaglandins
• Misoprostol is a prostaglandin E1 analogue(cytotec, Pfizer).
• It can be given as an oral dose of 200ug diluted in 200ml of water.
• The dosage is 20ml every 2 hours for 12 doses.
• Misoprostol can also be given as a low-dose vaginal tablet. The
dosage if given vaginally is 25ug every 6 hours.
• Current evidence supports the oral route as the best one
• If the patient experiences any contractions, the next dose should be
omitted
• Patients should give informed consent
Oxytocin
• Administered once spontaneous contractions occur
• Administered 6 hours after the last dose of misoprostol
Modified Bishop score of less than 9
• Prostaglandin vaginal gel(Prandin E2, Pfizer) 1mg can be inserted in
the posterior fornix of the vagina. The patient should be re-evaluated
6 hours later. If minimal cervical changes have occurred and there are
no uterine contractions, a 2mg dose may be administered.
• Prostaglandin gel(Prepidil Gel, Pfizer) 0,5mg is inserted intracervically
under direct vision. The cervix should be re-evaluated 6 hours later. If
the cervix is unchanged, the dose may be repeated.
Modified Bishop score of less than 6
• Administration of prostaglandin E2 with a dinoprostone containing
vaginal inserts, Propess(ferring).
• Contains 10mg dinoprostone and is left intravaginally for 12 hours and
constantly releases 0,3-0,4mg of dinoprostone per hour.
• Once contractions have started or hyperstimulation has occurred, it
can be removed.
Amniotomy
• Artificial rupture of the membranes where the cervix is ripe.
• Allows easy access to the membranes and increases the probability of successful membrane rupture
• Should be reserved for HIV negative patients as there to be a correlation between the duration of
membrane rupture and vertical viral transmission
• Under sterile conditions a vaginal examination is performed
• Cervical maturity confirmed and cord presentation excluded.
• An Amnihook(EMS medical group) or a pair of Kocher’s forceps is passed through the cervical canal
with digital guidance.
• The forewaters are then snagged, allowing amniotic fluid to drain.
• The color and volume of the amniotic fluid should be noted.
• Once procedure is completed, cord prolapse should be excluded. Fetal wellbeing should be
monitored. Oxytocin may be administered if spontaneous contractions do not occur within an hour
of amniotomy.
Mechanical methods
• Membrane stripping
• A finger is inserted through the cervix and moved in a circular motion between the
membrane and lower segment of the uterus.

• It is not considered a true form of induction as it take days rather than hours
• Foley’s catheter
• Under direct vision, the cervix is cleaned and then the tip of the large-bulb (25-50ml)
Foley’s catheter is passed into the endocervical canal.

• Once the bulb of the catheter is in the endocervical canal, it is inflated with sterile saline.

• The inflated bulb stretches the cervix,causing endogenous prostaglandin release.

• Cervical ripening usually occurs about 8-12 period.

Cont.….
Mechanical Hydroscopic dilators
 More acceptable alternative method to stimulate endogenous
prostaglandin release
 When inserted in the cervix, extract water from cervix. This causes
the dilator to swell and apply dilatory force to the cervix, thus
stimulating endogenous prostaglandin release.
Complications
• Prostaglandins ■ Amniotomy
• Uterine hyperstimulation;
• Fetal distress – Maternal trauma,
• Uterine rupture – Fetal trauma
• Hypotension
– Cord prolapse
Contraindicated – asthma, hepatic and renal failure – Prolonged ROM
Oxytocin – Ascending infection
(chorioamnionitis)
 Uterine hyperstimulation;
– Increased mother-to-child
Foetal distress transmission of HIV with
 Antidiuretic effect that may increased duration of
lead to water intoxication membrane rupture
 Uterine rupture – Postpartum hemorrhage
 Abruptio placentae