Induction of Labor

International

Induction of Labor

dr. Samodra Suparman, SpOG

 Induction of Labor

International

Objectives
• Definitions
• Indications and contraindications
• Pregnancy dating
• Comparison of methods
• Management considerations
 Induction of Labor

International

Induction

• initiation of uterine activity and cervical change

with fetal descent by pharmacological or other
means in a woman who is not in labor.
 Induction of Labor

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Cervical Ripening
• promotion of cervical change by
pharmacological or other means
• not primarily intended to induce labor but to
increase the success of subsequent induction
 Induction of Labor

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Contraindications to Induction

• Any contraindication to labor

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Indications for Induction

• when continuation of the pregnancy is a
greater risk to the mother or fetus than the
risk of induction and delivery
• must be convincing, compelling, fully
discussed and documented
 Induction of Labor

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Indications - Emergent
• severe gestational hypertension
• suspected acute fetal compromise
• severe IUGR
• significant maternal disease not
responding to treatment
• significant APH
• chorioamnionitis
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Indications - Urgent
• PROM at term or near term
• IUGR without evidence of acute
compromise
• poorly controlled diabetes mellitus
• isoimmune disease at term or near term
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Indications - Non-Urgent
• 'post-term' pregnancy
• well controlled diabetes mellitus
• intrauterine death in a prior pregnancy
• intrauterine fetal demise
• logistic problems (rapid labours, distance to
hospital)
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Indications - NOT

• elective induction
- induction, in the absence of maternal or fetal
indication, should not be undertaken
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Risks of Induction
• failure to achieve labour
• uterine hyperstimulation with fetal
compromise
• uterine hyperstimulation with uterine rupture
• increase risk of C/S
 Induction of Labor

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Labour Induction Methods

Likelihood of Successful Vaginal Delivery

MOST MOST
favourable multiparous previous vaginal
cervix delivery

unfavourable
cervix nulliparous previous C/S
LEAST LEAST
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• If attempted induction does not achieve

labor reevaluate the indication and method
of induction
 Induction of Labor

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Methods of induction include mechanical

and pharmacological means.

The best choice depends on the cervical

score (A cervix is unfavorable if the Bishop
score is < 6)
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Bishop Scoring System

Score
Factor 0 1 2 3

Dilatation (cm) 0 1-2 3-4 >5

Effacement (%) 0 - 30 40 - 50 60 - 70 > 80

Consistency Firm Medium Soft

Position Posterior Mid Anterior

Sp -3 or Sp +1 or
Station Sp -2 Sp -1 or 0
above lower
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Effect of Cervical Status on C/S Rate

50 Nulliparous Parous
Cesarean Section (%)

40 34

30 23
20
20 13 12
6
10

0
0-3 >3 Spontaneous Labour
Cervical dilatation at induction
Xenakis Obstet Gynecol (1997) 90: 235
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Labour Induction - Unfavourable Cervix

• Stripping of membranes
• Cervical ripening followed by oxytocin
• laminaria / artificial tents
• Foley catheter
• prostaglandins
• Prostaglandins (intracervical or vaginal)
• Amniotomy or oxytocin
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Mechanical Methods catheters and tents

• cause cervical softening and effacement
- this may facilitate an early amniotomy
- these methods are effective by producing local
prostaglandin along with direct dilatation
• less hypertonus and FH rate abnormalities than
with pharmacologic agent
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Prostaglandin Preparations

Vaginal preparations are:

- easier to administer
- easier to remove
- less likely to be placed extra-amniotically
- less likely to cause patient discomfort
 Induction of Labor

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Prostaglandin E2
• myometrial contraction
• cervix
- causes collagen breakdown and proteoglycan
deposition
• vasodilator
• bronchodilator
• GI motility and secretory effects
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Prostaglandin E2 - Route and Dose

• intracervical (Prepidil )
- prostaglandin E2 0.5 mg into cervical canal
• vaginal (Prostin E2 vaginal gel )
- prostaglandin E2 1 or 2 mg into posterior fornix
• vaginal (Cervidil vaginal insert)
- prostaglandin E2 10 mg into posterior fornix
• any formulation may be used for cervical ripening
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Guidelines for PGE2 Use

• insertion in hospital by experienced caregiver

• monitor appropriately for FHR and uterine
activity
• if labour develops manage as appropriate
• if no labour, reassess, repeat as necessary or
choose an alternative induction method
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Prostaglandin E2 - Advantages
• improved patient acceptance
• lower operative delivery rate
• less need for oxytocin induction
• may be used in PROM
• cost considerations
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Prostaglandin E2 - Disadvantages
• adverse reactions
- hyperstimulation
- CVS events
- nausea, vomiting, diarrhea
• gel preparations are difficult to remove
• cost considerations
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Precautions with Prostaglandins

• avoid placing PG’s adjacent to myometrium
• use cautiously in patients with previous C/S
• do not repeat more frequently than every 6 hours
• wait 6 hours prior to oxytocin infusion following
gels
- may be started 30 minutes after Cervidil
removal
• do not use for augmentation
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Labour Induction - Favourable Cervix

 Stripping of membranes
 Amniotomy

 Oxytocin

 Vaginal prostaglandins
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Amniotomy
• creates commitment to delivery
• effective with favourable cervix
• often used in conjunction with oxytocin
• caution in cases of high presenting part
( risk of cord prolapse)
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Oxytocin Effects
• myometrial contraction
• cervix - no direct effect
• vasoactive
- hypotension possible with bolus IV
administration
• antidiuretic activity
- water intoxication possible with high dose
oxytocin
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Oxytocin Guidelines

• cervix should be favourable

• experienced caregivers and access to caesarean
delivery
• auscultation or EFM depending on indication
• administration
- intravenous
- concentrations vary but avoid large free water
load
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Uterine Hypertonus
• discontinue oxytocin if in use
• intravenous bolus
• prepare for emergency delivery
• consider tocolytic agents
- ritodrine at 250 - 500 mg/min IV until desired effect
- nitroglycerin 50 mg IV push to maximum of 200 mg
- nitroglycerin spray sublingual
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Post partum consideration:

• if oxytocin was used in labor, PPH may occur

• for all induced patients , give oxytocin bolus post
partum ( oxytocin 10 units I.M. 20 units 1L at
100 cc/hr for 2 hours or more
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Conclusions
• reasons for induction must be compelling,
convincing and documented
• risk and benefits must be discussed with patient
• patient preference must be considered
• ripen the cervix as much as possible
• match the method with the urgency and cervical
status
- do not use oxytocin if cervix unfavourable
• don't overestimate your ability to succeed
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Goal of Induction
• avert anticipated adverse outcome associated with
continuation of pregnancy
• to effect uterine activity sufficient for cervical
change and fetal descent without causing uterine
hyperstimulation or fetal compromise
• to allow as natural a birthing experience as safely
possible and maximize maternal satisfaction

happy baby + happy mom + vaginal delivery

 Induction of Labor

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 Induction of Labor

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 Induction of Labor

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 Induction of Labor

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 Induction of Labor

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 Induction of Labor

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 Induction of Labor

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 Induction of Labor

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 Induction of Labor

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 Induction of Labor

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 Induction of Labor

International