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Labor Augmentation John P. Horton MD Wendy F. Hansen MD James E. Ferguson II MD Basics Description Induction re ers to any inter!

!ention used to initiate "abor in a non"aboring patient. Augmentation re ers to any inter!ention used to intensi y e#isting "abor.

$er!ica" ripening re ers to any inter!ention used to prepare the cer!i# or induction o "abor.

Indications %are abso"ute indications or induction $onsider &A' as (e"" as materna" and eta" conditions.

Indications may inc"ude)

o o o o o o o o

Preec"ampsia*Ec"ampsia Postdates +,-./-0 (ee1s2 P%3M $horioamnionitis I4&% 5onreassuring eta" testing Abruptio p"acentae Feta" demise

Induction is not indicated or materna" desire or "i esty"e. $ontraindications)

o o o

P"acenta pre!ia 6asa pre!ia Pe"!ic obstruction

7ite +3 ice' 7urgica" $enter' 3%2 With e( e#ceptions' inductions shou"d ta1e p"ace as an inpatient procedure (ith proper monitoring. $oncurrent Procedures Feta" monitoring) o E#terna" Dopp"er

Interna" F7E

4terine monitoring)
o o

E#terna" tocometer I4P$

o o o

Loca" Intra!enous Epidura"*7pina"

Epidemio"ogy Induction o "abor occurred in 08.9: o cases in the 47 in 0888. %ates !ary according to patient popu"ation and hospita" setting. ;reatment Procedure In ormed $onsent Patients must understand a"" indications' ris1s' bene its' and a"ternati!e procedures prior to initiating induction o "abor. Patient Education $"inicians shou"d pro!ide in ormation regarding) Mode*Method o induction E#pected hospita" course*stay

Postpartum care

%is1s' Bene its %is1s) o Fai"ed induction (ith need or surgica" inter!ention
o o o o o o

B"eeding In ection Anesthesia 4terine rupture 4terine hyperstimu"ation Feta" into"erance to "abor

Bene its)

7hortened inter!a" to de"i!ery !ersus a(aiting spontaneous "abor

A"ternati!es A(ait spontaneous "abor in the ace o prescribed indications $onsider c"ose eta" sur!ei""ance

Medica" 3#ytocic agents) o Pitocin +synthetic o#ytocin2 I6


8.</-8 mu*min' titrated to increasing dose at .</=8 minute inter!a"s

P&E. agents)
o o o o

$ontraindicated in patients (ith pre!ious cesarean section $ytotec +misoprosto"2) ;ab"et +ora"' bucca"' !agina"2 0< >g ?=/-h' at term ,<8 >g dosing associated (ith uterine hyperstimu"ation


P&E0 agents) o $ontraindicated in patients (ith pre!ious cesarean section

o o o o

Prepidi" +dinoprostone2) $er!ica" ge" 8.< mg intracer!ica" app"ication ?.0h $er!idi" +dinoprostone2) 6agina" insert .8Amg insert p"aced !agina""y ?.0h

7urgica" 3smotic di"ator +"aminaria2 Fo"ey bu"b

Amniotomy +A%3M2 Membrane s(eeping EA7I

Fo""o(up Intrapartum) o Fre?uent monitoring o materna" and eta" status and (e""Abeing


7ur!ei""ance or abnorma" b"eeding or in ection

Prognosis Assessment o cer!ica" status is the most important prognostic actor. ;he Bishop score is the most common cer!ica" assessment too" in the 47)

Bishop score +8/.=2)

$er!ica" di"ation +8/=2 $er!ica" e acement +8/=2 $er!ica" consistency +8/02 $er!ica" position +8/02 Feta" station +8/=2

Bishop score BC)

High "i1e"ihood or !agina" de"i!ery

Bishop score D<

E<8: ris1 o ai"ed induction

Mu"tiparity' eta" (eight F='<88 g' and a norma" materna" BMI are associated (ith impro!ed success rates.

$omp"ications 4terine hyperstimu"ation 4terine rupture

5onreassuring eta" status B"eeding $horioamnionitis 5eed or surgica" inter!ention Hyponatremia*Water into#ication (ith pro"onged o#ytocin in high doses

Bib"iography A$3& Practice Bu""etin 5o. .8. Washington D$) A$3&G .HHH. Bishop EH. Pe"!ic scoring or e"ecti!e induction. 3bstet &yneco". .H9-G0-)099. $rane JM. Factors predicting "abor induction success) A critica" ana"ysis. $"in 3bstet &yneco". 0889G-H)<@=. Martin JA. Births) Fina" data or 0880. 5ationa" $enter or Hea"th 7tatistics. 5at" 6ita" 7tat %ep. 088=G<0+.82)./..-. Misce""aneous $"inica" Pear"s I Assess eta" presentation) / 5on!erte# "ie may be considered a re"ati!e contraindication. I $ombining medica" induction agents shou"d be a!oided secondary to increased ris1 or hyperstimu"ation. I A "o( Bishop score may indicate need or cer!ica" ripening prior to initiating induction. I A "o( Bishop score a"so suggests a decreased o!era"" success rate. Abbre!iations

I EA7IJE#traAamniotic sa"ine in usion I &AJ&estationa" age I F7EJFeta" sca"p e"ectrode I I4&%JIntrauterine gro(th restriction I I4P$JIntrauterine pressure catheter I P&EJProstag"andin E I P%3MJPremature rupture o membranes Patient ;eaching I ;eaching shou"d center on e#p"anations*description o induction method. I Patients must understand a"" indications' ris1s' bene its' and a"ternati!e procedures prior to initiating induction o "abor) / E#pected hospita" course*stay / Postpartum care' inc"uding any perinea" care