Labour is the onset of regluar uterine contractions that last at least 30 sec, occuring

every 10 mins, and should last at least 60mins, acccompanied by dilatation and
efffacement of the cervix and descent of the presenting part.
 Artificial stimulation of uterine contractions before
spontaneous onset of labour with the purpose of accomplishing
successful vaginal delivery.

Stimulation of spontaneous contractions that are considered

inadequate because of failed cervical dilation and fetal descent.
 Obstetrician must be convinced that time of delivery is optimal
and further in utero existence places fetus in jeopardy, to the
extent that if induction of labour fails, a Caesarean section will be
performed
 Prolonged Fetal compromise
pregnancy(>42weeks) Fetal growth restriction
Hypertensive disorders Isoimmunization
Pre-eclampsia/eclampsia Non-reassuring

Maternal medical conditions antepartum fetal testing

Oligohydramnios
Diabetes mellitus
Renal disease Fetal demise
Chronic pulmonary disease
Heart disease

PROM & PPROM

Chorioamnionitis
 Hypertensive disorders
Chronic hypertension
Maternal medical condition
Systemic Lupus
Erythematosus
Gestational diabetes
Hypercoagulable disorders
Cholestasis of pregnancy
Fetal anomalies requiring
specialized neonatal care
Previous still birth
Post term pregnancy
(>41weeks)

Polyhydramnios
Placental abruption
 Prior classical uterine incision
or transfundal uterine surgery Cervical carcinoma
Previous 2 LSCS Malpresentation (breech)
Active genital herpes infection Grand multiparity
Placenta or vasa praevia Unengaged head
Umbilical cord prolapse Maternal cardiac disease
Transverse or oblique fetal lie
Absolute cephalopelvic
disproportion (as in women
with pelvic deformities)
Hypersensitivity to inducing
agents
 Failure leading to Cesarean section Fetal distress .
Uterine hyperstimulation Fetal death
Rupture uterus Neonatal sepsis
Intrauterine infection, Iatrogenic delivery of a preterm
Chorioamnionitis infant
Amniotic Fluid Embolism Cord prolapse
Precipitate labor , Dysfunctional Neonatal jaundice
labor Increased risk of birth trauma
Increased risk of operative vaginal
delivery
Increased risk of PPH
Abruptio Placentae
Fluid overload
 Confirm indication for induction
Get written informed consent
Review contraindications to
labor and/or vaginal delivery
Perform clinical pelvimetry to
assess pelvic shape and
adequacy of bony pelvis
Assess cervical condition (assign
Bishop score)
Review risks, benefits and
alternatives of induction of labor
with patient
**Availability of trained personnel and adequate facilities.
Confirm gestational age
Assess need to document fetal
lung maturity status
Estimate fetal weight (either by
clinical or ultrasound
examination)
Determine fetal presentation
and lie
Confirm fetal well-being (NST)
 Vaginal examination
Cervical status
Presentation of fetus
Pelvis adequacy
Bishop Scoring System
Determines if the cervix is unprepared and requires a priming
agent
Success of induction is directly proportional to cervical score
Score =/> 9 is favourable

Score </= 5 has significant failure rate

 Dilatation
measure of the diameter of the stretched cervix; complements
effacement; important indicator of progression through the 1st
stage of labour
Effacement
measure of stretch already present in the cervix
Station
Position of the fetus' head in relation to the distance from the
ischial spines, which can be palpated deep inside the posterior
vagina (approximately 810 cm) as a bony protrusion. Negative
numbers indicate that the head is further inside, above the
ischial spines
 Consistency
Primigravid cervix is tougher and resistant to stretching,
much like a balloon that has not been previously inflated
Young women cervix is more resilient
Subsequent vaginal deliveries cervix less rigid and allows for
easier dilation at term
Position of Cervix
Varies between individual women.
Whether anterior, posterior or mid
Anatomical location of the vagina = downward facing, anterior
and posterior locations relatively describe the upper and lower
borders of the vagina.
Anterior position is better aligned with the uterus, and
therefore there is an increased likelihood of spontaneous
delivery.
 Breast/nipple Balloon catheters
stimulation
Lamineria tents
Sexual intercourse
Membrane stripping Hygroscopic
Amniotomy dilators
Acupuncture/acupress
ure

Natural Mechanical

Nonhormonal Hormonal

Herbs, evening Oxytocin

primrose oil Prostaglandins
Homeopathic prep PGE2,Misoprostol
Enemas Relaxin
Nitric oxide donors
Castor oil
Mifepristone


Performed by inserting the examining finger through the internal

cervical os and moving it in a circular direction to detach the inferior
pole of the membranes from the lower uterine segment.
Risks of this technique include
Infection
Bleeding
Accidental rupture of the membranes,
Patient discomfort.
Results in
Less labor inductions
Less post dated pregnancies
Greater spontaneous onset of labor
Inexpensive, safe, efficacious in promoting labor over several days


Technique: Membranes separated from foetal head by examiners

fingers. Hook then inserted through cervical os by sliding it along hand
and fingers (hook toward hand). Membranes hooked to rupture
Risks associated with this procedure include
umbilical cord prolapse (if presenting part still high) or compression
maternal or neonatal infection
FHR deceleration
bleeding from placenta praevia or low-lying placenta
possible fetal injury.
Vaginal, cervical laceration
Rupture of Vasa Praevia
Contraindications
HIV +ve
Active HSV
 Transcervical 36 Fr Foley Catheter
or Commercially available cervical
ripening balloon (Atad Ripener
Device)
Inserted into potential space b/w
lower uterine segment and
amniotic membrane. Balloon
inflated with 30-50 ml saline, and
retracted so that the uterine
balloon is at the internal os and
the cervicovaginal balloon is at the
external os.
+/- add weight to catheter,
tug on catheter 4x/hr
+/- saline infusion into
catheter

Laminaria japonicum
Laminaria digitata
Isapgol

Lamicel
Dilapan

MOA: They absorb endocervical and local tissue fluids, causing

the device to expand within the endocervix and provide
mechanical pressure leading to mechanical dilation and release
of prostaglandins.
 Cheap Skill needed for proper
placement in internal os.
Outpatient placement Delay in obtaining maximum
Easy for placement
effect.
Patient discomfort.
No need for fetal
Inability of tents to be molded
monitoring without compromising
mechanical integrity.
Rapid improvement of
Potential for incomplete
sterility. ETO gas does not
eradicate spores in the
interstices of the sea weed
stem
 Prostaglandins
PGE2 : Dinoprostone
PGE1 : Misoprostol
Oxytocin
Others
Estrogen
Relaxin
Hyaluronic acid
Progesterone receptor antagonist
 The chemical precursor is arachidonic acid
PGs are endogenous compounds found in the myometrium,
deciduas, and fetal membranes during pregnancy.
Cervical production of PGE2, PGI2, PGF increases at term.
MOA: Act on the cervix to enable ripening by a number of
different mechanisms.
They alter the extracellular ground substance of the cervix, and
PG increases the activity of collagenase in the cervix.
They cause an increase in elastase, glycosaminoglycan,
dermatan sulfate, and hyaluronic acid levels in the cervix. A
relaxation of cervical smooth muscle facilitates dilation.
PGs allow for an increase in intracellular calcium levels,
causing contraction of myometrial muscle.
 Prostaglandins administration results in dissolution of
collagen bundles and an increase in submucosal water
content of the cervix.
These changes in cervical connective tissue at term are similar
to those observed in early labor.

Prostaglandin Preparations
PGE2: Dinoprostone PGE1: Misoprostol
Vaginal gel: Prepidil, CerviprimeTM MisoprostTM

Removable tampon: CervidilTM CytotecTM

Vaginal pessary: Prostin E2TM
 CERVIPRIME GEL PREPIDIL
is commonly used for cervical
ripening.
is available in a 2.5-mL syringe
for an intracervical
application of 0.5 mg of
dinoprostone.
 Vaginal insert containing 10 mg
of dinoprostone in a timed-
release formulation. The vaginal
insert administers the
medication at 0.3 mg/h and may
be left in place for up to 12
hours.

ADVANTAGE: the insert may be

removed with the onset of active
labor, rupture of membranes, or
with the development of uterine
hyperstimulation.

More common with intra vaginal application.
1-5%, similar to low dose oxytocin <=4mu/ml.
Begins within 1 hr
Irrigation of Cervix, vagina : not helpful
Rapidly reversed with terbutaline or removal of
insert.
Hence fetal heart rate monitoring is needed for 2
hours following single dose and longer if
contractions persist after that.
 Defined as contraction frequency being more than five in
10 minutes or contractions exceeding 2 minutes in
duration.
 A synthetic PG E1 analogue which has been used as a gastric
cytoprotective agent since 1988 for patients of peptic ulcer.

Studies in late 1980s and early 1990s noted that oral

administration of this drug causes uterine contractions in early
pregnancy.

Subsequent studies showed that intravaginal misoprostol causes

first and second trimester abortion and there has been recent
evidence of its use for cervical ripening and labor induction.
 Cheap drug
Does not require storage conditions
Can be given by oral, buccal or vaginal routes although
vaginal route is the most extensively used
Tablets are available as either 100 mcg or 200 mcg
Dosage: 25 - 50 mcg is administered 4-6 hourly
The tablet is inserted into the posterior vaginal fornix ,
one may or may not wet the tablet with saline prior to
insertion
 25mcg should be the initial dose for labor induction at term ,
should not be administered more frequent than 3-6 hours ,
oxytocin should not be administered < 4 hours after the last
misoprostol use and the drug should be avoided in patients with
previous cesarean delivery or major uterine surgery.

Use of higher dosage 50 mcg may be appropriate in some

situations and have a greater likelihood of vaginal delivery within
12 hours, such doses increase the risk of hyperstimulation and
rupture.
 A polypeptide hormone secreted from the posterior
pituitary gland
Acts as a potent uterotonic agent.
Most commonly used drug for induction and augmentation
of labor.
Routes of administration:
Any parenteral route, intravenous route being the most widely used.
It can be absorbed from the nasal or buccal mucosa,
When given orally it is rapidly inactivated by trypsin.
 Oxytocin infusion is set up following preparation of the cervix
and amniotomy.

This combination of methods markedly reduces the induction

delivery time interval.
The clinical response to syntocinon infusion depends upon the parity
of the patient and the period of gestation. The myometrium of
highly parous patients is more sensitive to oxytocin than in a
primigravida.

The closer the patient is to term the greater the response of the
uterus to an oxytocin infusion.

Thus in scenarios of high parity and increased gestation cervical

compliance and myometrium sensitivity are increased and a
cautious dose schedule should be employed, with the smallest
possible effective dose being utilized.
 Dose: 30iu in 500 ml of NS (1ml/hr) or 10iu in 500 ml of NS
(3ml/hr)
Commenced at 10 drops per minute and increased every 30 mins
by 10 drops per minute, until uterine contractions are occuring
every 3-4 minutes & each contractions lasting 45 -50 secs.

During the infusion it is important to monitor

a) the frequency and intensity of uterine contractions
b) the fetal heart rate
c) the maternal vital signs.
 Hyperstimulation , with or without fetal heart rate
changes
Failed induction with need for repeat induction or
possibly cesarean
Increased risk for uterine rupture in some studies
Hypotension if administered by IV bolus
Hyponatremia if administered with large amounts of
sodium poor fluids
Antidiuretic hormone like effect if administered at high
doses
Increased risk for neonatal hyperbilirubinemia
 It is defined when crervix failed to dilate up to 3-4 cm
in 24 hrs of induction.
What to do now ?
Option to wait-- if No PROM and postponement is not harmful
for fetus as well as mother.
Review the case and if there is urgency, Caesarean delivery is
performed.
 Premature Delivery this may occur if the estimated
date of conception has been inaccurately calculated
from the patients history of her last period. It is for this
reason that one must establish fetal pulmonary maturity
either by clinical, bio-physical or biochemical means.
Determining the L/S ratio in amniotic fluid is
recommended.
Physical injury from precipitous delivery
Cord prolapse post-amniotomy
Fetal demise in utero, fetal distress, or delivery of a
baby with poor APGAR scores - following injudicious
administration of oxytocin or inadequate observation.
 Chorioamnionitis bears direct relationship to duration of
ruptured membranes and frequency of vaginal
examinations