Induction of labour is defined as the elective

process of artificially initiating and

maintaining uterine contractions with cervical
effacement and dilatation resulting in the
delivery of the baby.This is a therapeutic
option when the benefits of expeditious
delivery outweigh the potential maternal and
foetal risks of continuing pregnancy
Induction
 it implies stimulation of contractions
before the spontaneous onset of labor,
with or without ruptured membranes.

Augmentation
 It refers to - intervention to correct slow
progress in labor.
 Correction of ineffective uterine
contraction includes Amniotomy and/or
Oxytocin infusion

3
MATERNAL FETAL

 Preeclampsia,eclampsia  IUD
 PROM  Fetal anomaly
 Postterm pregnancy
incompatible with life
 Abruptio placenta
 Chorioamnionitis
 Severe IUGR
 Medical conditions-  Rh isoimmunisation
DM,Heart ds, Renal  Macrosomia
ds,Chr. HT etc
 Prolonged pregnancy
 Oligohyrdamnios

4
 Contraindications to induction of labour centre
primarily on the risks of uterine hyperstimulation
vis a vis uterine integrity.
 Classical caesarean section
 Inverted T
 J incision
 Unknown Uterine Surgery
 Hysterotomy
 Myomectomy with entry into uterine
cavity/extensive dissection
 Previous uterine rupture
 More than one previous ceasarean section
 HIV positive mothers
 Suspected cephalo pelvic disproportion
 Cord presentation
 Severly compromised foetus
 Multiple pregnancy(triplets and above)
 Active herpes genitalis
 Foetal malpresentation
Establish indication clearly
Informed consent

Conformation of gestational age

Assessment of fetal size & presentation

Pelvic assessment

Cervical assessment (BISHOPs score)

Availability of trained personnel

7
Cervix favourability

- The most important determinant of

successful induction of labour is the
favourability of the uterine cervix.Cervical
assesment is made utilising the Modified
Bishop’s Score.If the score indicates that
the cervix is not favourable,cervical
ripening is required

8
 2 1 0 Characteristics
Anterior Axial Posterior 1.Position
0cm 1cm 2cm 2.Length
2cm 1cm <1 cm 3.Dilatation
Stretchable Soft Firm 4.Consistency
0 -1 -2 5.Station

A favourable cervix is defined as one with a modified

Bishop Score of > 6
 Until recently, the most common practice has been to
induce labor by the end of the 42nd week of
gestation. This practice is still very common.

 Recent studies have shown an increasing risk of

infant mortality for births in 41st and particularly 42nd
week of gestation, as well as a higher risk of injury to
the mother and child .

 The recomended date for induction of labor has

therefore been moved to the end of the 41 week of
gestation in many countries

10
Method of induction

11
 Most methods of inducing labour before the last half
century involved mechanical manipulations, including,
 Galvinism,
 repeated pressurised douches,
 extra-amniotic aqua picea,
 tents, bougies and catheters.

Among the more common approaches are

 frequent walking,
 vaginal intercourse,
 participating in heavy exercise,
 consumption of laxatives,
 spicy foods or herbal tea,
 nipple stimulation and administration of an enema

12
NATURAL
Breast/nipple stimulation CHEMICAL
Sexual intercourse
NONHORMONAL
Membrane stripping  Herbs,evening primrose oil
Acupuncture/acupressure  Homeopathic prep
 Enemas
 Castor oil

HORMONAL
MECHANICAL  Oxytocin
Balloon catheters  Prostaglandins –PGE2
Lamineria tents  Relaxin
Synthetic osmotic
dilators  Nitric oxide donors
 mifepristone
13
 Several effective methods of cervical
ripening and induction of labour are used
for initiating labour at or around term.
Currently, medical expert consensus
recommends the following:


◦ Sweeping the membranes

◦ Artificial rupture of membranes (ARM)

◦ Prostaglandin E2 (PGE2)

◦ Intravenous oxytocin (Pitocin)

◦ Foley’s catheter

14
 Use of the Foley catheter technique alone, in
which catheters are passed through an undilated
cervix before inflation, was shown to be as
effective as use of PGE2 gel.

 The successful use of extra-amniotic saline

infusion with a balloon catheter has also been
reported

15
16
 . The balloon portion of the Foley, used to
keep the bladder empty, is inserted into
the uterus feeling that the balloon is
between the amniotic sac and the lower
uterine segment (bottom of the uterus).

 The balloon is then inflated with saline

solution and left in place

17
 The goal of this induction is to cause the cervix
to mechanically open. Sometimes this will start
labor spontaneously and sometimes it will
simply make the cervix more favorable for a
Pitocin, other drug induction or amniotomy

 You may have to have baby's heart rate

monitored before, during and just after the
procedure to see if the baby tolerated this
process, but this is very unlikely to cause fetal
distress because it does not use drugs.

 To review after 24hours or when ballon falls or

when patient has contraction 3:10 moderate

18
Stripping of the membranes causes an increase in the activity of
phospholipase and prostaglandin as well as causing mechanical
dilation of the cervix, which releases prostaglandins.

 performed by inserting the index finger as far through the

internal os as possible and rotating twice through 360 degrees
to separate themembranes from the lower segment

Risks of this technique include infection, bleeding, accidental

rupture of the membranes, and patient discomfort.

19
The reviewers concluded that stripping of
the membranes alone does not seem to
produce clinically important benefits,
but when used as an adjunct does seem to be
associated with a lower mean dose of
oxytocin needed and an increased rate of
normal vaginal deliveries.

20
Cervical dilator is a HYDROPHILIC polymer rod used for dilation and
ripening of the cervix. When inserted into the cervical canal, these sterile
rods act in two ways

Draws fluid from the cervical tissue into the rod causing-
expansion of the rod which produces an outward radial force
Initiates endogenous prostaglandin release causing collagen -
degradation which softens the cervix
Made from a synthetic polymer so there is no drug side effects -
extremely resistant to breakage - elastic characteristic allow for safe
.removal even when entrapped
Use of hygroscopic dilators are reported to be associated with-
increased peripartum infections

21
M/A :
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.

 prostaglandins allow for an increase in intracellular calcium

levels, causing contraction of myometrial muscle..

22
Contraindications

 Known hypersensitivity to dinoprostone gel,

Prostin E2 vaginal tablets or its constituents
(triacetin, colloidal silica or urethane)

 History of previous uterine surgery including

caesarean section

 Ruptured membranes

23
 Intravaginal mode of administration

Dinoprostone gel dosage

 The initial dose for dinoprostone (PGE2) gel is 2 mg

per vaginam (PV) in nulliparous women with an
unfavourable cervix , 1 mg PV for multiparous
women and 1 mg PV in cases of suspected fetal
compromise (intra uterine growth restriction)
 A second dose of 1-2 mg of dinoprostone (PGE2)
gel may be administered 6 hours later
 The maximum dose in a 12 hour period is 4 mg
PGE2 for nulliparous women with an unfavourable
cervix and 3 mg for all other women

24
Patient selection: Patient is afebrile.

No active vaginal bleeding is present.

Fetal heart rate tracing is reassuring.

Patient gives informed consent.

Bishop score is < 4.

25
 Complete 20 minutes CTG tracing that fulfils the
hospital’s accepted criteria

 Ensure the woman has emptied her bladder

 Confirm maternal pulse, blood pressure, respiration rate

and uterine activity meet accepted criteria

 Abdominal palpation to confirm cephalic presentation

 Vaginal examination to obtain a modified Bishop score

26
 Insert dinoprostone (PGE2) gel into the
posterior fornix of vagina .

 Advise the woman to remain recumbent in

30˚ left lateral tilt for at least thirty
minutes (allows prostaglandin absorption)
before sitting up or walking around

27
Dosage and procedure:

 CTG -before induction,1 hour after

induction
 Fetal heart monitoring – ¼ hourly, ½ hourly

for 2hours, and hourly for 4hours

 Contraction monitoring
 Review vaginal examination by MO in 6hrs

28
 One tablet (3 mg) to be inserted high into the
posteriorfornix. A second tablet may be inserted after six to
eight hours if labour is not established. Maximum dose 6
mg/24hrs

 Not more than 2 prostin per day unless decided by specialist

 If patient failed to progress after 3rd prostin,specialist

to make further decision

 Usually patient is allowed a day rest before 4th prostin

29
  

30
 After the maximum dose has been
administered, if the cervix is favourable,
induction can be undertaken immediately with
amniotomy

  Pitocin augmentation may be commenced 6

hours after the last dose of PGE2 gels has
elapsed to avoid uterine hyperstimulation

 Admission to the labour / delivery suite should

occur before amniotomy or Pitocin
augmentation is commenced
31
 Inform the woman to notify the midwife
should uterine contractions become
regular and / or painful, or if the woman
has any vaginal loss

 Ensure there is a documented plan for

ongoing management in the woman’s case
notes

 If not in labour within 12 hours of the first

dose of dinoprostone (PGE2) gel or
Prostaglandin E2 vaginal tablet, review IOL
management

32
 The risk of hyperstimulation was reduced
when compared with prostaglandins
(intracervical, intravaginal ). Compared to
oxytocin in women with unfavourable cervix,
mechanical methods reduce the risk of
caesarean section

33
 ARM is a surgical procedure to induce or
augment labour

 Amniotomy for induction

:used to induce labor but, it implies a firm
commitment to delivery

:disadvantage
-the unpredictable and occasionally long
interval to delivery

34
Cord prolapse
To reduce the likelihood of cord prolapse, which may occur at
the time of amniotomy, the following precautions should be
taken:

• Before induction, engagement of the presenting part should

be assessed.

• We should palpate for umbilical cord presentation during

the preliminary vaginal examination and avoid dislodging the
baby’s head.

• Amniotomy should be avoided if the baby’s head is high.

We should always check that there are no signs of a low-lying
placental site before membrane sweeping and before
induction of labour.
35
 Indications
 Pitocin is a synthetic oxytocin and the most common induction
agent in use
 It may be used:
◦ Alone
◦ In combination with amniotomy
◦ After cervical ripening with other pharmacological or non
pharmacological methods
 Induction of labour using a combination of amniotomy and
intravenous Pitocin is the preferred method of induction for
women who have a favourable cervix
 When compared to dinoprostone (PGE2) gel, induction with
Pitocin® results in a lower rate of some infective sequelae e.g.
chorioamnionitis in women who have ruptured membranes 

36
Primigravida

unit of pitocin in 500mls Dextrose saline and 2-

.start at 15dpm,increase every 30,45 and 60dpm

May increase to 4unit and 8unit if good-

.contraction failed to achieve

Good contraction is 4-5 contraction in-

10minutes lasting 45 seconds

37
Para 2-4

units of Pitocin in 100mls normal saline 1,2,4

Start at 9mls/H then increase to 18mls/H, 27mls/H to
maximum of 36mls/H

Para 5 & above

units in 100mls Normal saline 2 ,1, ½

Start at 9mls/H then increase to 18mls/H, 27mls/H to
maximum of 36mls/H

38
 Rational Interventions
to reduce anxiety-1 .Explain procedure-1
To establish baseline-2 2-Apply fetal monitor
.and ensure fetal activity and monitor FHR.
To minimizes the risk-3 Start an-3
.of water intoxication electrolytes
solution I.V infusion
(primary line)

39
 Rational Interventions

Oxytocin must be-4 Add the prescribed amount of.4

administered with an oxytocin
infusion pump to ensure
accurate dose
.administration

40
 Rational
If uterus become-6
hyperstimulated, blood flow to
uteroplacental site will be
decreased and fetus will suffer
.from hypoxia
Sensitivity to oxytocin-7
.increases as labor progresses
These results indicate that the
pattern of normal labor has
.been established
Interventions
Monitor FHR, uterine contraction-5
(frequency, duration, and intensity),
BP,and Pulse and record at intervals
comparable to the dosage regimen. All
observation and increases or decreases
in oxytocin are documented on the
.fetal heart tracing and mother chart
Once the desired frequency of -6
contractions has been reached (every 2
to 3 minutes and 45 to 60 second's
duration. oxytocin may be stop or
.reduced the increases of the rate
41
 Contraction occur more frequently than every 2 minutes.

 Duration of contraction is longer than 90 seconds.

 Elevation of resting tone of uterus is greater than 15 to 20

mmHg over her baseline of intrauterine pressure.

 Blood pressure increases when contractions increase in

frequency, duration, and intensity because of decrease in
uteroplacental circulation.

 Client experience increasing pain because of increased

frequency, duration, and intensity of contractions.

 Sustained tetanic contractions occur.

42
 Tachycardia or bradycardia.
 Late decelerations, variable

decelerations, or prolonged deceleration.

 Loss of variability.
 Increased fetal activity.
 Excessive molding or caput-

succedaneum formation.
 Meconium stained amniotic fluid in

cephalic presentation.

43
 Rational Interventions

To prevent fetal anoxia-1 1-Turn off immediately

.and uterine rupture oxytocin infusion

To improve fetal--2 Turn woman on her left-2

.placental blood flow .side

To provide adequate-3 Increase primary I.V-3

intravascular volume, rate up to 200 ml/hr unless
support maternal BP, and .contraindicated
I.V route for emergency
.medications
44
 Rational Interventions

4-To saturate the blood with oxygen 4-Give oxygen 6 to 10

as much as possible to prevent fetal l/min ( per protocol) by
anoxia. face mask.

5-This indicate induction failed. 5-Notify experience doctor

If membrane intact discontinue
induction and try again later. If
membrane ruptured cesarean
birth may be necessary.

45
 In addition to hyper-stimulation of uterus and fetal
distress those complications may occur:

 Ruptured uterus as a result of over-stimulation if any

cephalopelvic disproportion present.
 Amniotic fluid embolism is rare which may caused by
strong, tumultuous contractions. (usually occur in 3rd
stage after placenta separation and with tetanic
condition of uterus)

46
Antiprogestins
 Epostane, the 3ß-hydroxy dehydrogenase
inhibitor, and subsequently mifepristone,
the progesterone receptor blocker, were
shown to have a dramatic effect upon
reducing induction to abortion intervals
during second trimester therapeutic
abortion.A more recent large study involving
mifepristone 200 mg produced very similar
conclusions but unfortunately women of
mixed parity were studied and conclusions
must be guarded

47
 Dehydroepiandrosterone sulphate

Intravenous dehydroepiandrosterone sulphate

(DHEAS), which is transformed into oestrogens
in the fetoplacental unit, has been explored as a
possible cervical ripening agent, achieving
effacement without inducing uterine
contractions.

 Relaxin

This polypeptide has been studied in humans,

using purified porcine relaxin 1–4 mg in viscous
gel vaginally or endocervically. It was hoped
that it would have the same properties as
exhibited in certain animal species. To date,
there have been no well-conducted trials to
determine its value for ripening the
unfavourable cervix

48
 Nitric oxide
There have been a number of studies
suggesting that nitric oxide is involved in
the process of cervical ripening during the
latter stages of pregnancy

49
Breast stimulation
 It has been suggested as an effective inexpensive non-
medical means of inducing labour. A Cochrane Database
review of six randomised controlled trials involving 719
women reported a significant reduction in the number of
women with a favourable cervix not in labour 72 h
following the start of nipple stimulation compared with
no intervention. There was, however, no reduction in the
need for delivery by caesarean section

Sexual intercourse
 during the latter weeks of pregnancy has been suggested
as a logical strategy to encourage labour since semen is
presumed to contain the highest prostaglandin
concentration of any body fluid.

50
Failure leading to CS

Uterine hyperstimulation

Fetal distress,death

Rupture uterus

Intrauterine infection,sepsis

51
 Iatrogenic delivery of preterm infant

 Precipitate/dysfunctional labour

 Inc. risk of operative vaginal delivery

 Inc. risk of birth trauma

 Inc. risk of PPH

52
Failed induction

Failed induction is defined as labour not starting after

one cycle of treatment

If induction fails, healthcare professionals should

discuss this with the woman and provide support.

The woman’s condition and the pregnancy in general

should be fully reassessed, and fetal
wellbeing should be assessed using electronic fetal
monitoring.

53
If induction fails,the subsequent management options
:include

a further attempt to induce labour (the timing should •

depend on the clinical situation and the woman’s wishes)

caesarean section •

54
 Induced labour tends to be more intense and
painful for the woman, often leading to the
increased use of analgesics and other pain-
relieving pharmaceuticals (Vernon, 2005).

 This cascade of intervention has been said to

lead to an increased likelihood of caesarean
section delivery for the baby. (Roberts 2000).

55
 Guidelines on management of induction of
labour-Kementerian Kesihatan Malaysia
 Obst & Gynecology Guidelines and

protocols-HOS SHAS
 Obst by Ten Teachers- Philip N Baker
 Mayo clinic ref.
 Various internet web sites

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