M.M.

COLLEGE OF
NURSING
PEER TEACHING

ON

AUGMENTATION OF LABOUR
SUBMITTED TO: SUBMITTED BY:

DR. POONAM SHEORAN NADIYA RASHID

H.O.D & PROFESSOR MSC NURSING II YEAR
OBG DEPARTMENT 1918721
 INTRODUCTION
The culmination of normal pregnancy involves three stages:
prelabour, cervical ripening and labour.
•Endogenous prostaglandins play a part in all these processes.
•Interventions to artificially ripen the cervix, induce uterine contractions and augment labour
once it is in progress also lack distinct boundaries.
•Labour induction and augmentation may be a source of conflict and distress.
•For most health workers they are seen as routine, technical procedures.
For many women, they have emotive connotations, evoking a sense of personal
inadequacy and eroded self-esteem. It is important for health workers to approach the question of
labour induction with sensitivity, and to involve women in the decision-making process. Labour
induction is one of the most frequent medical procedures in pregnant women. It is a major
intervention in the normal course of pregnancy, with the potential to set in motion a cascade of
interventions, particularly Caesarean section.
However, with modern methods of labour induction, this risk appears to have diminished.

DEFINITION:
Induction of Labor (IOL) is defined as artificial stimulation of uterine contractions before the
onset of labor.
Augmentation refers to stimulation of spontaneous contractions that are considered inadequate
because of failed cervical dilation and fetal descent.

GOAL:
The goal of IOL is to eliminate the potential risks to the fetus with prolonged intra uterine
existence while minimizing the likelihood of operative delivery .

INCIDENCE:
The overall incidence of IOL has increased globally. In a survey by the National Center for
Health Statistics the rate of labor induction was noted to have increased from 90 per1,000 live
births in 1989 to 184 per 1,000 live births in 1997 .

Indications For induction:

•Hypertensive disorders of pregnancy ( pre-eclampsia, eclampsia,chronic hypertension)
•Diabetes, renal disease, chronic pulmonary disease
•Premature rupture of membranes
•Chorioamnionitis
•Fetal growth restriction
•Rh isoimmunization
•Postdated pregnancy
•Fetal demise
•Abruptio placentae
•Fetal malformations incompatible with life
•Logistic factors: Risk of rapid labor, distance from hospital, psychosocial indications

Contraindications to the induction of labor:

•Major degree of Placenta praevia
•Vasa praevia
•Previous classical uterine incision or incision because of metroplasty or extensive myomectomy
when the cavity is opened
•Cephalopelvic disproportion because of malpresentation or abnormal pelvic bone structure
•Active genital Herpes infection
•Invasive cervical carcinoma
•Hypersensitivity to cervical ripening agents Transverse lie

Conditions where IOL is not a true contraindication but where special caution is required:
•Multiple pregnancy
•Polyhydramnios
•Grand multiparity
•Maternal heart disease.
•Severe hypertension.
• Breech presentation
•One or more previous cesarean section
•Abnormal fetal heart rate not requiring emergencycesarean section

Risks of IOL:
Maternal Risks :
•Failure leading to Cesarean section
•Uterine hyperstimulation
•Rupture uterus
•Intrauterine infection, Chorioamnionitis
•Amniotic Fluid Embolism
•Precipitate labor , Dysfunctional labor
•Increased risk of operative vaginal delivery
•Increased risk of post partum hemorrhage
•Abruptio Placentae
•APH from undiagnosed placenta praevia
•Water intoxication

Fetal Risks :
•Fetal distress .
•Fetal death
•Neonatal sepsis
•Iatrogenic delivery of a preterm infant
•Cord prolapse
•Neonatal jaundice
•Increased risk of birth trauma

Pre- requisites for IOL:

•Evaluate the indication
•Explain the indication of induction to the patient along with details ofthe method to be used and
take a written informed consent
•Assess adequacy of the pelvis and fetal size
•Confirm the gestational age, fetal lie, and assess the fetal lung maturity where ever indicated
Uterine activity and fetal heart rate should be continuously monitored. In case of clinical
auscultation, FHR should be heard during and for 30seconds after a contraction at least every 15
minutes during the active phase of labor and after every contraction in the second stage.
Otherwise electronic fetal monitoring is preferable· Partograph is to be maintained for active
labour· Trained personnel and well equipped center

According to the ACOG Committee Opinion , if one of the following criteria are met then
fetal maturity may be assumed and amniocentesis need not be performed to confirm fetal
maturity:-

1. Fetal heart tones have been documented for 20 weeks by non electric fetoscope or for 30
weeks by Doppler
2. It has been 36 weeks since a positive serum or urine human chorionic gonadotropin
pregnancy test was performed by a reliable method-
3. An ultrasound measurement of the crown rump length, obtained at 6-11 weeks,supports a
gestational age of 39 weeks or more-
4. An ultrasound scan obtained at 12 to 20 weeks confirms the gestational age of 39 weeks or
more determined by clinical history and physical examination

Structures of the cervix and Physiology of cervical ripening :

The uterine cervix has broadly two components which are:
a) cellular portion and,
b) extracellular matrix
The distal portion has greater connective tissue as compared to the part close to the myometrium
which is richer in the cellular component.

a) cellular portion

The cellular component has: smooth muscle cells, fibroblasts, epithelium, and blood vessels.
Cervical stromal cells produce collagenases, elastases and metallo proteinaeses which are
involved in remodeling of the cervix. Fibroblasts also secrete cytokines like interleukin 1 beta
and interleukin -8

Extracellular matrix is composed of :

a) Collagen: collagen is in two forms Type I (70%) and type II (30%) and is arranged in the
form of a triple helix. In the non pregnant cervix these are arranged in a dense and irregular
fashion

b) Elastin: these fibres are arranged parallel to and between the collagen fibres and play an
important role in taking the pregnancy to term by keeping the os closed

c) Decorin: is a glycosaminoglycan and its relative proportion to collagen is important in the

remodeling of the cervix at labor
d) Hyaluronic acid: is the most important proteoglycan whichis responsible for the increased
water content of the cervix

Changes during pregnancy:

a. Collagen is reorganized and consolidated in early pregnancy with proliferation and
hyperplasia of the cellular component
b. Near the onset of labor, an overall decrease in the concentration of collagen occurs with
dispersion and remodeling into fine fibres ,making the cervix softer in consistency
c. Increases in decorin levels and physiologic cell death are in partresponsible for this
process.

d. Hyaluronic acid levels increase thereby increasing the watercontent of the cervix and
causes a loosening and dispersal of the fibres

e. Chemotactic response at term leads to an influx of neutrophils and an increased levels of

cyokines (interleukin 1 beta and interleukin –8 ) which in turn release collagenases and
elastases to allow effacement.

f. Mechanical forces of uterine contractions extend the elastin and allow dilatation

PRE INDUCTION CERVICAL ASSESSMENT:

It is known that success of labor induction is closely related toripeness of the cervix . Various
scores have been proposed to evaluate the cervical status.

a) Bishop’s Score : This was proposed by Bishop in 1964 and is the most widely used score.
It was originally proposed to determine the suitability of a patient for IOL in patients who
were parous, at term , had an uncomplicated pregnancy and the fetus was in cephalic
presentation.

. Bishop Score for Assessing Favor ability for Induction of labour .

Score
Factor 0 1 2 3
Dilatation (cm) 0 1-2 3-4 5-6
Effacement(%) 0-30 40-50 60-70 80
Station -3 -2 -1 or 0 +1 or +2
Consistency Firm Medium Soft -
Position Posterior Mid Anterior -

* A score of 9 or more ensured a safe and uniformly successful induction

* Induction with a score of 16 more is considered

Evaluating the performance of Bishops score, Lange et al . observed that cervical dilatation was
twice as important as the other factors and proposed a modification of the original score which
predicted successful induction equally well.
 Pelvic Score Proposed by Lange et al

Score Factor 0 1 2 3 Multiply by

Dilatation (cm)
0 1-2 3-4 >4 X2
Length (cm) 3 2 1 0 X1
Station(cm) -3 -2 -1 or 0 +1 or +2 X1

METHODS OF CERVICAL RIPENING AND LABORINDUCTION:

Cervical priming before labor induction in an unfavorable cervix increases the success rates and
shortens the induction to delivery interval. Methods for cervical ripening and labor induction can
be broadly classified as :
1. Pharmacological methods (Prostaglandins, Oxytocin& others)
2. Non pharmacological methods (Natural, Surgical ,Mechanical and others)

1. PHARMACOLOGICAL METHODSPROSTAGLANDINS :
PG E2 gel has been widely used for pre-induction cervical ripening. Local applications of
PGE2 causes cervical ripening by three mechanisms:

•Alteration of extracellular grounds substance of cervix by increasing collagenase , elastase,

glycos aminoglycans , dermatan sulfate, and hyaluronic acid levels
•Relaxation of smooth muscle of cervix
•Gap junction formation leading to initiation of uterine contractions

Preparations available, Dosage and Usage Guidelines :

I. Intracervical PGE2 gel: ( Cervigel , Dinoripe , Prepidil )
•Contains 0.5 mg of PGE2
•Bring the gel to room temperature before use and instill in the cervical canal below the
internal os
•The patient lies supine for 15-30 minutes after the insertion .
•If no response occurs in one use a repeat insertion may be required after 6 hours.
•Maximum of 1.5 mg or three insertions are allowed over a period of 24 hours.
•If required oxytocin is to used only after 6- 12 hours of the last insertion.

II. Intravaginal PGE2 gel:

•Vaginal PG E2 gel : - contains 2.5 mg PGE2 - 2 doses 6 hours apart are used
•Vaginal controlled release insert :
a. (Cervidil )- 10 mg insert which releases 0.3 mg / hr of theprostaglandin
b. No need to pre warm the insert .
c. The patient should lie supine for 2 hoursfollowing the insertion
 d. The insert is to be removed after 12 hours or when active labor begins or in case
of hyperstimulation.

PGE 2 Routes : Controlled trials : Some observations

•Intra cervical use is technically more difficult

•Vaginal route ( gel or insert ) is superior to intra cervical route for cervical ripening but it causes
higher uterine activity
•Controlled release vaginal insert use gives a better post ripening score, decreased the time to
delivery, time to active labor and need for oxytocin use as compared to vaginal gel 2 doses 2.5
mg six hours apart.
•The overall incidence of hyper stimulation is 4.8% - same as with oxytocin. However , the
incidence is more when used in active labor(12.5 %) , more with vaginal gel (5%) than intra
cervical (1%) and least with controlled release insert which can be reversed with terbutaline
administration or removal of the vaginal insert. Washing the vagina does not offer any benefit .
•Use of PGE 2 does not alter C. S. rates

Contraindications:
 Established uterine activity
 Glaucoma
 Asthma
 severe hepatic or renal impairment
 known hypersensitivity to prostaglandins
 active vaginal bleeding

Side Effects
Uterine tachysystole has been reported to follow vaginally administered prostaglandin E2 in 1 to
5 percent of women . Although definitions may vary among studies, most use the terms defined
by the American College of Obstetricians and Gynecologists (1999a) to describe increased
uterine activity as follows:
1. Uterine tachysystole is defined as 6 contractions in a 10-minute period.
2. Uterine hyper tonus is described as a single contraction lasting longer than 2minutes.
3. Uterine hyperstimulation is when either condition leads to a non reassuring fetal heart rate
pattern.
Because hyperstimulation that can cause fetal compromise may develop when
prostaglandins are used with preexisting spontaneous labor, such use is not recommended.
If hyperstimulation occurs with the 10-mg insert, its removal by pulling on the tail of the
surrounding net sac will usually reverse this effect. Irrigation to remove the gel preparation
has not been helpful.

ACOG Guidelines :
Bishop’s score should be less than 4. Drug should be administered near the delivery suite. Patient
should lie recumbent for 30 minutes after the instillation. FHR and uterine activity should be
monitored for 30 minutes to 2hours after the instillation. After this, patient may be transferred
elsewhere, if there is no increase in uterine activity and FHR is normal. The controlled release
insert should be removed at the onset of labor. Oxytocin should be avoided for initial 6-12 hours
RCOG Guidelines :
Intra vaginal PGE2 should be used in preference to intra cervical preparations as they are equally
effective and administration of intra vaginal PGE 2 is less invasive of the vaginal preparations.
Tablets should be preferred over the gel as they are more cheap and equally effective.

MISOPROSTOL:

Misoprostol is a synthetic PG E1 analogue which has been used as a gastric cytoprotective agent
since1988 for patients of peptic ulcer. Studies in late 1980’s and early 1990’s noted that oral
administration of this drug causes uterine contractions in early pregnancy. Subsequent studies
showed that intra vaginal misoprostol causes first and second trimester abortion and there has
been recent evidence of its use for cervical ripening and labor induction.

Pharmacokinetics: The pharmacokinetics of misoprostol have been extensively studied by

Ziemann etal . They have observed that peak plasma concentration is higher and achieved earlier
after an oral administration. Peak levels with vaginal administration are attained more slowly and
sustained for longer periods because of the pre systemic gastrointestinal and hepatic metabolism
that occurs with oral route . Overall the systemic bioavailability is three times higher with the
vaginal route.

Dosage schedules and usage guidelines:

•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

Misoprostol : Controlled trials : some observations:

•Oral route is not recommended at this point of time
•Misoprostol shortens the Induction delivery interval as compared to PG E2 and oxytocin
•25 mcg vaginal dose has less hyperstimulation but a longer IDI as compared to 50 mcg
•It effectively lowers the cesarean rates
•However it is not recommended as an outpatient setting or with previous C. S.
•An increase in the incidence of meconium staining of amiotic fliud and tachysystole is noted
•Overall the use of misoprostol is not associated with an increased rate of operative intervention
for fetal distress and NICU admission.
ACOG Guidelines

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. There is at present insufficient clinical evidence to address the safety of misoprostol
in patients with multiple gestations and suspected fetal macrosomia.

RCOG Guidelines :

Misoprostol appears to be more effective than oxytocin or vaginal PG E2in presence of ruptured
membranes for induction of labor. Use of misoprostol in obstetrics must be restricted to RCTs.
Oral misoprostol appears to be less effective than vaginal misoprostol, however, oral route is
associated with less incidence of uterine hypercontractility but a higher incidence of meconium
stained liquor. Its use is associated with increased uterine hypercontractilty but this is not
translated in increased operative delivery rates. The safety issues surrounding the use of
misoprostol have not been clearly evaluated.

* Despite a lot of clinical use, misoprostol is still not approved by the Drug Controller of India
for use in induction of labor.

2. OXYTOCIN:

Oxytocin is a polypeptide hormone secreted from the posterior pituitary gland which acts as a
potent uterotonic agent. The drug was used intravenously in 1948 by The obaldet al to induce
labor. Later in 1958 Du Vigneaud et al synthesized the drug. Since then it has been the most
commonly used drug for induction and augmentation of labor.

Routes of administration:

Oxytocin can be administered by any parenteral route, intravenous route being the most widely
used. It can be absorbed from the nasal or buccal mucosa, however when given orally it is
rapidly inactivated by trypsin.

Pharmacokinetics and mechanism of action:

The half life of oxytocin is 3-5 minutes. Once absorbed it is distributed in the extra cellular fluid
and does not bind to plasma proteins and is excreted by the liver and kidneys. The action is
mediated by oxytocin receptors (OTR) which are present on the myometrium. Myometrial
response to oxytocin begins at 20 weeks , increases through out pregnancy and peaks just before
initiation of labor. The response varies according to the status of the cervix, uterine sensitivity,
variability in oxytocin clearance rate, duration of pregnancy and the pre-existing myometrial
contractions. The OTR concentration is the rate limiting step for oxytocin action. Oxytocin on
binding to the OTR increases the intracellular concentration of calcium causing myometrial cell
contraction. Uterine contractions are also stimulated by a calcium independent mechanism
involving the prostaglandins. PGE and PGF are increased during oxytocin administration. It has
been postulated that Prostaglandin release by oxytocin is necessary for fully efficient uterine
contractions during labor.

Dosing and Usage Guidelines:

10 –20 units are dissolved in 1000 ml of balanced salt solution ( Ringer Lactate solution nor
Normal saline ) making it as 10-20 mu/ml and it is preferable to give it through an infusion
pump. Further increments are made according to the low dose or high dose protocol given below

Regimen Starting dose Incremental dose Dosage interval

(mU/ min) (mU/ min) ( min)
Low Dose 0.5 – 1 1 30-40
1 –2 2 15
High dose 6 6 15
6 6, 3*, 1* 20-40
* The incremental increase is reduced to 3 mU/min in presence of hyperstimulation and reduced
to 1mU/min with recurrent hyperstimulation .

After intravenous infusion , uterine response occurs within 3-5 minutes and a steady state
plasma concentration is reached in about 40 minutes. The end point to be achieved is uterine
contractions every 2-3 minutes lasting for 60-90 seconds and a uterine pressure of50- 60 mm Hg
or 150 Montevideo units.

Risks of Oxytocin:

 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

In the management of active-phase arrest, and with no contraindication to intravenous oxytocin,

decisions must be made with knowledge of the safe upper range of uterine activity. Importantly,
despite no labor progression, there were no adverse maternal or perinatal effects in those
undergoing cesarean delivery. There are no data regarding safety and efficacy of contraction
patterns in women with a prior cesarean delivery, with twins, or with an over distended uterus.

Duration of Oxytocin Administration—

Active Phase Arrest First-stage arrest of labor is defined by the American College of
Obstetricians and Gynecologists (1989, 1995a) as a completed latent phase along with
contractions exceeding200 Montevideo units for more than 2 hours without cervical change.
Some investigators have attempted to define a more accurate duration for active-phase arrest.

Rouse and colleagues (1999) prospectively managed 542 women at term with active-phase arrest
and no other complications. Their protocol was to achieve a sustained pattern of at least 200
Montevideo units for a minimum of 4hours.This time frame was extended to 6 hours if activity
of200 Montevideo units or greater could not be sustained. Almost 92 percent of these women
were delivered vaginally. These and other studies support the practice to allow an active-phase
arrest of 4 hours (Rouse and associates, 2001).

RCOG Guidelines:

Oxytocin should not be started for 6 hours following administration of vaginal prostaglandins· In
women with intact membranes , if feasible amniotomy should be performed prior to
commencement of oxytocin infusion· Minimum possible dose of oxytocin should be used and
titrated against uterine contractions. Maximum licensed dose is 20 mU/min and should not be
exceed 32 mU/min· Local protocols should specify the dose , dilution of oxytocin and preferably
be delivered via infusion pump or syringe driver with non-return valve

Infusion pumps are an electronic apparatus designed to deliver drugs and biologicals, at low
doses. The delivery process of these pumps is associated with local hemolysis which consists the
potential benefits of a calibrated delivery system. infusion pumps are easy to use as these are
designed keeping in mind the requirements of patrons at our vendors end.

Oxytocin Administration via the Infusion Pump.

1. Oxytocin for the purpose of induction or augmentation of labor, will be ordered by the
physician and administered by an RN.

2. Oxytocin administered for induction or augmentation of labor will be performed only in L&D
after a minimum 30 minute baseline FHR and UA tracing is obtained.

3. A registered nurse is responsible for the operation of the pump (adjustments to infusion rate
per MD order).

4. Continuation of an oxytocin infusion beyond 20 milliunits/min requires an MD order.

5. In accordance with ACOG recommendations, the practice of elective

* delivery prior to 39 weeks gestation is prohibited (unless approved by Chairman/Clinical
Chief).

CONTRA-INDICATIONS:

Contraindications include but are not restricted to:

1. Unfavorable fetal positions

2. Uterine tachysystole

3. Hypersensitivity to the drug

4. Cases where vaginal delivery is contraindicated, such as complete placenta previa, vasa
previa, and cord prolapse

EQUIPMENT:

Infusion pump Premixed 500ml bag of D5W with 20units of oxytocin Infusion pump tubing

PROCEDURE:

ACTION

1. Place patient on external electronic fetal monitor to establish a continuous fetal heart rate
(FHR) tracing and uterine activity (UA) pattern.
2. The determination of cervical dilation, effacement, station and position should be
performed either prior to the initiation of the infusion or within the first 2 hours after the
initiation of the infusion.
3. Assist with the placement of internal fetal monitoring and intrauterine pressure catheters
when ordered by3. Provide additional information regarding fetal status and uterine
contractions.
4. Piggyback oxytocin infusion to main IV line as close to venipunture as possible. It may
be necessary to remove oradd different IV tubing so the oxytocin can be placed close to
the venipuncture site.
5. Piggybacking the solution away from the venipuncture site can result in an oxytocin
bolus.
6. Program infusion pump. Select Intrapartum pitocin concentration (20 units oxytocin in
500 ml)
7. Confirm pitocin concentration.6. Concentration is 40 milliunits/ml.
8. Select dose in milliunits/min.
9. Enter the volume to be infused.
10. Begin infusion at 2 milliunits/min and increase by 2 milliunits/min every 30 minutes or as
ordered by the physicianuntil an adequate labor pattern is established. When the infusion
rate reaches 20 milliunits/min notify the physician.
 11. Continuation of the infusion beyond 20 milliunits/min requires a physician’s order.
12. Decrease oxytocin if:
 Tachysystole is present.
 The uterine resting tone is increased by palpation assessment or Intrauterine
Pressure Catheter (IUPC)
 For fetal heart rate tracing concerns as assessed by nurse or physician. MD should
be notified.
13. Discontinue oxytocin if:
 Uterine tetany
 Fetal indications as assessed by nurse or physician
14. Notify physician
15. If restarting oxytocin is indicated, begin with the following guidelines:
 If the oxytocin was discontinued for less than 30 minutes because of:
 Uterine tachy systole restart oxytocin 4 milliunits/min lower than the previous level
 Fetal indications: restart oxytocin at 2.0 milliunits/min or at the discretion of the
physician.
 If the oxytocin discontinued for more than 30 minutes, restart at2.0 milliunits/min
or at the discretion of the physician

Other Pharmacological methods:

a) Mifepristone: 200 mg misoprostone for 2 days has been recently used for cervical priming .
However this method is not cost effective and needs further trials.

b) Relaxin : Relaxin has been demonstrated to causes changes in the collagen resulting in
cervical softening . Both purified porcine and DNA produced human relaxin have been tried with
success in promoting cervical ripening with no adverse maternal and fetal outcomes . It is not yet
commercially available.

c) Nitric Oxide: Animal studies have shown it to be a cervical ripening agent but it is unlikely to
be used for human use unless safety of NO in late pregnancy is established

d) Cytokines: Theses are chemotactic agents which also can promote cervical ripening by
causing changes in the extra cellular matrix

NATURAL MODALITIES:

a) Herbal supplements: Commonly used herbal cervical ripening agents include evening
primrose oil, black cohosh, raspberry leaves. The liquid of black cohosh is given as 10 drops
sublingually hourly until the cervical change occurs. Evening primrose oil is given as 3 capsules
orally daily for one week, this can be repeated for three such administrations. red raspberry
leaves also enhance uterine contractions in a synchronous manner
b) Intercourse : results in a 10-50 fold increase in cervical mucus prostaglandin concentrations
which occurs after 2-4 hours and remains for more than 12 hours duration . There is an
associated increase in the uterine contractile activity .

2. SURGICAL METHODS:

AMNIOTOMY: Ideally amniotomy or ARM is performed when the cervix is effaced and 2 cm
dilated but it can be performed with minimal cervical dilatation.

Methodology of ARM:

1) Auscultate the FHR

2) Evaluate the cervix and station of head. The cervix should be well applied to the head
3) Introduce two fingers into the cervix , sweep away the membranes from the cervix
4) Pass an Allis or Kocher’s forceps in between the groove of your two fingers , hook the
membranes and rupture them ; look for the clarity of liquor

•Risks: Cord prolapse

 FHR deceleration
 Bleeding through vasa praevia
 Fetal injury
 Maternal and fetal infection

Advantages: -

1. It shortens duration of labor

2. Allows for early diagnosis of meconium staining of amniotic fluid, specially in high risk
pregnancy
3. Facilitates invasive fetal monitoring

MECHANICAL MODALITIES:

a) Hygroscopic dilators: These are natural or synthetic rods inserted through the cervical os and
left in situ for a particular time where in because of their osmotic properties they absorb
endocervical and local tissue fluids . This swelling causes a controlled dilatation of the cervix
along with releasing prostaglandins. Natural dilators are obtained from the seaweed Laminaria
japonicum.

b) Balloon devices : Foley’s catheter or designer balloon devices when inserted intra cervically
can facilitate cervical ripening. Once properly placed ( beyond the internal os) balloon or the
catheter is inflated with 30-50 ml saline. It is recommended to either attach a defined weight to
the catheter end ( 1litre of i.v. fliud ) or to use “gentle tugs” – 2 to 4 each hour until the catheter
or the balloon passes out . Some recommend infusion of extra-amniotic saline at the rate of 1
cc/minute. There is no infection associated with balloon devices
MISCELLANEOUS:

a) Castor Oil : It is an extract from “Ricinus communis”and is mainly crude ricinoleic acid .It is
known to stimulate gut peristalsis and labor most likely is stimulated due to release of
prostaglandins. The method is no longer used now. One study has reported an increased
incidence of meconium staining of amniotic fluid.

b) Accupuncture and TENS( Transcutaneous electric nerve stimulation) : Few studies have
reported successful induction of labor with these methods but further trials are needed before
planning a large scale use.

CERVICAL RIPENING AND IOL IN SPECIAL CIRCUMSTANCES:

a) Previous C. S :· One or more previous C. S. are not a contraindication to the induction of

labor.· Cervical ripening can be done in these situations with PGE2 gel – either intravaginal or
intracervical· Misoprostol is an absolute contraindication· Oxytocin can be safely used in low
doses with close monitoring of uterine contractions and FHR.· It is preferable to have continuous
electronic fetal monitoring.

b) Twin pregnancy:· PGE 2 gel can be safely used for cervical ripening· ARM facilitates
induction· Oxytocin in low doses can be used.

c) Premature rupture of membranes (PROM) :· Use of PGE2 gel– 2 doses 6 hours apart is not
associated with higher incidence of infection·

Misoprostol can also be used in 25 mcg dose·

Oxytocin infusion should be closely monitored· Beware of hyperstimulation

d) Intrauterine fetal demise (IUFD ) :· Oxytocin is effective for IOL near term with a favorable
cervix.· All prostaglandins can safely be used in recommended dosages for cervical ripening
remote from term.

Induction of labor : Summary of evidence based ACOG recommendations:

 Recommendations based on good and consistent scientific evidence (Level A)

 Prostaglandin E analogues are effective in promoting cervical ripening and inducing
labor
 Women in whom induction of labor is indicated may be appropriately managed with
either a low or high dose oxytocin regimen
 Fetal heart rate and uterine activity should be continuously monitored from the time the
PGE 2 vaginal insert is placed until at least15 minutes after it is removed
 High dose PGE 2 vaginal suppositories may be used in the management of intrauterine
fetal demise in the second trimester of pregnancy
  Although the optimal dose and timing interval of misoprostol is unknown , lower doses
( 25 mcg every 3-6 hours) are effective for cervical ripening and induction of labor

Recommendations based on evidence that maybe limited or inconsistent ( Level B)

 Misoprostol use in women with prior cesarean birth should be avoided because of the
possibility of uterine rupture
 The use of higher doses of misoprostol (50 mcg every 6 hours) to induce labor may be
appropriate in some situations , although there are reports of increased risk of
complications, including uterine hyperstimulation.

Recommendations based on consensus and expert opinion ( Level C) :

 For women with third trimester intrauterine fetal demises, intravaginal misoplrostol can
be used to induce labor.
 Fetal heart rate and uterine activity should be continuously monitored from 30 minutes to
2 hours after administration of PG E2 gel
References:

From books

 Myles “Textbook for Midwives”14th Edition, “published by Churchill Livingstone

 Hollend and Brews” Mannual of Obstetrics” 4th edition, published by Reed Elseviver
India Pvt .Ltd Dickason, Schult,Silverman Maternal infant Nursing care,C .V. Mosby :
 ParulekarV . Shashank Text Book for midwives VORA medicalpublications:
 Dutta’s D.C Text Book of Obstetrics 9th edition New Central Book Agency (P) Ltd

 From net
 http://www.emedicinehealth.com/pregnancy_augmentation of labour /page5_em.htm
 http://www.gfmer.ch/Obstetrics_simplified/maternal_obstetric_.htm
 https://sogc.org/wp-content/uploads/2013/02/gui285CPG1301E