Induction of Labor

International

Induction of Labor
 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
International

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
International

Contraindications to Induction

• Any contraindication to labor

 Induction of Labor
International

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
International

Indications - Emergent
• severe gestational hypertension
• suspected acute fetal compromise
• severe IUGR
• significant maternal disease not
responding to treatment
• significant APH
• chorioamnionitis
 Induction of Labor
International

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
 Induction of Labor
International

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)
 Induction of Labor
International

Indications - NOT

• elective induction
- induction, in the absence of maternal or fetal
indication, should not be undertaken
 Induction of Labor
International

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
International

Labour Induction Methods

Likelihood of Successful Vaginal Delivery

MOST MOST
favourable multiparous previous vaginal
cervix delivery

unfavourable
cervix nulliparous previous C/S
LEAST LEAST
 Induction of Labor
International

• If attempted induction does not achieve labor

reevaluate the indication and method of induction
 Induction of Labor
International

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).
 Induction of Labor
International

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
 Induction of Labor
Labour Induction -
International

Unfavourable Cervix
 Stripping of membranes
 Cervical ripening followed by
oxytocin
- laminaria / artificial tents
- Foley catheter
- prostaglandins
 Prostaglandins (intracervical or
vaginal)
 Amniotomy or oxytocin
 Induction of Labor
International

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
 Induction of Labor
International

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
International

Prostaglandin E2
• myometrial contraction
• cervix
- causes collagen breakdown and proteoglycan deposition
• vasodilator
• bronchodilator
• GI motility and secretory effects
 Induction of Labor
International

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
 Induction of Labor
International

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
 Induction of Labor
International

Prostaglandin E2 - Advantages
• improved patient acceptance
• lower operative delivery rate
• less need for oxytocin induction
• may be used in PROM
• cost considerations
 Induction of Labor
International

Prostaglandin E2 - Disadvantages
• adverse reactions
- hyperstimulation
- CVS events
- nausea, vomiting, diarrhea
• gel preparations are difficult to remove
• cost considerations
 Induction of Labor
International

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
 Induction of Labor
International

Labour Induction - Favourable Cervix

 Stripping of membranes

 Amniotomy

 Oxytocin

 Vaginal prostaglandins
 Induction of Labor
International

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)
 Induction of Labor
International

Oxytocin Effects
• myometrial contraction
• cervix - no direct effect
• vasoactive
- hypotension possible with bolus IV administration
• antidiuretic activity
- water intoxication possible with high dose oxytocin
 Induction of Labor
International

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
 Induction of Labor
International

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
 Induction of Labor
International

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
 Induction of Labor
International

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
 Induction of Labor
International

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