INDUCTION AND AUGMENTATION OF

LABOR
By: Yibelu Bazezew ( MSc in clinical Midwifery)

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 INDUCTION & AUGMENTATION OF LABOR
Learning Objectives:

At the end of this session the learners will be able to:

Define induction and augmentation of labor

List indications and contra-indications for induction and

augmentation of labor
Identify Procedures/protocol for induction and
augmentation of labor
List complications of induction and augmentation of labor
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 INDUCTION OF LABOR

Definition
Induction of labor is initiation (stimulation) of uterine

contraction artificially to accomplish delivery prior to the

onset of spontaneous labor for the purpose of delivering the
fetus vaginally after the fetus has reached viability (after the
28th week of gestation).
An induction of labor is the process by which medical or

surgical means are used to initiate and maintain labor any

3 time after the 28th week of gestation.
 INDUCTION OF LABOR( CONTI…….)
It could be either as:

Planned (elective)

Emergency

The decision to induce labor is largely governed by the assessment of obstetric

balance and
the heath professionals should assess the presence of the following three

necessary points
The risk if the pregnancy continues

The risk if the pregnancy is interrupted and

The hazards of induced labor

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 INDUCTION OF LABOR( CONTI…….)
 Thus induction is done when the benefits of delivery to

the fetus or the mother exceed the benefits of continuing

the pregnancy.

 Its Purpose is to bring

An adequate contraction consists of 3-5 strong contractions

in 10 min. each lasting for 40-60 sec.

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 INDUCTION OF LABOR( CONTI…….)

Indications for inductions

Because of associated risks, induction of labor should

be performed only upon specific maternal or fetal

indications.
 The following are the indications for induction of labor.

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INDUCTION OF LABOR( CONTI…….)

A. Obstetrical indications
 Hypertensive Disorders of Pregnancy including eclampsia

 Post term pregnancy

 Intra-uterine Fetal death (IUFD)- fetal demise

 Unexplained Recurrent Intrauterine Fetal Death near term

 Polyhydramnious and oligohydramnious

 Premature Rupture of Membranes (PROM)

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 Obstetrical indications cont….

 Rh-Isoimmunization

 Intra-uterine Growth Retardation (IUGR)

 Placental Abruption and low lying anterior placenta previa

 Chorioamnionitis

Risk of rapid labor

 Gross congenital malformations incompatible with life

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 INDUCTION OF LABOR( CONTI…)

B. Maternal Medical Disorders aggravated by Pregnancy

 Chronic renal disease

 Chronic hypertension

 Severe cardiac disease

 Diabetes mellitus

  Chronic pulmonary disease

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 Contraindications of Induction
Any condition that is contraindication for spontaneous

labor and vaginal delivery should be a contraindication for

induction of labor.

Contraindications may include but are not limited to the

following;

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 Contraindications of Induction (conti……)
I. Absolute contraindications
 placenta previa, vasa previa,
 abnormal lie, malpresentations
 previous uterine scar (e.g. myomectomy, CS),
 contracted pelvis, macrosomia, twin pregnancy,
 invasive cervical cancer,
 active genital herpes infection,
 severe IUGR with confirmed fetal compromise.
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 Contraindications of Induction(conti….)
Extensive vaginal plastic operations like repaired fistulas

Cord presentation

NRFHP or fetal distress, MSAF

Absence of cesarean section facility

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 II. Relative contraindications

Elderly primigravida or grand multiparity

One lower segment cesarean section

Bad obstetrics history

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 Prerequisites of induction

Get informed consent.

Document the indication.
 Make sure that there are no contraindications.
Determine Bishop score (cervix score) and if unfavorable,
consider cervical ripening.
Ascertain availability of labor ward staff and also the capacity
to do emergency caesarean section.

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 Unfavorable cervix is another relative contraindication
especially for elective induction.

Favorability of the cervix for induction is evaluated by pelvic

examination to assess the Bishop score.

Bishop score of more than or equal to six is taken as

favorable for elective induction.

Cervix is said to be unfavorable if the score is lees than or

equal to five.

The chance of vaginal delivery is lesser in unfavorable cervix.

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 Assessment of cervix for induction of labour
(Modified Bishop score)

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Methods of Cervical Ripening before induction
 Cervical ripening is the use of pharmacological or mechanical
means to soften the cervix.
I.PHARMACOLOGIC METHODS
1. PGE2 (dinoprostone)
2. PGE1 (misoprostol)  
II. MECHANICAL METHODS
3. Membrane stripping (sweeping)
4. Transcervical balloon catheters
5. Hygroscopic dilators (Laminaria)
 

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 Dinoprostone ( PGE2)
PGE2 Gel (dinoprostone)
 Used widely for cervical ripening

 Causes dissolution of collagen bundles and increase in sub mucosal

water content
 PG induced cervical ripening often includes initiation of labor.

 Low dose PG

 Increases chance of successful induction

 Decreases incidence of prolonged labor

 Reduces total and maximum oxytocine dose

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Dinoprostone ( PGE2) conti…..
 Preparation

Intra-cervical (0.3 – 0.5mg)

Intra-vaginal (2.5 – 5mg)

Dinoprostone vaginal insert (cervidil) 10mg.

provides slower release 0.3mg/hr

One advantage of the insert is it can be removed in

case of hyper stimulation

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 Dinoprostone ( PGE2) conti…..
 Intra-cervical gel of 0.5 mg of PGE2 is placed in the endo-

cervical canal & repeated after 6 hrs for a maximum of 3

doses.
 Intra-vaginal gel of 2.5mg PGE2 (Prostin) is applied on the

upper vaginal canal (or posterior fornix) every 6 hours for a

maximum of 4 doses.
 10 mg of dinoprostone is placed into the posterior fornix and

repeated after 6 hours for a maximum of 4 doses.

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 Dinoprostone ( PGE2) conti…..
Side Effects
 Uterine tach systole/ hyper stimulation has been reported

following vaginally administered prostaglandin E2 in 1 to 5

percent of women
 B/c of hyper stimulation: foetal compromise may occur

 When hyperstimulation occurs with the 10-mg insert, its

removal by pulling on the tail of the surrounding net will

usually reverse this effect.
 Irrigation to remove the gel preparation has not been helpful.
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 Misoprostol (PGE1)
Misoprostol: is a synthetic prostaglandin E1, available as a
100- or 200-mcg tablet.
Less expensive than dinoprostone.
It has been used for pre-induction cervical ripening and
may be administered vaginally or orally.
Vaginal Administration
Several investigators have reported that misoprostol
tablets placed into the vagina were either superior to or
equivalent in efficacy when compared with intracervical
prostaglandin E2 gel.
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 Misoprostol (PGE1) conti….
Intra vaginal misoprostol of 25mcg not more frequent

than every 3-6hrs is effective in women with

unfavorable cervix

It is placed into the upper vagina and repeated after 6

hours.

If there is no response after 2 doses of 25mcg, the

dose is increased to 50 mcg every 6hours for a total of

24 200 mcg.
 Oral Administration of PGE1

It has similar efficacy for cervical ripening as intravaginal

administration.
A 50 mcg of oral misoprostol was less effective than 25g

administered vaginally for cervical ripening.

But a 100 mcg oral dose was as effective as the 25g

intravaginal dose.

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 General guideline for PG use in cervical ripening
 The insertion should be in a hospital and the patient is

kept recumbent for at least 30 minutes after insertion.

 FHB and uterine activity are monitored for 30 minutes

to 2 hours after insertion.

 When contractions occur, they usually apparent in the

first hour and peak in the first 4 hours of insertion.

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 General guideline conti….
 Repeat doses of PGE are given after an interval of 6- 12 hours of

the last dose only if the cervical change is insufficient and with
minimal uterine activity.

 Discontinue use of PG and begin oxytocin infusion if:

Membranes ruptures

Cervical ripening has been achieved

Contractions are achieved; or

6 hours have passed from last planned dose

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 General guideline conti….

 Effects of PGE2 may be exaggerated with oxytocin, so oxytocin

induction should be delayed for 6-12 hours after the last dose.

 In case of hyper stimulation, intravenous/subcutaneous

terbutaline, 250 μg or magnesium sulfate (2-6 g in 10-20%
dilution) maybe used for uterine relaxation.

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 Cervical ripening cont…

Membrane stripping
 The membrane is stripped (separated) by inserting the

examining finger gently through the internal os & moving it in

a circular direction to detach the inferior pole of the intact
membranes from the lower uterine segment and internal os.
 Stripping the membranes mechanically dilates the cervix

which releases prostaglandins (???).

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 Membrane stripping conti….

 Risks include :

Patient’s discomfort

Bleeding from undiagnosed placenta previa (low lying

placenta)
Accidental ROM and

Infection

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 Cervical ripening cont…
Trans-cervical balloon catheters
Folly catheter (size 16 or 18 gauge) is introduced aseptically
through the cervix above the internal os (about 5-8 cm).

The balloon is then inflated with 30 -50 ml of sterile saline and

pulled gently to the level of the internal os and

 Pressure applied by hanging weight of 1 kg ( e.g. IV

fluid bag). The Balloon provide mechanical pressure directly on
the cervix which respond by ripening and dilation.

It is left for 12 hours or labor starts and expelled spontaneously.

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 Cervical ripening cont…

Hygroscopic dilators

Osmotic cervical dilators: laminaria japonicum or synthetic

laminaria (e.g., Lamicel) are kept in the cervix for overnight.

The use of hygroscopic dilators appears to be safe

The attraction of dilators is their low cost and ease of placement

and removal.

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 Types of induction
1. Medical:- using drugs alone

2. Surgical:- amniotomy or membranes

sweep → increasePGE2 secretion
3. Combined:- medical & surgical.

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 Artificial rupture of the membranes (ARM)

 ARM is a recommended practice in both induction and

augmentation.
 In most cases, failure of induction or augmentation is

certain if use of both ARM and oxytocin fail to initiate

contractions or correct the poor contractions.
 However, ARM should be delayed as long as reasonably

possible to reduce vertical transmission of HIV.

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 ARM conti….

 Prerequisites

 Appropriate indication

 Engaged fetal head (relative)

 No contraindications such as cord presentation, vasa previa

 No fetal distress (unless immediate vaginal delivery is

possible)

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 ARM conti….
 Preparation and procedure

 Explain the procedure to the woman,

 Ask her empty her bladder,

 Check FHB

 Put her in lithotomy position,

 Check for pulsation that may indicate cord presentation (or

very rarely vasa previa)

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 ARM conti….

 Perform ARM using amniotic-hook or Kocher forceps

with aseptic technique and may use fundal pressure if

head is high to avoid prolapse
 Keep your fingers inside the vagina and allow the

amniotic fluid to drain slowly around the forefingers.

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 ARM conti….

 Note the amount and color of the amniotic fluid (clear,

greenish, bloody)
 Check for cord prolapse after ARM: Remove your fingers

from the vagina once the fluid is drained well and are
certain there is no cord prolapse
 Listen to the FHB after ARM and after next contraction to

be sure there is no deceleration or bradycardia

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 Methods of induction conti…
2. Medical induction– Intravenous oxytocin
administration
The goal of oxytocin induction is to get sufficient
(adequate) contractions without causing hyperstimulation
and fetal distress.
The principles of oxytocin induction are:
Use oxytocin diluted in ringer lactate or normal saline as
continuous intravenous infusion

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 Cont…
It has to be started from the minimum dose capable of

causing contractions and increased every 20- 30 minutes

until adequate contraction is achieved or maximum dose
is reached.

Close monitoring of uterine contractions and fetal heart

beat (intermittently or continuously) should be done.

If hyperstimulation or fetal distress occurs discontinue the

infusion.
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 Cont…

• When oxytocin is stopped, its concentration in plasma rapidly falls

because the mean half-life is approximately 5 minutes.

• Uterine response occurs 3-5 minutes after beginning

of infusion of oxytocin – steady plasma level is

achieved 40minuts later

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  Response to oxytocin depends on

Previous uterine activity

pregnancy duration

Uterine sensitivity

Cervical status

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 Protocols of induction using oxytocin
 Open IV line using No 18 canula
 Perform artificial rupture of membranes(ARM)
 Add 5 IU(primipara) & 2.5 IU(multipara) of oxytocin into
1000 ml of N/S or R/L solution and adjust the number of
drops every 20- 30 minutes.
 Start oxytocin infusion, and monitor the dose and rate of
infusion strictly
 Starting with a low dose of oxytocin and increase every
20- 30 minutes till adequate uterine contraction is
achieved or maximum dose is reached.

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 Protocols conti….

Start with 20 drops/ minute and double the drop rate

every 20 minutes until 3-5 contractions each lasting 40-
60 seconds is achieved.

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 Protocols conti….
 Label the bottle and keep timely record of the drops used.

 Aim to maintain the lowest possible dosage consistent with

adequate uterine contraction.

 Monitor mother, fetus and labor according to labor

protocol.
 Record maternal and fetal conditions and progress of labor.

 Uses the partograph once active phase of labor is reached.

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 Protocols conti….

Maintain the drop rate that brought adequate

contractions till delivery and continue for one hour

after delivery.

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 Cont…
Multipara Primigravida
1st dose: Start with 2.5 IU oxytocin 1st dose: Start with 5 IU
in 1000 ml of NS OR RL Running at Oxytocin in 1000 NS or RL
20 drops / min. If no adequate running at 20 drops per min.
contraction Double every 20- 30 If no adequate contraction
minutes (20, 40, 60, 80). double every 20 minutes.
Always stops at 80 drops/min Always stop at 80 drops/min
2nd dose: If no adequate contraction 2nd dose: If no adequate
add 2.5IU of oxytocin and start with contractions add 5 IU of
40 drops (40,60, 80) oxytocin and start with40
drops(40,60,80)
3rd dose: If no adequate 3rd dose: If no adequate
contractions add 2.5 IU oxytocin contractions add 5 IU of
and start with 40 drops (40, 60, 80) oxytocin and start with 40 drops
(maximum 7.5 units. (Maximum 15 units )(40,60,80)
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 Oxytocin infusion rates for induction of labor …….updated

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 Complications of induction using oxytocin

 Failure to initiate labor or achieve good contractions

leading to failed induction leading to increased risk of
cesarean section
Atonic PPH

Iatrogenic prematurity

 Uterine hyper stimulation/ tetanic contractions (oxytocin,

PG)
Uterine rupture

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Fetal distress
  Complication cont…..

 Chorioamnionitis (prolonged rupture of membranes after

ARM and repeated VE)

 Fetal sepsis and vertical HIV transmission (ARM)

 Cord prolapse (ARM)

 Placental abruption (ARM)

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 Failed induction
 Definition: Failed induction is failure to initiate good

uterine contraction.
 It is diagnosed if adequate uterine contractions are not

achieved after 6 to 8 hours of oxytocin administration and

use of the maximum dose for at least one hours.

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 Tetanic contractions
 Definition: Six or more contractions in 10 min and/ or durations
of 90 or more seconds
 Management
Stop oxytocin infusion
Use tocolytics if available
Assess fetal and maternal conditions carefully for possible
fetal distress or ruptured uterus.
 If there is fetal distress (e.g. NRFHP, meconium stained
amniotic fluid) or uterine rupture, manage accordingly.
If both mother and fetus are in good condition, restart at half
dose of the last dose causing tetanic contractions.

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 Augmentation of Labour
Definition: The process of promoting (enhancing) more
effective uterine contractions when labour has already
begun spontaneously but then becomes weak, irregular or
ineffective (hypotonic) that assistance is needed to
strengthen it.
 Correction of dystocia due to inefficient uterine contractions

(power) by the use of oxytocin. 

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 Augmentation of Labour conti……
INDICATION of Augmentation
 Poor progress of labor due to inefficient uterine

contractions.
 The most commonly used methods of labour
augmentation are also methods for induction of labour:
Amniotomy

Intravenous oxytocin infusion

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 Augmentation of Labour
Dose of oxytocin for Augmentation

Half of induction dose

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 Augmentation of Labour conti……
CONTRAINDICATIONS of Augmentation
 Breech presentation

 CPD

 Malpositions

 Invasive cervical ca.

 Active genital herpes infection

 Outlet and mid-pelvis contracture

 Non-reassuring FHB pattern

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 Fetal macrosomia
 Augmentation of Labour conti……
Procedure of Augmentation

 Do ARM aseptically if membrane is intact

 Add half induction dose of oxytocin to 1000 ml of N/S or

R/L and label the bottle

 Start oxytocin infusion

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 Augmentation of Labour conti……
During augmentation, monitor;
 Progress of labor, FHB pattern, maternal status frequently

 No need to increase the dose after adequate contraction

has been reached.

 Give antibiotics when membrane has ruptured for more

than 8 hrs.

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 THANK YOU!
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