Induction and

Augmentation of
Labor
Definitions

• Induction of labor:– is the artificial stimulation of uterine

contractions before the spontaneous onset of true labor at 28 or more
weeks of gestation to achieve vaginal Delivery
• Augmentation of labor- artificial stimulation of uterine contractions
in cases of inefficient uterine contractions to attain required efficiency
to effect delivery
• Induction and augmentation of labor can be achieved through medical
and surgical means or a combination of both
• Induction and augmentation interventions incur maternal and fetal
risks and should be institute with clear medical indications and after
informed maternal consent
Indications of Induction
• Labor may be induced for either maternal or fetal
indications.
• Induction of labor is undertaken when the following criteria
are met :
 Continuing the pregnancy is believed to be associated
with greater maternal or fetal risk than intervention to
deliver the pregnancy, and
 There is no contraindication to vaginal birth .
Indications for Induction of Labor
Maternal
• Intrauterine fetal death
• Pre-eclampsia/Eclampsia
• Chronic hypertensive
disease
• APH (placental abruption)
• PROM
• Chronic renal disease.
• Severe cardiac disease.
• DM
• Chorioamnionitis
Fetal
• Congenital anomaly
incompatible with life
• RH Isoimmunization
• Fetal growth restriction
• Post term pregnancy
• Diabetes mellitus in
pregnancy
• Abnormal fetal well being
tests suggesting chronic
intrauterine asphyxia

• Indications are classified as maternal and fetal based on the

predominant reason for termination.
• In most cases maternal and fetal indications overlap and may
be difficult to classify as maternal and fetal.
Pre requisites for labor induction
• Valid indication
• Obtain informed consent of the mother
• Assure fetal maturity --> 39 completed weeks or fetal lung maturity tests
• Rule out contraindications for vaginal delivery
• Assess pelvic adequacy
• Assess favorability of cervix by the Bishop’s Score
• Assess presentation ( vertex) and fetal size
• Induction to be conducted mostly as an elective planned procedure with
maternal preparation – hemoglobin determination.
• Sometimes emergency inductions may also need to be conducted due to obstetric
emergencies such as eclampsia and abruptio placenta
Contraindications to induction of labor
• Fetal distress – acute or chronic asphyxia
• Gross cephalopelvic or feto pelvic disproportion
• Gross contracted pelvis
• Malpresentations
– Transverse and oblique lie fetal lie,
– Breech with contraindication for vaginal deliver (e.g., footling,
extended neck),
– Brow presentation,
• Fundal uterine scars
• Multifetal gestations
• Uterotonics hypersensitivity
 Absolute
• Fetal distress – acute or chronic asphyxia
• Gross cephalopelvic or feto pelvic disproportion
• Gross contracted pelvis
• Malpresentations
• Fundal (upper uterine segment) uterine scars
• 2 or more lower uterine segment previous scar
• Active genital herps, invasive cervical cancer, major degree
placenta previa, pelvic tumor obstructing the birth canal,
extensive genital wart
• Uterotonics hypersensitivity
 Relative:-
• Multifetal gestations
• Grand multiparity
• Macrosomia
• One lower uterine segment previous scar
Types of induction
• Elective planned procedure:- to be conducted mostly with
maternal preparation.
• Emergency inductions:- conducted due to obstetric
emergencies such as severe preeclampsia/ eclampsia and
abruptio placenta, ruptured membranes with
chorioamnionitis
 Timing of induction:- the point at which the benefits to
the mother &/or the fetus are greater if the pregnancy is
interrupted than continued & is gestational age dependent
Predicting a successful induction
• Cervical status is one of the most important factors for predicting the
likelihood of successfully inducing labor.
• Cervical examination should be performed before initiating attempts at
induction.
• The modified Bishop score is the system most commonly used in clinical
practice .
• This system tabulates a score based upon the station of the presenting
part and four points of the cervix: dilatation, effacement,
consistency, and position.
• The Bishop score appears to be the best available tool for predicting
the likelihood that induction will result in vaginal delivery.
• Cervical dilatation is the most important element of the Bishop
score .
The Bishop Score
Parameter 0 1 2 3

Cervical dilatation Closed 1-2 3-4 >5

Cervical effacement 0-30% 40-50% 60-70% >80%

Cervical position Posterior Midposition Anterior _

Cervical consistency Firm Medium Soft _

Fetal station -3 -2 -1,0 +1,+2

The Bishop score indicates the ripening of the cervix for labor indirectly indicating
the possibility of success of an induction.
• Scores > 9/13 indicate a ripe cervix;
• 5-8 intermediate cervix and
• < 4 an unripe cervix and a high probability of unsuccessful induction.
Cervical Ripening
• is a complex process that results in physical softening and
distensibility of the cervix, ultimately leading to partial cervical
effacement and dilation
• Oxytocin is less successful for labor induction when used in women
with uneffaced and undilated cervix. Therefore, a ripening process
should be used prior to oxytocin induction when the cervix is
unfavorable.
• Cervical ripening methods fall into two main categories:
pharmacologic and mechanical
– Pharmacological (misopristone) or surgical means to soften the
cervix (laminaria).
Methods of Cervical Ripening
Pharmacological Mechanical
• Prostaglandin E2 (dinoprostone) - • Foley catheter method
intravaginal, intracervical – repeated • Stripping of the fetal membranes
3-5 mg doses applied until the cervical • Laminaria insertion into the cervix –
status improves or a maximum of 3 to hygroscopic dilators that dilate and
4 doses soften the cervix by absorbing its
• Prostaglandin E1 (misoprostol) 25 water content. Extracts of laminaria
mcg four dose – intravaginal or oral sea weeds.

 An unripe cervix needs to be ripened by these cervical ripening methods in order

to be softened and more ripe.
 The pharmacologic methods are the most preferred but in cases where these are
not accessible, mechanical agents can also be used to ripen the cervix.
 A ripe cervix indicates a dilated, soft, anterior and effaced cervix that is easily
pliable to uterine contractions.
Methods of Labor Induction and Augmentation
Medical
1. Oxytocin infusion
• Low dose regimen-
beginning at 1mu/min and
doubling every 20-30
mins to a maximum of 40
mu/min
• High dose regimen- start
at 6mu/min and escalate
every 20-30 mins to a
maximum of 42 mu/in
2. Prostaglandin E 1
(Misoprostol) induction –
intravaginal or intracervical
3. Prostaglandin E 2
(Dinoprostone) – 3 mg
vaginally every 6 hours for
two – four doses
Surgical Combination of both
1. Amniotomy – 1. Amniotomy with
artificial rupture of the oxytocin induction
membranes 2. Stripping of fetal
2. Stripping of the fetal membranes with
membranes oxytocin induction
3. Foley catheter 3. Foley catheter method
method with oxytocin induction
….. Etc
• Surgical methods are
often used in • Most methods of labor
conjunction with induction are also used
medical methods and for augmentation of
not alone for labor labor as well.
induction.

• Failed induction: No established labor 6-8hrs after the last oxytocin

dose or no change in Cx dilatation or descent.
 Procedures of Labor induction
Procedure Description
Amniotomy • After ascertaining the fetal
station and ruling out cord
presentation membrane is
ruptured with an amnion
hook or a kocker and
controlled release of
amniotic fluid effected
Oxytocin • An IV line is opened and
infusion oxytocin infusion
administered gradually by
either a graduated perfusor
prepared for the purpose or
by IV drip method
manually calibrated –
dosage expressed in mu/min
Complications
• Cord prolapse
• Infection –
chorioamnionitis
• Abruptio placentae- if
sudden decompression of
uterus occurs due to
excessive release of
amniotic fluid
• Uterine hypertonus – fetal
distress; uterine rupture
• Water intoxication –
sodium retention and fluid
overload
• Hypersensitivity reaction
to oxytocin
• Higher risk of atonic PPH
 Procedure Description
Prostaglandin • Usually applied for cervical
E1, E2 induction ripening but also used for
induction of labor.
• Tablet or gel or cream inserted at
the posterior fornix or near the
cervix repeatedly at 6 hourly
intervals until labor is
established
Stripping of the • The membranes are separated
fetal membranes from the lower uterine segment
by the examining finger for 3-4
cms from the os and await for
labor onset in hours or days.
Foley catheter • Foley catheter inserted into the
method uterus above the internal os,
balloon inflated with 30 cc of
normal saline and pressure
applied by hanging weight of 1
kg ( e.g. IV fluid bag).
(extra-amnionic
saline infusion)
Complications
• Nausea, vomiting,
diahorrea, fever, chills,
respiratory
complications ( rare),
• uterine hypertonus-
fetal distress, uterine
rupture
• Possibility of placenta
previa and bleeding.
• Placenta should be
localized before
membrane stripping.
• Infection
• Membrane rupture
Complications of Labor Induction
• Prematurity
• Infection- chorioamnionitis;
o Neonatal sepsis; puerperal sepsis
• Water intoxication
• Uterine hypertonus- fetal distress, uterine rupture
• Hypersensitivity reactions
• Side effects of prostaglandins
• Post partum hemmorhage risk
• Unforeseen cephalopelvic disproportion
Complications
• 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)
o Uterine rupture
o Fetal distress
• Chorioamnionitis (prolonged rupture of membranes after ARM and
repeated VE)
• Fetal sepsis and vertical HIV transmission (ARM)33
• Cord prolapse (ARM)
• Placental abruption (ARM)
• Water intoxication (oxytocin)
• Amniotic fluid embolism
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.
Tetanic contractions
• Definition: Six or more contractions in 10 min and/ or durations of 90
or more seconds
• Management
o Stop oxytocin infusion
o Use tocolytics if available
o 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.
o If both mother and fetus are in good condition, restart at half dose of the last
dose causing tetanic contractions.
Local protocol: Induction
• Premi (5IU) & multipara (2.5IU).
• Start the drop with 20 drop/min, increase the drop every 30’ till
adequate Ux action.
• Start with 2mu/min up to 8mu/min, then increase by 4mu/min up to
32mu/min.
• Drop/min: 20-40-60-80, 50-60-80, 50-60-80.
• Oxytocin mu/min: 2-4-6-8, 10-12-16, 20-24-32.
Local protocol: Augmentation.
• Premi (2.5IU) & multipara (1.25IU).
• Start with 5mu/min for multi & and 1mu/min for primi-
gravida.
• Increase every 30` up to max 20mu/min.
• Drop/min: 20-40-60-80, 60-80, 60-80, 50.
• Oxytocin mu/min:1-2-3-4, 6-8, 12-16, 20.