Induction and augmentation

By Tewodros M.
 INDUCTION OF LABOR

• DEFINITION:
– Induction of labor is the artificial stimulation of uterine
contractions before the spontaneous onset of true labor to
achieve vaginal delivery.
– It can be either planned (elective) or emergency
• INDICATIONS
Common indications include:
- Hypertensive disorders of pregnancy
- maternal medical complications (DM, severe cardiac disease),
- chorioamnionitis, term PROM, IUFD, post term, abruptio
placenta, congenital anomaly, RH isoimmunization
 INDUCTION OF LABOR

• CONTRAINDICATIONS
• Absolute: 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
• Relative: bad obstetric history, grand multiparity
 PRECONDITIONS
--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
 CERVICAL RIPENING

• Cervical ripening is the use of pharmacological or

mechanical means to soften the cervix
– The cervical ripening agent may also initiate labor
– If not, further pharmacologic agents (i.e. oxytocin) can be
used for induction
• Generally, cervical ripening and induction of labor are
on a continuum and not all women undergoing
induction of labor need cervical ripening
– The Bishop scoring system can be used to determine if the
cervix is favorable or unfavorable
– If the cervix is unfavorable (Bishop score < 6), cervical
ripening is indicated
PHARMACOLOGIC METHODS FOR CERVICAL
RIPENING AND INDUCTION
– Prostaglandin E1 (Misoprostol):
• Possible routes of administration:
• Vaginal (place into the posterior fornix): 25
mcg (only if misoprostol is available in the
form of a 25-mcg tablet), if required repeat
after 6 hours
– Do not divide or cut a 200-mcg tablet into smaller
pieces, as this is inaccurate
PHARMACOLOGIC METHODS FOR CERVICAL
RIPENING AND INDUCTION
• Oral: 25 mcg; if required repeat after 3 hours
– ▪ If 25 mcg is not available, dissolve one 200 mcg tablet in
200 mL of water and administer 25 mL of that solution as a
single dose
• For patients with PROM, oral route of administration is
preferred for priming and induction
• Discontinue misoprostol and begin oxytocin infusion if:-
– Membranes rupture or cervical ripening has been achieved;
or 12 hours have passed since the first dose of prostaglandin
 Prostaglandin E2 (Dinoprostol)

– Prostaglandin E2 (3 mg pessary) is placed high in

the posterior fornix of the vagina and may be
repeated after six hours if required
MECHANICAL AGENTS FOR CERVICALRIPENING

• Mechanical agents work by directly causing cervical dilation,

and by releasing endogenous prostaglandins and oxytocin
• Balloon / Foley catheter:
– • After insertion, leave the Foley catheter until it is spontaneously
expelled or keep it in place for at least 12 hours, or until
contractions begin
– • Following priming with catheter, most women require further
induction of labour with oxytocin and/or amniotomy.
– • Note that oxytocin infusion can be started with a balloon catheter
in place or after it has been removed.
– • If there is a history of bleeding or ruptured membranes or
obvious vaginal infection, do not use a balloon or Foley catheter
• Osmotic dilators:
– These are hydrophilic agents that absorb water and thus gradually
expand within the cervical canal, which in turn causes the cervix to
dilate (E.g. laminaria)
• AMNIOTOMY (Artificial Rupture of Membranes)
– Amniotomy is a non-pharmacological method where the amniotic
membranes can be ruptured artificially to induce or augment labor
– Amniotomy may be contraindicated in pregnancy with known or
suspected vasa previa, any contraindications to vaginal delivery or
unengaged presenting part (although this obstacle may be
overcome with the use of a controlled amniotomy or the
application of fundal or suprapubic pressure)
 OXYTOCIN INDUCTION
– During induction, monitor and record rate of infusion of
oxytocin, duration and frequency of contractions, maternal
pulse and fetal heart rate every 30 minutes (never leave her
alone)
– The effective dose of oxytocin varies greatly among women.
Cautiously administer oxytocin in IV fluids; gradually
increase the rate of infusion until good labor is established
• Oxytocin infusion
– In women with intact membranes, amniotomy should be
performed where feasible before starting oxytocin infusion
– Allow a delay of six hours after administration of the last
dose of vaginal prostaglandins before commencing oxytocin
– Use 0.9% N/S or R/L for infusion. To ensure even mixing, the
bag must be turned upside down several times before use
– The initial infusion rate should be set at 1 to 2 milli units /
minute. The infusion rate is increased every 30 minutes up
to a maximum of 40 mU / min (250 ml/hour)
– As alternative, for induction of a primigravid woman only,
oxytocin with starting dose of 3.0 to 6.0 mU / min can be
used
– Aim to maintain the lowest possible dosage consistent
with regular uterine contraction that is until 3-5
contractions are achieved in 10 min, each lasting 40-60 sec.
– Label the bag and keep timely record of the drops used
– Monitor mother, fetus and labor according to the labor
protocol
– Record maternal and fetal conditions and progress of labor
– Continue the oxytocin infusion for at least one hour after
delivery
– In the event of uterine hyperactivity and/or fetal distress,
the infusion must be discontinued immediately
 Prolonged oxytocin infusion:
• If a new bag of fluid is required and if the oxytocin dose is
maintained with the first dose of oxytocin, add 2 IU of
Oxytocin in one liter of IV fluid and continue with the last
maintenance drop (see table)
• Oxytocin infusions which are maintained with the second
and third dose need adjustment of oxytocin concentration
i.e. If the oxytocin dose is maintained with the second
dose, add 5 IU of oxytocin in one liter of IV fluid and if the
oxytocin dose was maintained with the third dose, add 10
IU of oxytocin in one liter of IV fluid and continue with the
last maintenance drip rate
 Oxytocin infusion with pump:
• when induction of labor is undertaken with infusion pump the
recommended regimen is a starting dose of 1-2 milliunits per minute
and increased at intervals of 30 minutes
• The minimum dose possible of oxytocin should be used and this should
be titrated against uterine contractions aiming for a maximum of 3-4
contractions every 10 minutes
• The maximum dose used should not exceed 32 milliunits per minute
• Suggested standardized dilutions and dose regimens for oxytocin
infusion with pump include:
– 30 IU Oxytocin in 500mls of normal saline, hence 1ml/hr = 1 milliunit Oxytocin
per minute
– 10 IU Oxytocin in 500mls of normal saline, hence 3mls/hr = 1 milliunit Oxytocin
per minute
 COMPLICATIONS OF INDUCTION:
– Failed induction
– increased risk of caesarean section
– atonic PPH, iatrogenic prematurity
– uterine hyper stimulation/ tetanic contractions
– uterine rupture, fetal distress
– placental abruption, water intoxication, amniotic fluid embolism
• FAILED INDUCTION
• Definition: failure to achieve regular (e.g. every 3 minutes) contractions
and cervical change after at least 6 - 8 hours of the maintenance dose
of oxytocin administration, with artificial rupture of membranes if
feasible
– If the induction is not for an emergency condition and the fetal membranes are
intact (e.g. IUFD with unruptured membranes), the induction can be postponed
– If the pregnancy has to be terminated on the day of the induction or the
membranes are ruptured, cesarean section is the only available option
 UTERINE HYPERSTIMULATION
• Definition:
• Six or more contractions in 10 min and/ or
durations of 60 or more seconds
• Management
– Stop the infusion, position the woman on her left side
(left lateral position) and assess the FHR: If the FHR is
abnormal, manage for non-reassuring fetal heart rate
pattern and relax the uterus using betamimetics (if
feasible): terbutaline 250 mcg IV slowly over five
minutes OR salbutamol 10 mg in 1 L IV fluids (normal
saline or Ringer’s lactate) at 10 drops per minute
 UTERINE HYPERSTIMULATION
– If the FHR is normal, observe for improvement in
uterine activity and monitor the FHR. If normal
activity is not established within 20 minutes and
betamimetics have not been administered, relax
the uterus using betamimetics
– Observe for improvement in uterine activity, and
monitor the FHR: If both mother and fetus are in
good condition, restart at half dose of the last dose
causing uterine hyper stimulation
 AUGMENTATION OF LABOR
• DEFINITION:
– Augmentation of labor is stimulation of the uterus to increase its frequency,
duration and/ or strength of spontaneously initiated labor.
• METHODS
– The methods for augmentation are ARM and oxytocin and procedure is generally
similar to induction (see the section above).
– If there is no urgency to expedite delivery, oxytocin infusion is initiated one hour
after ARM and if the ARM failed to correct the weak contractions
• INDICATION
• The main indication for augmentation is weak and ineffective uterine
contractions leading to abnormal progress of labor
• CONTRAINDICATIONS
• Contraindications for oxytocin use include; breech presentation, scarred
uterus, multiple pregnancy, feature of CPD, secondary hypotonic
contractions due to obstructed labor etc
Finished