INDUCTION OF LABOUR

KOROS E.K., BSc.N, UoN,

Lecturer, AIC Litein MTC
Definition;
 Induction of labour is the process of initiation of
uterine contractions by artificial means at 38
weeks gestation or before term when the foetus is
viable.
NB: Augmentation of labour is the process of
strengthening uterine contractions that are already
established.
Augmentation of labour should not be confused
with induction of labour
 General Principles for induction of labour
(WHO 2011)
1. Induction of labor should be performed only when
there is a clear medical indication for it and the
expected benefits outweigh its potential harms.
2. When inducing labor, consideration must be given
to the actual condition, wishes and preferences of
each woman, with emphasis being placed on
cervical status, the specific method of induction of
labour and associated conditions such as parity
and rupture of membranes.
3. Induction of labour should be performed with
caution since the procedure carries the risk of uterine
hyper stimulation and rupture and fetal distress.
4. Wherever induction of labour is carried out, facilities
should be available for assessing maternal and fetal
well-being.
5. Women receiving oxytocin, misoprostol or other
prostaglandins should never be left unattended.
6. Failed induction of labour does not necessarily
indicate caesarean section.
7. Wherever possible, induction of labour should be
carried out in facilities where caesarean section can
be performed
Indications for induction of labour
 Prolonged pregnancy one that exceeds 42
completed weeks
 APH due to placenta praevia
 Previous large babies
 Previous precipitate labour
 IUFD (intrauterine fetal death)
 IUGR (intrauterine growth retardation)
 Unstable lie
 Diabetes mellitus
 Maternal request
 Cont’...
 Severe foetal abnormalities
 Rhesus iso-immunization to prevent severe
haemolysis of RBC
 Chronic renal diseases
 Severe pregnancy induced hypertension
 PROM after 37/40 and labour has not started
after 12 hrs
 Pre-eclampsia
 Contra-indications for Induction of
labour
 CPD
 Malpresentation
 Malposition
 Grand multiparous except DM patients
 Foetal compromise
 Unreliable EDD
 Previous scar
 History of recent extensive myomectomy
Favourable factors for success of induction

Gestation of 38 wks and above or near term

because the uterus is sensitive
Level of the presenting part 2/5 down or below
the ischial spines and if breech it must be
engaged
Ripe cervix with a Bishop score greater than 8
 BISHOP’S SCORE
ASSESSM DILATATION EFFACEMENT STATION CONSISTENCY POSITION
ENT (cm) ( %)
SCORE

0 0 cm 0-30 -3 FIRM POSTERIOR

1 1-2 cm 40-50 -2 MEDIUM MID/

CENTRAL

2 3-4 cm 60-80 -1,0 SOFT ANTERIOR

3 5-6 cm 90-100 +1,+2,+3 ------ -------

 Cont’...
NOTE: Add the score for each of the clinical
assessments. If the total score is greater than 8,
the success of induction approaches that of
spontaneous labour.
 -3 = engaged; +3 = on the perineum.
METHODS OF INDUCTION

a) Medical induction
b) Surgical induction
c) Mechanical induction
 a) Medical Induction
This refers to use of oxytocic drugs e.g.
i. Syntocinon,
ii. Prostaglandins,
iii. Misoprostol.
NB: Excess oxytocic drug cause;
 water retention
 over stimulation of the uterus producing unduly
strong contractions may endanger the life of the
foetus and cause rupture of the uterus.
 i. Syntocinon
Used to initiate contractions;
Start with 10 drops per minute and increase by 15 mins
until there are 3-4 contractions in 10 minutes. The
maximum should be 60 drops per minute
When there is good labour pattern, maintain the same
until delivery
Stop syntocinon if;
 contractions become very strong with no relaxation
 contractions occur more frequently in < 2 minutes
 there is change in FHR suggestive of foetal distress
 maternal distress due to continuous contractions
 Cont’…
Ifthe mother is not in active labour after 8 hrs of
syntocinon drip, consider C/S
After 2nd Stage, open to full rate flow of
syntocinon to assist in expulsion of placenta and
control bleeding
 Risks associated with use of intravenous
oxytocin
Induction by use of syntocinon may have the following
complications;
i. Failure to induce contractions
ii. Uterine hyper-stimulation or hypertonus
iii. Foetal hypoxia due to hypertonic uterus
iv. Uterine rapture due to hyper-stimulation
v. Fluid retention as a result of antidiuretic effect of
oxytocin
vi. PPH
vii. Amniotic fluid embolism due to strong
contractions resulting in placenta abruption
 ii. Prostaglandins
They are used for ripening the cervix as well as
initiation of uterine contractions
They be used intravaginally (pessaries), extra-
amniotic (injected through Foley catheter) ,oral or
IV PG E2.
 Foley catheter may cause trauma to the uterus.
Insert when the membranes are intact; repeat after
6 hrs and let the mother rest
Monitor the FHR and the contractions for 15
mins and if the progress is good rupture the
membranes
Discontinue PGE when:
-membranes rupture
-cervix has ripened
-there is established labour
-12 hrs have elapsed
Prostaglandins may be have the following
complications
- precipitate labour
- foetal hypoxia
- discomfort during the insertion
- uterine rupture
- cervical injury
 iii. Misoprostol
Oral (sublingual) misoprostol (25 μg, 2-hourly) is
recommended for induction of labour.
Vaginal low-dose misoprostol (25 μg, 6-hourly) is
also recommended for induction of labour.
Misoprostol use is not recommended for women
with previous caesarean section
 b) Surgical Induction
This is done by amniotomy in which the
following happen;
 the membranes are ruptured (ARM)
 amniotic fluid is expelled
 pressure decreases in the uterus
 prostaglandins are produced
 contractions are initiated
It is contraindicated in cases of malpresentation,
IUFD, of when the presenting part is high
 Cont’…
Complications of surgical induction may include;
 cord prolapse if done when the head is high
 early placenta separation especially in
polyhydramnios
 infection if membranes are ruptured for
more than 12 hrs
NB: Antibiotics should be given if labour
progress for more than 12 hrs after ARM
 c. Mechanical Induction
Balloon catheter is recommended for induction
of labour.
The combination of balloon catheter plus
oxytocin is recommended as an alternative
method when prostaglandins & misoprostol are
not available or are contraindicated.
Balloon catheter may be preferred for women
with scarred uterus, since it is less likely to be
associated with hyper stimulation of the uterus.
 Cont’…
Sweeping membranes is recommended for
reducing formal induction of labour. However,
maternal discomfort and bleeding associated with
the procedure should be balanced with the
anticipated benefits.
Since the interval between intervention and result
(i.e. sweeping membranes and initiation of labour)
can be longer than with formal methods of
induction of labour, this intervention would be
suitable for non-urgent indications for pregnancy
termination.
Cont’...
Breast Stimulation and sexual intercourse;
Assumptions of breast stimulation asserts that it
leads to ripening and dilatation of the cervix thus
promoting labour
However, regarding breast stimulation, sexual
intercourse and other similar methods of pre-
induction of labour, there is insufficient evidence
for recommending those methods.
Risks associated with induction of labour

1. Premature delivery
2. Sepsis
3. Foetal distress
4. Failed induction and Caesarean section
5. Hyper stimulation
6. Umbilical cord accidents
7. Uterine rupture
 ASSIGNMENT
Mrs. L, 30 year old, reports to MCH/FP clinic at
42 weeks gestation and the doctor orders
induction of labour
a) Differentiate induction of labour and augmentation of
labour (2 marks)
b) State five (5) indications for induction of labour
c) Explain five (5) features considered when doing
bishop score (5 marks)
d) Describe the management of a patient during
induction of labour (10 marks)
THANK YOU