Induction of Labour

Samina Hussain
18/158
Definition:
IOL is the planned initiation of
labour prior to its spontaneous
onset.
Interventions are designed to
artificially initiate uterine
contractions leading to progressive
dilatation and effacement of the
cervix and birth of the baby
Indications:
.
Performed when the risks to the fetus
and/or the mother of the pregnancy
continuing outweigh those of bringing
the pregnancy to an end.
 PROLONGED PREGNANCY
 FETAL GROWTH RESTRICTION
 PRE ECCLAMPSIA
 DETERIORATING MATERNAL ILLNESSES
 PRE LABOUR RUPTURE OF MEMBRANES
 UNEXPLAINED ANTEPARTUM HAEMORRHAGE
 DIABETES MELLITUS
 TWIN PREGNANCY(CONTINUATION BEYOND 38
WEEKS)
 INTRAHEPATIC CHOLESTASIS OF PREGNANCY
 MATERNAL ISO IMMUNIZATON AGAINST RED
CELL ANTIGENS
 SOCIAL REASONS
Prolonged Pregnancy
The most common reason for IOL
Recommended IOL between 41 and 42 weeks’
gestation
Prolonged pregnancy are associated with a
higher risk of:
- stillbirth
- fetal compromise in labour
- meconium aspiration and
- mechanical problems at delivery.
Prelabour rupture of membranes
(PROM)
The longer the delay between membrane rupture
and delivery of the baby, the greater the risk of
ascending infection (chorioamnionitis) and neonatal
and maternal infectious morbidity.
It is beneficial to induce labour approximately 24
hours following membrane rupture, this reduces
rates of chorioamnionitis, endometritis and
admission to the neonatal unit.
However, before 34 weeks some other indication is
also required to induce labour (e.g suspected
maternal infection, fetal compromise and growth
restriction)
Pre-eclampsia and other maternal hypertensive
disorders
 Pre-eclampsia at term is normally managed with IOL;
however, at very preterm gestations (<34 weeks) or
where there is rapid maternal deterioration or significant
fetal compromise, caesarean delivery may be a better
option
Maternal diabetes, twin gestation and
intrahepatic cholestasis of pregnancy are all
common reasons for IOL at 38 weeks’ gestation, and
sometimes earlier
‘Social’ induction of labour is controversial and is
performed to satisfy the domestic and organizational
needs of the woman and her family. It is mostly
discouraged, and there must be careful counselling as
to the potential risks involved
.
Fetal indication
1. Suspected fetal compromise (IUGR)
2. Intrauterine death (IUFD)
Contraindications:
Major placenta praevia(Type 3 & 4)
 Vasa praevia
Abnormal lie/ presentation eg. Transverse
lie and breech presentation
Cord prolapse
Previous one or more caesarean sections
Previous myomectomy entering
endometrial cavity.
Pelvic structural abnormality
Bishop Score
Bishop score is a scoring system to quantify
how far the process of labour has
progressed prior to IOL
As the time of spontaneous labour
approaches, the cervix becomes softer,
shortens, moves forward, effaces and starts
to dilate. This reflects the natural
preparation for labour.
If labour is induced before this process has
occurred, the induction process will tend to
take longer.
 High scores (a
‘favourable’ cervix) are Score <5 :
further ripening
associated with an easier, needed
shorter induction process
that is less likely to fail.
 Low scores (an
Score 5-7:
‘unfavourable’ cervix) equivocal
point to a longer IOL that
Score 8 or
is more likely to fail and greater:
result in caesarean favorable for
induction, or the
section. chance of a
vaginal delivery
with induction
Methods of Induction
Most common formulation in current use is
Prostaglandin E2 (PGE2), inserted
vaginally into the posterior fornix as a
tablet or gel.
Prostaglandins promote cervical
ripening and encourage the onset of
labour by acting on cervical collagen so as
to encourage the cervix to soften and
stretch in preparation for childbirth.
Prostaglandins may also stimulate uterine
contractions.
Oxytocin has a short half-life and is given
intravenously as a dilute solution. 10 IU of oxytocin
is added to 1L of 5% dextrose or saline solution.
The starting infusion rate is low and defined
increments follow every 30 minutes until 3–5
contractions are achieved in every 10 minutes

Mifepristone (an antiprogesterone) and misoprostol

.
 Membrane sweeping is the process of insertion of gloved
finger through cervix and rotate around the inner rim to
strip off the chorionic membrane from underlying decidua
and to release natural Prostaglandins
 Intracervical balloon of foley bulb induction. It
involves inserting a Foley catheter into the cervix .The
balloon is inflated with 30-50 mL of normal saline and is
retracted so that it rest on the internal os, helping it dilate
and increasing the tissue’s response to oxytocin and
prostaglandins.
Amniotomy or artificial rupture of
membranes. Simple rupture of
membranes using sharp instrument that
passes over a finger into the cervix
which allows discharge of amniotic fluid.
Nature of amniotic fluid is recorded
(clear, bloody,thick, thin or mecomium)
FHR is recorded after the procedure
Fetal surveillance following
IOL
CTG should be performed for a minimum of
20 minutes before its administration and
for 60 minutes thereafter CTG should be
recommenced once the uterine
contractions begin.
On p/v examination feel for sutures,
presence of cord , station of head , caput
and moulding also watch for color of liquor.
Complications of induction of
labour
Women are likely to experience more pain in
an induced labour and use of epidural for
analgesia is more common.
The rates of instrumental delivery and C
section are higher following induction.
Long labour augmented with oxytocin
predisposed to post partum hemorrhage
secondary to uterine atony.
Fetal compromise is more common during
induced labour and this, in part is due to
uterine hyper-stimulation caused by the
injudicious use of prostaglandins.
A contraction frequency of more than 5 per ten
minutes should be treated by stopping the oxytocin
and administration of a tocolytic drug most commonly
the subcutaneous injection of beta 2 agonist,
terbutaline.
Uterine hyperstimulation may precipitate fetal
bradycardia and the need for emergency C section.
If ARM is performed while the fetal head is high then
cord prolapse may occur again precipitating the need
for emergency C-section.
Women with previous C section scar or some other
form of other uterine injury are at a greater risk of
uterine rupture if they are induced.
Failed Induction
Thank you