Nor Fareshah bt Mohd Nasir

071303057
Batch 21/ F2

INDUCTION OF LABOR
REFERENCES..

 www.nice.org.uk –review of NICE

inherited guideline D (CG70)
 www.mdconsult.com – books –
Gabbe : Obstetrics Normal and
Problem Pregnancies, 5th ed.
 www.wikipedia.org
 Hacker and Moore’s Essentials of
Obstetrics & Gynecology 5th Ed.
REFERENCES..

 www.uptodate.com/contents/i
nduction-of-labor?
 Obstetrics Illustrated 6th Ed.
 Protocols in O & G – Hospital
Melaka
DEFINITIONS – INDUCTION of
LABOR
 refers to the iatrogenic stimulation of uterine
contractions before the onset of spontaneous
labor to accomplish vaginal delivery.[1], [2]

 Induction of labor is the process whereby

labor is initiated by artificial means.[3]

[1] Gabbe’s – mdconsult.com

[2]uptodate.inc
[3] Hacker & Moore’s
 DEFINITIONS – AUGMENTATION
of LABOR
 Artificial stimulation of labor that has begun
spontaneously. [4]

 refers to increasing the frequency and

improving the intensity of existing uterine
contractions in a patient who is in labor and
not progressing adequately, in order to
accomplish vaginal delivery.[5]
[4] Hacker & Moore’s
[2]Gabbe’s obstetrics - mdconsult
 Why is it important?

 it is believed that the outcome of the

pregnancy will be better if it is artificially
interrupted rather than being left to follow its
natural course.[6]
 Induction of labor is one of the most
commonly performed obstetric procedures in
the United States, UK. [7], [8]

[6] NICE inherited guigeline CG70

[7,8]Gabbe’s obstetrics – mdconsult ; NICE
 Criteria for induction [9]

 Continuing the pregnancy is believed to be

associated with greater maternal or fetal risk
than intervention to deliver the pregnancy.

 There is no contraindication to vaginal birth

[9] UptoDate inc

INDICATIONS FOR INDUCTION [10]

Maternal fetoplacental
•preeclampsia •Abnormal fetal testing
•Diabetes Mellitus •Rh incompatibility
•Heart Disease •Fetalabnormality
•Prolonged Pregnancy •PROM
•IUGR •Chorioamnionitis

[10] Hacker & Moore’s

INDICATIONS FOR INDUCTION [11]

ACCEPTED ABSOLUTE RELATIVE INDICATIONS

INDICATIONS
Hypertensive disorders
•Preeclampsia / eclampsia •Chronic hypertension

Maternal medical conditions

•Diabetes mellitus •SLE
•Chronic pulmonary disease •GDM
•Renal disease •Hypercoagulable disease
•Cholestasis
Prelabor Rupture of Membranes Polyhydramnios
Chorioamnionitis Fetal anomalies requiring special
neonatal care

[11] Gabbe’s obstetrics – mdconsult

INDICATIONS FOR INDUCTION [11]

ACCEPTED ABSOLUTE RELATIVE INDICATIONS

INDICATIONS
Fetal compromise Logistic factors
•Fetal growth restriction •Risk of rapid labor
•Isoimmunization •Distance from hospital
•Nonreassuring antepartum fetal •Psyshosocial indication
testing •Advance cervical dilatation
•oligohydramnios
Fetal demise Previous Stillbirth
Prolonged pregnancy (>42 weeks) Postterm pregnancy (>41 weeks)

[11] Gabbe’s obstetrics – mdconsult

CONTRAINDICATIONS

Maternal
ABSOLUTE  Contracted pelvis [12] , active genital
herpes, placenta/vasa praevia , cord prolapse[13]
RELATIVE 
 Prior uterine surgery
 Classic caesarean birth
 Complete transection of uterus (myomectomy,
reconstrution)
 Overdistended uterus
 Ca cervix
[12] Hacker & Moore’s
[13] Gabbe’s Obstetrics- mdconsult
 CONTRAINDICATIONS[14]

Fetoplacental
 preterm fetus without lung maturity
 Acute fetal distress
 Abnormal presentation

[14] Hacker & Moore’s

PREDICTING A SUCCESSFUL
INDUCTION [15]

 Modified Bishop Score

 Fetal Fibronectin
 Sonographically measured cervical length

[15] uptodate Inc

Modified Bishop Score
Modified Bishop Score

 Significance : to predict the success of labor

induction[16] or likelihood of vaginal delivery.
[17]

 high ( ≥5 or ≥8), the likelihood of vaginal

delivery is similar whether labor is
spontaneous or induced.
 low Bishop score is predictive that induction
will fail to result in vaginal delivery.[17]
[16] Gabbe’s Obstetrics-mdconsult.com
[17] uptodate Inc
Fetal fibronectin (fFN)

 is a protein produced by fetal cells and is

found at the interface of the chorion and the
decidua (between the fetal sack and the
uterine lining).[18]
 to predict uterine readiness for induction
 Positive- shorter interval to delivery, (even in
nulliparas with low (<5) Bishop scores).[19]

[18] wikipedia/fetal fibronectin

[19] uptodate Inc
Methods of Induction

Pharmacological Non
Pharmacological
PHARMACOLOGICAL

 PGE2  Misoprostol IUFD

 vaginal *  Mifepristone
 Oral
 Others :-
 IV
 Hyaluronidase
 Extraamniotic
 Corticosteroids
 Intracervical
 Estrogen

 Oxytocin
 IV*
 With amniotomy
NON PHARMACOLOGICAL

SURGICAL

NON-SURGICAL
NON PHARMACOLOGICAL

SURGICAL NON SURGICAL

 membrane sweeping
 Amniotomy  OTHERS
 Mechanical method  Herbal supplements
 Balloon catheters  Acupuncture
 Laminaria tents  Sexual intercourse
 Breast stimulation
 Hot baths, castor oil
Prostaglandins

 MOA : dissolution of collagen bundles & an

increase in submucosal water content of the
cervix  similar to those observed in early
labor; and mediates uterine contraction.
 PGs are endogenous compounds found in
the myometrium, deciduas, and fetal
membranes during pregnancy.[20]

[20] Gabbe’s Obstetrics- mdconsult

i) Vaginal PGE2 – Prostin
(dinoprostone)[21]
 Tablets – 3mg for favorable cervix
 Gel – 2.5 -5 mg
 Controlled released pessary – 10mg unfavorable

 Advantages
 Less invasive
 Convenient
 Less PPH
[20] NICE guidelines
Recommended Regimens

 Favorable cervix – 1 cycle of tab/gel [21]

 3mg tab (primi), 1.5mg tab (multi)
 After 6 hours if still not deliver
 GIVE 1.5mg tab

 Unfavorable cervix – 1cycle of controlled

released pessary [22]
 1 dose in 24 hours

[21]Melaka Hospital Protocols

[22]NICE guidelines
PGE2… continued

 All regimens have risk of :-

UTERINE
HYPERSTIMULATION [23]

[23]NICE guidelines
 OXYTOCIN–usually to
AUGMENT.. rather than INDUCE
MODE [24]
 Alone
 With amniotomy
 Following cervical ripening

-less efficacy compared to vaginal PGE [24]

 Fewer vaginal birth in 24hrs
 Lower bishop score
 More C-section birth
[24]NICE guidelines
Principles of oxytocin
administration.[25]
 Intravenously
 dilute infusion, and "piggybacked" into the
main intravenous line
 calibrated infusion pump
 not exceed 72 hours
 If adequate labor achieved, reduce infusion
rate and the concentration

[25]Hacker & Moore’s

Method for oxytocin
infusion[26]
 SOLUTION
10 units of oxytocin in 1000 mL of 5%
dextrose or balanced salt solution (10
mU/mL)

 ADMINISTRATION
Piggyback into main IV line; administer
solution by infusion pump
[26]Hacker & Moore’s
Major complications of
Oxytocin.[27]

 HYPERSTIMULATION  fetal distress

 SEVERE WATER INTOXICATION  ADH
like effect
 UTERINE MUSCLE FATIGUE (postdelivery
atony)

[27]Hacker & Moore’s

AMNIOTOMY
MECHANICAL METHODS

1. Balloon Catheters
2. Laminaria tents
BALLOON CATHETERS
LAMINARIA TENTS
 Mechanical methods…[28]

ADVANTAGES DISADVANTAGES
 Less risk of uterine  Neonatal infection
hyperstimulation
 Reduce risk of rupture is
presence of C-section scar

Overall  when compared to Prostaglandins by

any route, DOES NOT IMPROVE rate of vaginal
births within 24hrs & rate of c-section.

[28] NICE guidelines

Membrane Sweeping[29](mechanism)

 Passing examining finger through cervix


Rotates against wall of uterus beyond internal
os

Strip chorion away from decidua (richest source
of prostaglandins)
Membrane sweeping cont’d..

 Prior to induction, women should be offered

vaginal exam for membrane sweeping, esp
40, 41 weeks POG

 If labor does not start spontaneously,

additional membrane sweeping.
 Membrane sweeping..outcomes

 reduced need for formal induction of labour,

especially in multiparous women
 increased rate of spontaneous labour, if
performed more than once from 38 weeks of
gestation; the most appropriate regimen is not
clear from the evidence
 increased incidence of uncomplicated bleeding
 increased reports of pain but most women would
still choose sweeping in a future pregnancy and
recommend it to friends.
[29] NICE guidelines
 MONITORING INDUCED LABOR.[30]
• Uterine contractions
• Fetal monitoring
• CTG – watch out for hyperstimulation
• Glucometer 2 hourly (GDM/DM)
• BP 4 hourly (PIH/HTN)
• Adequate sedation if in pain?
• Phenergan 25 mg stat, pethidine 75 mg stat

[30] Hospital Melaka protocols

 MONITORING INDUCED LABOR. [31]

• BEFORE: Bishop score- assess** & record, FHR

confirmed with EFM (electronic fetal monitoring)

• DURING : continuous electronic fetal heart

monitoring, uterine contraction.

** 6hrs after vaginal PGE2

24hrs after PGE2 controlled release pessary

[31] NICE guidelines

 Complications of Induction.
[32]

[32] NICE guidelines

1. UTERINE HYPERSTIMULATION

2. FAILED INDUCTION

3. CORD PROLAPSE

4. UTERINE RUPTURE
 TIMING OF IOL in Hospital
Melaka

 At 6 am except Saturday, Sunday & Public

holiday unless exceptional cases.[33]
 women more satisfied when induction takes
place in the morning. [34]

[33] Protocols of Hospital Melaka

[34] NICE guidelines
SPECIAL CONSIDERATIONS..

1) Prolonged pregnancy
2) PPROM
3) PROM
4) Previous C-section
SPECIAL CONSIDERATIONS..

5) Breech
6) IUGR
7) H/O Precipitated Labor
8) IUFD
Thank You …