INDUCTION OF LABOUR

Induction of labour means initiation of uterine contractions by any method for the
purpose of vaginal delivery.
INDICATIONS OF LABOUR INDUCTION

Postdated pregnancy
Premature rupture of membranes/chorioamnionitis
Hypertensive disorders of pregnancy
Intra uterine fetal demise
Fetal compromise (IUGR/Oligo/major congenital anomaly)
Maternal medical complications like diabetes mellitus/chronic renal
disease/chronic hypertension/cholestasis of pregnancy

MOST COMMON CONDITIONS FOR WHICH WE INDUCE LABOUR

Postdatism
PROM
IUD
Hypertensive disorders

PRE REQUISITES FOR IOL

Facilities of assessment of maternal and fetal well being

Full time attendee to patient
Facilities for 24*7 emergency LSCS

ASSESMENT BEFORE IOL

Clear indication
Exclude contra indication
Confirmation of gestational age/ fetal weight/lung maturation/presentation &
lie
Informed written consent ( after explaining chances of prolonged labour/
abnormal uterine contraction/ increased operative interference.

CONTRAINDICATIONS

Prematurity without a clear associated indication

Malpresentation
Previous classical CS/hysterotomy/myomectomy
Unexplained vaginal bleeding
When a clear indication of emergency LSCS exists.

BISHOPS SCORE
Bishops pre induction cervical scoring system
Score
dilatation
effacement
consistency
position
Station

0
closed
0-30
firm
post
-3

1
1-2cm
40-50
medium
midline
-2

2
3-4cm
60-70
soft
ant
-1,0

3
5cm+
>=80
+1,+2

METHOD OF INDUCTION

bishop's score

<6

cervical ripening
with intracervical
dinoprostone gel
followed by
amniotomy and
oxytocin infusion

>6

misopostol
vaginal tab can
be used
alternatively

oxytocin infusion low

dose (0.5-2mIU)
increasing at 1-2mIU
in 15-40min
high dose (6mIU
increasing at 3-6mIU
in 15-40min followed
by amniotomy

METHODS OF IOL
MEDICAL METHODS
DINOPROSTONE PGE2 (GEL, SUPPOSITORY, TABS,)

Collagenolytic
Helps in cervical ripening
Sensitizes myometrium to oxytocin
Most common regimen is intracervical gel 0.5 mg 6hrly for 3 doses.
Side effects few
Costly

MISOPROSTOL PGE1

Oral, buccal, sublingual or vaginal use

25mcg pv 4hourly for four doses
Tachysystole, MSL, uterine hyper stimulation and rupture are side effects
Contraindicated in prev LSCS.

OXYTOCIN

Stimulates contractions
Effective after cervical ripening
Acts by receptor mediated voltage gated calcium channels and
prostaglandin production

OTHERS

Mifepristone (prostaglandin antagonists)

Onapristone (selective progesterone receptor antagonists)

MECHANICAL METHODS

Intracervical foleys induction

Laminaria tents and hygroscopic dilaters

SURGICAL METHODS
Artificial rupture of membranes (amniotomy): induction occurs by stretching of
cervix, separation of membranes, PGs release, and reduced amniotic volume.
Not effective in unfavorable cervix, at least 1finger dilatation is required.
Added advantages in pre-eclampsia (reduces bp) polyhydramnios (relieves maternal
distress)
Hazards are cord prolapse, amnionitis, injury.
Membrane stripping
Risks

of induction
Uterine hyper stimulation
Uterine rupture
Fetal distress
Increases incidence of meconium staining
Prolonged labour
Increased infection with mechanical dilatation

Consent
Induction with intracervical PGE2 gel 0.5mg
Patient should remain in recumbent position for 30min
Fetal heart rate and uterine contraction should be monitored by CTG for half an hour
Fetal heart rate and maternal vitals monitoring half hourly.
Be vigilant for risks.

Failed induction is failure to induce labour after 1 cycle of treatment. Reassess

condition, explain, and attempt to induce depending on clinical conditions. Or go for
caesarean section.
IOL IN POSTMATURITY
As per WHO, IOL is recommended for women> 41wks gestation
At or beyond term
Sweep stretch membranes; wait for spontaneous onset of labour
Fetal monitoring by AFI, NST, FETAL KICK COUNT, USG for BIOPHYSICAL PROFILE
After taking consent miso 25mcg or pge2 0.5mg may be used to induce labour
followed by amniotomy and oxytocin infusion if required.
IOL IN PREV LSCS
Informed consent (explain 1.5 fold chances of caesarean section, 2to3 fold chances
of uterine rupture)
Assess prev vaginal delivery, period of gestation, lie, presentation, scar tenderness
Ultrasound for liquor volume and gestation, scar thickness and placental
localization.
Bishops score
Unfavorable: cervical priming using Foleys catheter
Favorable: vag PGE2 followed by amniotomy
After PGE2 veg reassess every 6hours, oxytocin should be used in low doses 0.5-1
mu/min
If, 2cm progress after 4hours of oxytocin, LSCS should be considered.
Monitoring strictly for uterine rupture, pulse, BP, scar tenderness, color of liquor,
electronic fetal monitoring.
IOL IN IUGR
Assess accurate dating, medical problem, drug intake, infection
Look for BP, pallor, nutrition, fundal height (4weeks discrepancy), lie, presentation,
NST
USG fetal biometry, AFI, umbilical artery and MCA Doppler.
Pregnancy > 37weeks induce
Pregnancy <37 weeks with mild IUGR- admit, fetal surveillance, induction after 37
weeks.
Pregnancy <37 weeks with severe IUGR- admit, administer steroids, monitor NST,
BPP, UA/MCA Doppler if normal induce after 37weeks
NST normal, Decreased or absent end diastolic flow induce at 36 weeks
Delivery at 34 weeks if clinically significant oligo
NST abnormal, Reversal of end diastolic flow Em LSCS
INTRA UTERINE FETAL DEMISE
Confirm diagnosis / USG Doppler/basic Inv,
Psychological stress, deranged coagulation profile, ruptured membranes, infection
then induce immediately

If, 28weeks oral mifepristone 200mg followed by vaginal misoprostol 200to400mcg

4-12hourly
If >28weeks, miso 25mcg 4hrly for 4doses PGE2 gel for unfavorable cervix
oxytocin infusion (amniotomy to be avoided)
If >28weeks with prev LSCS no miso, Foleys to be used.