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Induction of labor is common in obstetric practice. According to the most current studies, See page 2050 for
the rate varies from 9.5 to 33.7 percent of all pregnancies annually. In the absence of a ripe definitions of strength-
or favorable cervix, a successful vaginal birth is less likely. Therefore, cervical ripening or pre- of-evidence levels.
paredness for induction should be assessed before a regimen is selected. Assessment is
accomplished by calculating a Bishop score. When the Bishop score is less than 6, it is rec-
ommended that a cervical ripening agent be used before labor induction. Nonpharmaco-
logic approaches to cervical ripening and labor induction have included herbal compounds,
castor oil, hot baths, enemas, sexual intercourse, breast stimulation, acupuncture, acupres-
sure, transcutaneous nerve stimulation, and mechanical and surgical modalities. Of these
nonpharmacologic methods, only the mechanical and surgical methods have proven effi-
cacy for cervical ripening or induction of labor. Pharmacologic agents available for cervical
ripening and labor induction include prostaglandins, misoprostol, mifepristone, and relaxin.
When the Bishop score is favorable, the preferred pharmacologic agent is oxytocin. (Am
Fam Physician 2003;67:2123-8. Copyright 2003 American Academy of Family Physicians.)
L
abor is a process through which Over the past few years, there has been
the fetus moves from the intra- an increasing awareness that if the cervix
uterine to the extrauterine envi- is unfavorable, a successful vaginal birth is
ronment.It is a clinical diagnosis less likely. Various scoring systems for cer-
defined as the initiation and per- vical assessment have been introduced. In
petuation of uterine contractions with the 1964, Bishop systematically evaluated a
goal of producing progressive cervical efface- group of multiparous women for elective
ment and dilation. The exact mechanisms induction and developed a standardized
responsible for this process are currently not cervical scoring system. The Bishop score
well understood.1 Induction of labor refers (Table 1)1 helps delineate patients who
to the process whereby uterine contractions would be most likely to achieve a success-
are initiated by medical or surgical means ful induction. The duration of labor is
before the onset of spontaneous labor. inversely correlated with the Bishop score;
a score that exceeds 8 describes the patient
most likely to achieve a successful vaginal
TABLE 1 birth. Bishop scores of less than 6 usually
Bishop Score require that a cervical ripening method be
used before other methods.2-4
Nonpharmacologic Cervical
The rightsholder did not Ripening
grant rights to reproduce HERBAL SUPPLEMENTS
this item in electronic Given rapid growth in the herbal-sup-
media. For the missing plement industry, it is not surprising that
item, see the original print patients request information about alter-
version of this publication. native agents for labor induction. Com-
MAY 15, 2003 / VOLUME 67, NUMBER 10 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2123
Infection, bleeding, membrane rupture, and pla- SEXUAL INTERCOURSE
cental disruption are potential risks of using Sexual intercourse is commonly recommended for pro-
mechanical methods for cervical ripening. moting labor initiation. Sexual relations usually involve
stimulation of the breasts and nipples, which can promote
the release of oxytocin. With penetration, the lower uterine
segment is stimulated. This stimulation results in a local
monly prescribed agents include evening primrose oil, release of prostaglandins. Female orgasms have been shown
black haw, black and blue cohosh, and red raspberry leaves. to include uterine contractions, and human semen contains
Although evening primrose oil is the remedy most com- prostaglandins, which are responsible for cervical ripening.
monly used by midwives,5 it is unclear whether this sub- Only one study of 28 women resulted in minimally useful
stance can ripen the cervix or induce labor. Black haw, data, so the role of sexual intercourse as a method of pro-
which has been described as having a uterine tonic effect,6 moting labor initiation remains uncertain.7,9 [Reference 9
has been used to prepare women for labor. Black cohosh Evidence level B, systematic review of nonrandomized con-
has a similar mechanism of action, while blue cohosh may trolled trials)]
stimulate uterine contractions. Red raspberry leaves are
used to enhance uterine contractions once labor is initi- BREAST STIMULATION
ated. The risks and benefits of these agents are still Breast massage and nipple stimulation have been shown
unknown because the quality of evidence is based on a to facilitate the release of oxytocin from the posterior pitu-
long tradition of use by a certain population6 and anecdo- itary gland. The most commonly prescribed technique
tal case reports. The only conclusion that can be made at involves gently massaging the breasts or applying warm
this time is that the role of herbal remedies in cervical compresses to the breasts for one hour, three times a day.
ripening or labor induction is still uncertain.7 Oxytocin is released, and studies have demonstrated an
abnormal fetal heart rate (FHR) tracing similar to that
CASTOR OIL, HOT BATHS, AND ENEMAS occurring in oxytocin challenge testing in higher-risk preg-
Castor oil, hot baths, and enemas also have been recom- nancies. This abnormal rate may be caused by a reduction
mended for cervical ripening or labor induction. The in placental perfusion and fetal hypoxia.7 Two poorly
mechanisms of action for these methods are unknown. designed studies conducted in the 1970s and 1980s demon-
Review of the literature indicates that one poorly designed strated a difference in the intervention groups, but the poor
study involving 100 participants studied castor oil versus study design suggests that evidence is lacking to support
no treatment. While there did not appear to be any differ- breast stimulation as a viable method of inducing labor.7
ence in obstetric or neonatal outcomes, all women ingest-
ing the castor oil reported being nauseated. At this time, no ACUPUNCTURE/TRANSCUTANEOUS
evidence supports the use of these three modalities as NERVE STIMULATION
viable methods for cervical ripening or labor induction.7,8 Acupuncture involves the insertion of very fine needles
into designated locations with the purpose of preventing
or curing disease. In the Chinese system of medicine, it is
thought that acupuncture stimulates channels of qi (pro-
The Author
nounced chee), or energy. This energy flows along 12
JOSIE L. TENORE, M.D., S.M., is a full-time faculty member and assistant meridians, with designated points along these meridians.
professor in the Department of Family Medicine at Northwestern Uni-
versity Medical School, Chicago, and Evanston Northwestern Health- Each point is given a name and a number and is associated
care. She received her medical training at the University of Toronto Fac- with a specific organ system or function.10
ulty of Medicine, Ontario, and earned a master of science degree in In Western medicine, it is thought that acupuncture and
maternal and child health at Harvard School of Public Health, Boston.
transcutaneous nerve stimulation (TENS) may stimulate the
Address correspondence to Josie L. Tenore, M.D., S.M., Northwestern release of prostaglandins and oxytocin. Most of the studies
University Medical School, Department of Family Medicine, 303 E.
Chicago Ave., Chicago, IL 60611 (e-mail: josietenore@hotmail.com). involving acupuncture were poorly designed and do not
Reprints are not available from the author. meet the rigorous criteria for analysis set forth by the
2124 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 67, NUMBER 10 / MAY 15, 2003
Labor Induction
MAY 15, 2003 / VOLUME 67, NUMBER 10 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 2125
TABLE 4
Technique for Performing Amniotomy
MISOPROSTOL
Misoprostol (Cytotec) is a synthetic PGE1 analog that
ated with a lower mean dose of oxytocin needed and an has been found to be a safe and inexpensive agent for cer-
increased rate of normal vaginal deliveries.20 [Evidence
level A, RCT]
Amniotomy. It is hypothesized that amniotomy increases
TABLE 5
the production of, or causes a release of, prostaglandins
Technique for Placement of Dinoprostone Gel
locally. Risks associated with this procedure include umbil- (Prepidil)
ical cord prolapse or compression, maternal or neonatal
infection, FHR deceleration, bleeding from placenta previa
Patient selection:
or low-lying placenta, and possible fetal injury. The tech- Patient is afebrile.
nique for performing amniotomy is described in Table 4.7,19 No active vaginal bleeding is present.
Only two well-controlled trials studied the use of Fetal heart rate tracing is reassuring.
amniotomy alone, and the evidence did not support its use Patient gives informed consent.
for induction of labor.21 [Evidence level A, systematic Bishop score is < 4.
review of RCTs] Bring gel to room temperature before application, per
manufacturers instructions.
Pharmacologic Cervical Ripening Monitor fetal heart rate and uterine activity continuously starting
or Labor Induction 15 to 30 minutes before gel introduction and continuing for
PROSTAGLANDINS 30 to 120 minutes after gel insertion.
Introduce the gel into the cervix as follows:
Prostaglandins act on the cervix to enable ripening by a
If the cervix is uneffaced, use the 20-mm endocervical catheter
number of different mechanisms. They alter the extracellu- to introduce the gel into the endocervix just below the level
lar ground substance of the cervix, and PGE2 increases the of the internal os.
activity of collagenase in the cervix. They cause an increase If the cervix is 50 percent effaced, use the 10-mm endocervical
in elastase, glycosaminoglycan, dermatan sulfate, and catheter.
hyaluronic acid levels in the cervix. A relaxation of cervical After application of the gel, the patient should remain recumbent
smooth muscle facilitates dilation. Finally, prostaglandins for 30 minutes before being allowed to ambulate.
allow for an increase in intracellular calcium levels, causing May repeat every six hours, up to three doses in 24 hours.
contraction of myometrial muscle.22,23 Risks associated End points for ripening include strong uterine contractions, a
Bishop score of 8, or a change in maternal or fetal status.
with the use of prostaglandins include uterine hyperstimu-
Maximum recommended dosage is 1.5 mg of dinoprostone
lation and maternal side effects such as nausea, vomiting, (3 doses) in 24 hours.
diarrhea, and fever. Currently, two prostaglandin analogs Do not start oxytocin for six to 12 hours after placement of the last
are available for the purpose of cervical ripening, dinopro- dose, to allow for spontaneous onset of labor and protect the
stone gel (Prepidil) and dinoprostone inserts (Cervidil). uterus from overstimulation.
Prepidil contains 0.5 mg of dinoprostone gel, while Cervidil
contains 10 mg of dinoprostone in pessary form. The tech- Information from Hadi H. Cervical ripening and labor induction:
niques for gel and pessary placement are described in Tables clinical guidelines. Clin Obstet Gynecol 2000;43:524-36.
5 and 6, respectively.19
2126 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 67, NUMBER 10 / MAY 15, 2003
Labor Induction
TABLE 6
Technique for Placement of Dinoprostone Vaginal
Inserts (Cervidil)
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Labor Induction
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