PRESENTATION

ON
AUGMENTATION
AND
INDUCTION OF LABOR

SUBMITTED TO: SUBMITTED BY:

Mrs. R. Anitha Ms. B. Blessy Madhuri
Head of the Dept, OBG M.Sc (N) 2nd year, OBG
Government College of Government College of
Nursing, Nursing,
Somajiguda, Hyderabad. Somajiguda, Hyderabad.
 STUDENT PROFILE

NAME OF THE STUDENT : MISS. B. BLESSY MADHURI

COURSE : MSC (N) 2 nd YEAR.

SUBJECT : OBSTETRICS & GYNAECOLGY NURSING

UNIT : 3RD UNIT

TOPIC : AUGMENTATION AND INDUCTION OF

LABOUR

METHOD OF TEACHING : LECTURE CUM DISCUSSION.

GROUP : MSC. (N) 2 ND YEAR.

NUMBER OF STUDENT : 10

PLACE : MSC (N) 2ND YEAR OBG CLASS ROOM.

DATE : 22-01-2021

TIME : 2pm - 4pm

DURATION : 1 HOUR.

A.V AIDS : BLACK BOARD

OHP
CHARTS
HANDOUTS
PAMPLETS
SUPERVISED BY : MRS. R. ANITHA
LECTURER
GOVERNMENT COLLEGE OF NURSING,
SOMAJIGUDA, HYDERABAD.
 STUDENT TEACHER OBJECTIVES:
 Develop skills in teaching or explanation of the topic

 Understand the organisation of topic

 Develop skills in controlling the group
 Develop skills in using different types of AV aids
 OBJECTIVES
GENERAL OBJECTIVES:
By the end of the session, students will be able to gain in depth knowledge
about Augmentation and induction of labor.

SPECIFIC OBJECTIVES:
At the end of the session the group will be able to:
 Define augmentation and induction of labor
 Enlist the purposes and induction of labor
 Discuss the indications and contraindications of induction of labour
 List the dangers of induction of labor
 Explain the parameters to assess prior to the induction of labor
 List the methods of induction of labor
 Explain the medical induction of labor, common clinical condition’s ,
merits and demerits.
 Describe the surgical induction of labour
 Discuss the combined method of induction of labor
 Explain the active management of labour
 Discuss about the partograph
INTRODUCTION:
As the end of pregnancy nears, the cervix normally becomes soft (ripe) and
begins to open (dilate) and thin (efface), preparing for labor and delivery. When
labor does not naturally start on its own and vaginal delivery needs to happen
soon, labor may be started artificially (induced).
INDUCTION OF LABOR (IOL):
Induction of labor (IOL) means initiation of uterine contractions (after the
period of viability) by any method (medical, surgical or combined) for the
purpose of vaginal delivery.
AUGMENTATION:
Augmentation of labor is the process of stimulation of uterine
contractions (both in frequency and intensity) that are already present but found
to be inadequate.

PURPOSE OF INDUCTION OF LABOR:

 When the risks of continuation of pregnancy either to the mother or to the
fetus is more, induction is indicated.
 Before induction one must ensure the gestational age as well as
pulmonary maturity of the fetus. Rarely, preterm induction may have to
be done.
Elective induction of labor:
Elective induction of labor means initiation of labor at term pregnancy
without any acceptable medical or obstetric indication.
 It is done for the convenience of the patient, obstetrician or the hospital.
 Unless for a selective patient (e.g. who have history of rapid labors) the
social indications should not be recommended.
 The major risks are iatrogenic prematurity, increased caesarean delivery
for failed induction.
Indications for Induction of Labour (IOL):
 Pre-eclampsia, eclampsia (hypertensive disorders in pregnancy)
 Maternal medical complications
-Diabetes mellitus
-Chronic renal disease
-Cholestasis of pregnancy
 Post maturity
 Abruptio placentae
 Intrauterine Growth Restriction (IUGR)
 Rh-isoimmunization
 Premature rupture of membranes
 Foetus with a major congenital anomaly
 Intrauterine death of the foetus
 Oligohydramnios, polyhydramnios
 Unstable lie-after correction into longitudinal lie.

Contraindications of Induction of Labor:

 Contracted pelvis and cephalopelvic disproportion
 Malpresentation (breech, transverse or oblique lie)
 Previous classical cesarean section or hysterotomy
 Uteroplacental factors: Unexplained vaginal bleeding, vasaprevia,
placenta previa
 Active genital herpes infection
 High-risk pregnancy with fetal compromise
 Heart disease
 Pelvic tumor
 Elderly primigravida with obstetric or medical complications
 Umbilical cord prolapse
 Cervical carcinoma.
Dangers of Induction of Labor
1. Maternal:
 Psychological upset when there is induction failure and caesarean section
is done
 Tendency of prolonged labour due to abnormal uterine action
 Increased need of analgesia during labour
 Increased operative interference
 Increased morbidity.
2. Fetal:
 Iatrogenic prematurity
 Hypoxia due to uterine dysfunction
 Prolonged labour
 Operative interference.

PARAMETERS TO ASSESS PRIOR TO INDUCTION OF LABOR:

When induction is considered for foetal interest, one must ensure the
gestational age and maturity (pulmonary) of the foetus. However, induction for
maternal interest may compel to ignore the foetus.
1. Maternal:
 To confirm the indication for IOL
 Exclude the contraindication of IOL
 Assess Bishop score (score > 6, favourable)
 Perform clinical pelvimetry to assess pelvic adequacy
 Adequate counselling about the risks, benefits and alternatives of IOL
with the woman and the family members.
2. Fetal:
 To ensure fetal gestational age
 To estimate fetal weight
 Ensure fetal lung maturation status
  Ensure fetal presentation and lie.
 Confirm fetal well-being.

Predictive Factors for Successful Induction of Labor

1. Period of gestation Pregnancy nearer the term or post-term
more the success.

2. Preinduction score Bishop score ≥ 6 is favorable. Dilatation

of the cervix is most important.

3. Sensitivity of the uterus Positive oxytocin sensitivity test is

favourable for IOL

4. Cervical ripening Favourable in multiparous and in cases

with PROM. Less responsive in elderly
primigravidae or cases with prolonged
retention of dead fetus.

5. Presence of fetal fibronectin Presence of fetal fibronectin (FFN) in

(FFN) in vaginal swab (> 50 vaginal swab (> 50 ng/mL) Favourable
ng/mL) for successful IOL

6. Other positive factors Maternal height > 5'; Normal BMI, EFW
< 3 kg

Cervical Ripening: It is a series of complex biochemical changes in the cervix

which is mediated by the hormones. There is alteration of both cervical collagen
and ground substance. Ultimately, the cervix becomes soft and pliable.

METHODS OF INDUCTION OF LABOR:

1. Medical
2. Surgical
3. Combined
MEDICAL INDUCTION
DRUGS USED:
 Prostaglandins PGE2, PGE1
 Oxytocin
 Mifepristone.
1. Prostaglandins:
Act locally (autocrine and paracrine hormones) on the contiguous cells.
PGE2 and PGF2α both cause myometrial contraction. But PGE2 is primarily
important for cervical ripening whereas PGF2α for myometrial contraction.
PGE2 has greater collagenolytic properties and also sensitizes the myometrium
to oxytocin. Intracervical application of dinoprostone (PGE2 – 0.5 mg) gel is the
gold standard for cervical ripening. It may be repeated after 6 hours for 3 or 4
doses if required. The woman should be in bed for 30 minutes following
application and is monitored for uterine activity and fetal heart rate.
Side effects:
 Nausea, vomiting, diarrhoea, pyrexia, bronchospasm, tachycardia and
chills
 Cervical laceration may occur (PGF2α) when used as an abortifacient
 Tachysystole (hyperstimulation) of the uterus, may occur during induction
and may continue for a variable period.
 Risk of uterine rupture in cases with previous scar
2. Misoprostol (PGE1):
It is currently being used either trans-vaginally or orally for induction of
labour (ACOG 2003). Oral use of misoprostol is less effective than vaginal
administration. A dose of 25 µg vaginally every 4 hours is found either superior
or similarly effective to that of PGE2 for cervical ripening and labour induction.
With the above dose schedule, the risk of uterine hyperstimulation, meconium-
stained liquor and foetal heart irregularities are reduced. Total 6–8 doses are used.
Buccal and sublingual use of misoprostol can avoid the first pass hepatic
circulation and can maintain the serum bioavailability similar to that of vaginal
use.
Side effects are:
 Tachysystole
 Meconium passage and possibly uterine rupture.
It is contraindicated in women with previous caesarean birth.
3. Oxytocins:
It’s an endogenous uterotonic that stimulates uterine contractions. Oxytocin
receptors present in the myometrium are more in the fundus than in the cervix.
Receptor concentrations increase during pregnancy and in labor.
Oxytocin acts by:
a) receptor mediation
b) voltage-mediated calcium channels
c) prostaglandin production.
Because of short half-life (3-4 minutes) plasma levels fall rapidly when
intravenous infusion is stopped. Oxytocin is effective for induction of labor when
the cervix is ripe. It is less effective as a cervical ripening agent. Mifepristone
(progesterone receptor antagonists) blocks both progesterone and glucocorticoid
receptors. RU 486, 200 mg vaginally daily for 2 days has been found to ripen the
cervix and to induce labor. Onapristone (ZK 98299) is a more selective
progesterone receptor antagonists.
Mechanical methods: They are effective.
Advantages are low cost, low risk of tachysystole, disadvantages are infection.
COMMON CLINICAL CONDITIONS:
 Intrauterine fetal death
 Premature rupture of membranes
 In combination with surgical induction (ARM).
Merits and Demerits of Oxytocin and Prostaglandins in Medical Induction
of Labour:
Features Oxytocin Prostaglandins (PGE2
, PGE1 )
Cost Cheaper PGE2 costly, PGE1 less
costly
Stability Needs refrigeration PGE2 needs
(may be kept for 1 refrigeration;PGE1 is
month at 30°C). stable at room
temperature
Administration Intravenous (IV) Intravaginally or orally
infusion
Effectiveness Less with: More effective in those
 Low Bishop score cases as it has got more
 IUFD collagenolytic properties
 Lesser weeks of and it also sensitizes the
pregnancy myometrium to oxytocin
Side effects Uterine Low dose schedule has
hyperstimulation mainly got minimal side effects
with high dose (ceases Tachysystole may last
following stoppage of longer (may need Inj.
infusion) terbutaline 0.2 mg sc)
Systemic side effects Less; water intoxication Systemic side effects
may be troublesome
specially with oral or
intravenous infusion.
Vaginal route use has
got minimal side effects.
 Antidiuretic (ADH) In high dose No such
effect

SURGICAL INDUCTION METHODS:

 Artificial rupture of the membranes (ARM)
 Stripping the membranes
Low rupture of the membranes (LRM)
Mechanism of onset of labor: May be related with
a) stretching of the cervix
b) separation of the membranes (liberation of prostaglandins)
c) reduction of amniotic fluid volume.
Effectiveness depends on:
1. State of the cervix
2. Station of the presenting part.
Induction delivery interval is shorter when amniotomy is combined with oxytocin
than when either method is used singly.
Advantages of amniotomy:
 High success rate
 Chance to observe the amniotic fluid for blood or meconium
 Access to use foetal scalp electrode or intrauterine pressure catheter or for
foetal scalp blood sampling.
Limitation:
It cannot be employed in an unfavourable cervix (long, firm cervix with os
closed). The cervix should be at least one finger dilated.
Indications:
 Abruptio placentae
 Chronic hydramnios
 Severe pre-eclampsia/ eclampsia
  In combination with medical induction
 To place scalp electrode for electronic foetal monitoring.
Contraindications:
 Intrauterine foetal death
 Maternal AIDS
 Genital active herpes infection.
Immediate beneficial effects of ARM:
 Lowering of the blood pressure in pre-eclampsia-eclampsia.
 Relief of maternal distress in hydramnios.
 Control of bleeding in APH.
 Relief of tension in abruptio placentae and initiation of labour.
These benefits are to be weighed against the risks involved in the indications
for which the method is adopted.
HAZARDS OF ARM:
 Once the procedure is adopted, there is no scope of retreating from the
decision of delivery.
 Chance of umbilical cord prolapse-The risk is low with engaged head or
rupture of membranes with head fixed to the brim.
 Amnionitis -Careful selection of cases with favourable preinduction score
will shorten the induction-delivery interval. Meticulous asepsis during the
procedure reduces the risk.
 Accidental injury to the placenta, cervix or uterus, foetal parts or vasa
previa. Care taken during rupture of the membranes minimizes the
problem.
 Liquor amnii embolism (rare).
LOW RUPTURE OF THE MEMBRANES (LRM):
It is widely practised nowadays with high degree of success. The
membranes below the presenting part overlying the internal os are ruptured to
drain some amount of amniotic fluid.
Contraindication:
It is preferably avoided in chronic hydramnios, as there is risk of sudden
massive liquor drainage. Sudden uterine decompression may precipitate early
placental separation (abruption). In such a case-controlled ARM is done.
Procedures
Preliminaries:
 It is an indoor procedure.
 The patient is asked to empty her bladder.
 The procedure may be conducted in the labour ward or in the operation
theatre if the risk of cord prolapse is high.
Actual steps:
 FHR status is monitored before and after the procedure.
 The patient is in lithotomy position.
 Full surgical asepsis is to be taken.
 Two fingers are introduced into the vagina smeared with antiseptic
ointment. The index finger is passed through the cervical canal beyond the
internal os. The membranes are swept free from the lower segment as far
as reached by the finger.
 With one or two fingers still in the cervical canal with the palmar surface
upwards, a long Kocher’s forceps with the blades closed or an amnion hook
is introduced along the palmar aspect of the fingers up to the membranes.
 The blades are opened to seize the membranes and are torn by twisting
movements. Amni-hook is used to scratch over the membranes. This is
followed by visible escape of amniotic fluid.
If the head is not engaged, an assistant should push the head to fix it to the
brim of the pelvis to prevent cord prolapse. If the head is deeply engaged and the
drainage of liquor is insignificant, gentle pushing of the head up, facilitates escape
of desired amount of amniotic fluid.
After the membranes rupture:
The following are to be assessed:
 Colour of the amniotic fluid
 Status of the cervix
 Station of the head
 Detection of cord prolapse if any
 FHR pattern is again checked. In high-risk cases scalp electrode for fetal
monitoring is applied.
 A sterile vulval pad is placed. Prophylactic antibiotic may be prescribed.
Hazards:
1. Cord prolapse
2. Uncontrolled escape of amniotic fluid and placental abruption
3. Injury to the cervix or the presenting part
4. Rupture of vasa previa leading to foetal blood loss
5. Amnionitis.

STRIPPING THE MEMBRANES

Stripping (sweeping) of the membranes means digital separation of the
chorio-amniotic membranes from the wall of the cervix and lower uterine
segment. It is thought to work by release of endogenous prostaglandins from the
membranes and decidua. Manual exploration of the cervix triggers Ferguson
reflex which promotes oxytocin release from maternal pituitary. Sweeping of the
membranes is done prior to ARM. It is simple, safe and beneficial for induction
of labour.
As an isolated procedure, stripping the membranes off from its attachment
from the lower segment is an effective procedure for induction provided cervical
score is favourable. It is used as a preliminary step prior to rupture of the
membranes. It is also used to make the cervix ripe.
Criteria to be fulfilled for membrane stripping are:
 a) The foetal head must be well applied to the cervix
b) The cervix should be dilated so as to allow the introduction of the
examiner’s finger.
Comments: Each method has got its limitations and hazards. For induction of
labour, each case should be judged on individual basis.
Mechanical: Dilators, act by release of endogenous prostaglandins from the
membranes and maternal decidua to induce labour and cervical ripening.
Hygroscopic dilators, e.g., laminaria (desiccated seaweed), lamicel (magnesium
sulfate in polyvinyl alcohol) act by absorption of water. They swell and forcibly
dilate the cervix. Mechanical dilators are as safe and effective as PGE2 in cervical
ripening.
Transcervical Balloon Catheter (Foley catheter) and extra-amniotic saline
infusion is effective for cervical ripening.
Merits and Demerits of Oxytocin and Low Rupture of the Membranes
(Amniotomy) as an Isolated Method
Oxytocin Amniotomy (LRM)
Exclusive IUD -APH
indications -Hydramnios
-Severe pre-
eclampsia/eclampsia
Prerequisites Can be employed irrespective The cervical canal must be at
of the state of the cervix and least one finger dilated and the
the station of the head head should preferably be
engaged.
Effectiveness Quite satisfactory and the If the procedure fails to initiate
procedure can be repeated at labor within 4 hours, should be
intervals supplemented by oxytocin if
required.
 Special Reversibility of the decision -Observation of liquor for
benefits blood or meconium stain.
-Access to uterine cavity for
the use of:
i. foetal scalp electrode—
electronic monitoring,
ii. foetal scalp blood
sampling,
iii. intrauterine pressure
catheter

COMBINED METHOD
The combined medical and surgical methods are commonly used to
increase the efficacy of induction by reducing the induction-delivery interval. The
oxytocin infusion is started either prior to or following rupture of the membranes
depending mainly upon the state of the cervix and head brim relation. With the
head nonengaged, it is preferable to induce with prostaglandin gel or to start
oxytocin infusion followed by ARM.
Advantages of the combined methods:
1. More effective than any single procedure
2. Shortens the induction-delivery interval and thereby
 minimizes the risk of infection
 lessens the period of observation.
ACTIVE MANAGEMENT OF LABOR:
Active management of labor was introduced by O’Driscoll and his
colleagues in 1968 at National Maternity Hospital, Dublin. The term “Active”
refers to the active involvement of the consultant-obstetrician in the management
of primigravid labor. Active management applies exclusively to primigravidas
with singleton pregnancy and cephalic presentation who are in spontaneous labor
and with clear liquor. Husband or the partner is present during the course of labor.
Partograph is maintained to record the progress of labor.
Essential Components:
The essential components of active management of labor (AMOL):
 Antenatal classes to explain the purpose and the procedure of AMOL
(prenatal education)
 Woman is admitted in the labor ward only after the diagnosis of labor
(regular painful uterine contractions with cervical effacement)
 One to one nursing care with partographic monitoring of labor
 Amniotomy (ARM) with confirmation of labor
 Oxytocin augmentation (escalating dose) if cervical dilatation is
 Delivery is completed within 12 hours of admission
 Epidural analgesia if needed
 Fetal monitoring by intermittent auscultation or by continuous electronic
monitoring.
 Active involvement of the consultant obstetrician.
The key to active management involves strict vigilance (one to one care),
active and informed intervention in time. The incidence of operative delivery is
not increased and less analgesia is required.
Aim: To expedite delivery within 12 hours without increasing maternal morbidity
and perinatal hazards.
Active management of labor:
Objective are:
 early detection of any delay in labor
 diagnose its cause and
 initiate management.
Emotional support in labor:
Stress and anxiety during labor can make labor prolonged. Presence of a
supportive companion during labor (husband/female relative of choice) reduces
the duration of labor, need of analgesics and oxytocin augmentation. Such social
support is a low-cost useful intervention.
Stress-induced high levels of endogenous adrenalin is thought to inhibit
uterine contractions via stimulation of uterine muscle beta receptors.
Limitations of active management of labor:
It is employed only in selected cases and in selected centres where
intensive intrapartum monitoring by trained personnel is possible. It requires
more staff involvement in the antenatal clinic and labor ward.
Advantages:
1. Less chance of dysfunctional labor
2. Shortens the duration of labor (< 12 hours)
3. Fetal hypoxia can be detected early
4. Low incidence of caesarean birth
5. Less analgesia
6. Less maternal anxiety due to support of the caregiver and prenatal
education.
Contraindications:
1. Presence of obstetric complication
2. Presence of fetal compromise
3. Multigravida (not a routine).

PARTOGRAPH
Partograph is a composite graphical record of key data (maternal and fetal)
during labor, entered against time on a single sheet of paper. In cervicograph
(Philpott & Caste 1972), the alert line starts at 4 cm (WHO) of cervical dilatation
and ends at 10 cm dilatation (at the rate of 1 cm/hr). The action line is drawn 4
hours to the right and parallel to the alert line. In a normal labor, the cervicograph
(cervical dilatation) should be either on the alert line or to the left of it. When it
falls on Zone 2 it is abnormal and need to be critically assessed. When it falls in
Zone 3 case should be reassessed by a senior person. Decision is to be made either
for termination of labor (cesarean section) or for augmentation of labor
(amniotomy and or oxytocin).
Components of a partograph
They are:
1. Patient identification
2. Time-recorded at hourly interval. Zero time for spontaneous labor is the
time of admission in the labor ward and for induced labor is the time of
induction
3. Foetal heart rate is recorded at every 30 minutes
4. State of membranes and colour of liquor: to mark ‘I’ for intact membranes,
‘C’ for clear and ‘M’ for meconium-stained liquor
5. Cervical dilatation and descent of the head
6. Uterine contractions: the squares in the vertical columns are shaded
according to duration and intensity
7. Drugs and fluids
8. Blood pressure (recorded in vertical line) at every 2 hours and pulse at
every 30 minutes;
9. Oxytocin: concentration in the upper box and dose (m IU/min) in the lower
box
10.Urine analysis
11.Temperature record.
Advantages of a partograph:
1. A single sheet of paper can provide details of necessary information at a
glance
2. No need to record labor events repeatedly
3. It can predict deviation from normal progress of labor early. So,
appropriate steps could be taken in time
4. It facilitates handover procedure
 5. Introduction of partograph in the management of labor (WHO 1994) has
reduced the incidence of prolonged labor and caesarean section rate. There
is improvement in maternal morbidity, perinatal morbidity and mortality.

SUMMARY:
Induction of labor means initiation of uterine contractions (after fetal
viability) for the purpose of vaginal delivery. Augmentation is the process of
stimulation of uterine contraction that are already present but found to be
inadequate. the Induction of labor should be done when benefits of delivery to
either the mother or the baby out-weigh the risks of pregnancy continuation. The
Indications and contraindications must be carefully judged to avoid the dangers
of induction of labor. the Methods of cervical ripening are many. Bishop’s
preinduction cervical score can predict the success of induction. Score ≥ 6 is
favourable. The Methods of induction may be medical, surgical or combined,
depending upon the individual case. Each method has got its merits and demerits.
the Induction of labor with sweeping of the membranes is effective. Combined
use of amniotomy (ARM) and IV oxytocin is more effective than ARM alone.
The Active management of labor needs some criteria to be fulfilled. It has many
advantages. the Partograph is a composite graphical record of labor events
(maternal and fetal) entered against time on a single sheet of paper. It has many
advantages. It can predict deviation from normal progress of labor early so that
early steps could be taken.

CONCLUSION:
By the end of the session , the group has gained in-depth knowledge
regarding augmentation and induction of labor and it is important to know the
methods of induction of labor and the drugs, surgical and combined methods.
Bibliography:
Books:
 D.C dutta (2006) ‘Text book of obstetrics’ (6 th edition) new Delhi, new
central book agency ; page no.598-608.
 Annama Jacob (2002) ‘Text book of comprehensive midwifery’ (2 nd
edition) new Delhi , jaypee brothers pvt ltd.
Journals:
 https://www.jogc.com/article/S1701-2163(15)30842-2/fulltext.
 https://www.jognn.org/article/S0884-2175(15)32489-8/fulltext.
website:
 https://www.slideshare.net/imanswati/induction-and-augmentation-
og-labour-self-made.
 https://www.slideshare.net/drjayeshpatidar/augmentation-of-labour