INDUCTION AND

AUGMENTATION OF
LABOR
MANDAL, ALTHEA
GROUP 10 CDUH CLERK
INDUCTION
Stimulation of contractions before
spontaneous onset of labor, with or
without ruptured membranes
Cervical ripening
Soften and open cervix with
prostaglandins
AUGMENTATION
enhancement of spontaneous contractions
that are inadequate to bring about cervical
dilation and fetal descent - inertia uteri
LABOR INDUCTION
LABOR INDUCTION
INDICATIONS
membrane rupture without labor
gestational hypertension
oligohydramnios
nonreassuring fetal status
postterm pregnancy
chronic hypertension and diabetes
LABOR INDUCTION
CONTRAINDICATIONS

MATERNAL FACTORS FETAL FACTORS

prior uterine incision type

contracted or distorted
appreciable macrosomia
pelvic anatomy
severe hydrocephalus
abnormally implanted
malpresentation
placenta
nonreassuring fetal status
active genital herpes
cervical cancer
LABOR INDUCTION
TECHNIQUES
Oxytocin
Prostaglandins
Mechanical methods
Membrane stripping
Artificial rupture of membranes
Extraamnionic saline infusion (EASI)
Transcervical balloons
Hygroscopic cervical dilators
LABOR INDUCTION
RISKS
Maternal complications:
Cesarean delivery (2-3 fold greater risk)
Chorioamnionitis (high incidence associated
with amniotomy)
Uterine rupture
Postpartum hemorrhage from uterine atony
FAVORABLE FACTORS
AFFECTING
INDUCTION SUCCESS
Younger age
Multiparity
BMI <30 kg/m2
Favorable cervix
Birthweight <3500g
 PREINDUCTION
CERVICAL RIPENING
Bishop score
Bishop score of 9 conveys a high likelihood for a
successful induction.
Bishop score of 4 or less identifies an unfavorable cervix
and may be an indication for cervical ripening
Alternative: Transvaginal sonographic measurement.
PREINDUCTION
PHARMACOLOGICAL
TECHNIQUES
1. PROSTAGLANDIN E2
Dinoprostone
a synthetic analogue of
prostaglandin E2
available in three forms: gel,
vaginal insert, and suppository
reduced time to delivery within 24
hours
do not consistently show a
reduction in the cesarean delivery
rate
1. PROSTAGLANDIN E2
PGE2 should only be administered in or near the delivery
suite
contractions usually apparent in the 1st hour and peak in
the first 4 hours
oxytocin induction following prostaglandin use for cervical
ripening should be:
delayed for 6 to 12 hours - prostaglandin E2 gel
administration
delayed for at least 30 minutes - vaginal insert
1. PROSTAGLANDIN E2
Gel preparation
Prepidil
available in a 2.5-mL syringe for an
intracervical application of 0.5 mg of
dinoprostone
Administration:
supine position
place the tip of a prefilled syringe
intracervically
deposit gel just below the internal
cervical os
remains reclined for at least 30 minutes
Doses may be repeated every 6 hours;
maximum of 3 doses in 24 hours
1. PROSTAGLANDIN E2
Time-release vaginal insert
Cervidil
10-mg dinoprostone vaginal insert
thin, flat, rectangular polymeric wafer held within
a small, white, mesh polyester sac that provides a
slower release of medication - 0.3 mg/hr
single dose placed transversely in the posterior
vaginal fornix; remains in recumbent position for 2
hours
Lubricant can coat the device and hinder release
The insert is removed:
after 12 hours or with labor onset
at least 30 minutes before oxytocin
administration
1. PROSTAGLANDIN E2
20-mg suppository
not indicated for cervical ripening
indicated for:
pregnancy termination between 12 and 20 weeks
evacuation of the uterus after fetal demise up to 28
weeks
1. PROSTAGLANDIN E2
Side effects
Uterine tachysystole
>5 contractions in a 10-minute period qualified by the
presence or absence of fetal heart rate abnormalities
If following the 10-mg insert, removal will usually reverse
this effect
caution when used in women with ruptured membrane,
and those with glaucoma and asthma
1. PROSTAGLANDIN E2
Contraindications
history of dinoprostone hypersensitivity
suspicion of fetal compromise or cephalopelvic disproportion
unexplained vaginal bleeding
women already receiving oxytocin or with a contraindication
to oxytocin
those with six or more previous term pregnancies
those with a contraindication to vaginal delivery
those who may be endangered by prolonged uterine
contractions: history of cesarean delivery or uterine surgery
2. PROSTAGLANDIN E1
Misoprostol
Cytotec
synthetic prostaglandin E1 which is stable in room
temperature
administered orally/vaginally
approved as a 100- or 200-μg tablet for peptic ulcer
prevention
used “off label” for preinduction cervical ripening and
may be administered orally or vaginally
2. PROSTAGLANDIN E1
Vaginal administration
offer equivalent or superior efficacy for cervical ripening or
labor induction vs intracervical/intravaginal PGE2
increased vaginal delivery rate within 24 hours vs oxytocin or
intracervical/intravaginal PGE2
decreased need for oxytocin induction vs dinoprostone; higher
incidence of uterine tachysystole
increased frequency of meconium-stained amnionic fluid
ACOG recommends a 25-μg vaginal dose—a fourth of a 100-μg
tablet
2. PROSTAGLANDIN E1
Oral administration
reduced rate of cesarean delivery vs oxytocin, dinoprostone
higher Apgar scores and less postpartum hemorrhage vs
vaginal misoprostol
3. Nitric Oxide Donors
likely a mediator of cervical ripening
increased cervical nitric oxide metabolite concentrations at the
beginning of uterine contractions
very low production of cervical nitric oxide production in postterm
pregnancy
isosorbide mononitrate and glyceryl trinitrate.
isosorbide mononitrate
induces cervical cyclooxygenase 2
also brings about cervical ultrastructure rearrangement
less effective clinically than prostaglandins for cervical ripening
significantly more headache, nausea and vomiting
PREINDUCTION MECHANICAL
TECHNIQUES
reduced the risk of uterine tachysystole compared with
prostaglandins
cesarean delivery rates were unchanged
1. TRANSCERVICAL CATHETER

only used with unfavorable cervix

suitable for women with intact/ruptured membranes
Foley catheter placement through the internal cervical os and
downward tension by taping the catheter to the thigh
extraamnionic saline infusion (EASI)
modified version
consists of a constant saline infusion through the catheter
into the space between the internal os and placental
membranes
less frequent chorioamnionitis
2. HYGROSCOPIC CERVICAL DILATORS
Placement generally requires a speculum and positioning
of the woman on an examination table
LABOR INDUCTION AND
AUGMENTATION
METHODS
PROSTAGLANDIN E1
vaginal and oral Misoprostol
For labor induction at or near term with prematurely ruptured
membranes or a favorable cervix:
100 ug of oral or 25 ug of vaginal misoprostol has similar
efficacy compared with IV oxytocin
At higher doses, associated with an increased rate of uterine
tachysystole
For labor augmentation:
more uterine tachysystole
similar frequency of nonreassuring fetal status or cesarean
delivery with oxytocin
OXYTOCIN
a key component in the active management of labor
GOAL of induction or augmentation:
to effect uterine activity sufficient to produce cervical change and
fetal descent, while avoiding development of a nonreassuring fetal
status
discontinued if:
number of contractions persists with a frequency of >5 in a 10-
minute period or > 7 in a 15-minute period
with a persistent nonreassuring fetal heart rate pattern
HALF-LIFE: 3 to 5 minutes
uterus contracts within 3-5 minutes beginning infusion and plasma
steady state reached at 40 minutes; response highly varies and
depends on preexisting uterine activity, cervical status, pregnancy
duration and individual differences
OXYTOCIN
Dosage:
A 1-mL ampule containing 10 units usually is diluted
into 1000 mL of a crystalloid solution and
administered by infusion pump
typical infusate: 10-20 units mixed into 1000 mL of
lactated Ringer solution (10-20 mU/mL)
Regimens:
Higher-dose regimens are more favorable
Interval between Incremental Dosing:
varies from 15-40 minutes
OXYTOCIN
Maximal effective dose to achieve adequate uterine
contractions varies.
likelihood of progression to vaginal delivery decreased at
and beyond dosage of 36 mU/min
Risks vs Benefits
Uterine rupture is rare unless the uterus is scarred
Water intoxication can result
similar amino-acid homology with arginine
vasopressin, thus has a significant antidiuretic action
(🠗 renal free water clearance)
can lead to convulsions, coma, and even death
AMNIOTOMY
For labor induction:
artificial rupture of the membranes (surgical induction)
main disadvantage when used alone: unpredictable and
occasionally long interval until labor onset
amniotomy alone or combined with oxytocin was superior to
oxytocin alone
Early amniotomy (1-2 cm)
associated with a significant 4-hour reduction in labor
duration but with increased incidence of
chorioamnionitis
Late amniotomy (~5-cm)
accelerated spontaneous labor by 1 to 1 1⁄2 hours
AMNIOTOMY
For labor augmentation:
amniotomy is commonly performed when
labor is abnormally slow
amniotomy with oxytocin augmentation for
arrested active-phase labor shortened the
time to delivery by 44 minutes compared with
that of oxytocin alone
increased incidence of chorioamnionitis
AMNIOTOMY
associated with a risk of cord prolapse
to minimize risk, avoid disengagement of the fetal head during
amniotomy
do fundal or suprapubic pressure or both
some prefer to rupture membranes during a contraction
if vertex is not well applied to the LUS, a gradual egress of amnionic
fluid can be accomplished by
membrane punctures with a 26-gauge needle held with a ring
forceps
with direct visualization using a vaginal speculum
fetal heart rate is assessed before and immediately after amniotomy
MEMBRANE STRIPPING
safe and lowers the incidence of postterm
pregnancy without consistently raising the
incidence of ruptured membranes, infection, or
bleeding
Disadvantages:
discomfort
associated bleeding
Thank you!