Labor Induction

Anna Stork-Fury DO

Topics For Discussion

Indications and Contradictions For Induction Risks Of Induction Bishop Scoring Cervical Ripening Agents Labor Augmentation

Labor Induction
Induction- Stimulation of contractions before the spontaneous onset of labor, with or without ruptured membranes Augmentation Stimulation of contractions that are inadequate because of failure of progressive dilation or descent

Labor Induction
Labor induction rate has more than doubled from 1989 to 2002 Induction rate varies from region to region -10.9% in Hawaii to 41.6% in Wisconsin Increase is due in part to practitioners performing elective inductions for no clear medical indications

Labor Induction
Elective Induction
-Patients physician present at delivery -Ensure labor will occur when maximum physician, nursing, and support personnel coverage available in case of complications -To enable the patient to plan for care of other children and to allow partner to make arrangements

Labor Induction
15-20 % of all pregnancies require induction Cervical ripening is required in 50% of these cases

Indications For Induction

Maternal Indications -Severe Preeclampsia
12-22% of pregnancies are complicated by hypertensive disease

-Fetal death
5.1% of all pregnancies

-Chorioamnionitis -Other medical complications

Indications For Induction

Fetal Indications -IUGR -Isoimmunization -Chorioamnionitis -Premature Rupture of Membranes -Diabetes Mellitus

Indications For Induction

Fetal Indications -Post-term pregnancy
Pregnancy that extends beyond 41-42 weeks 10% of all pregnancies 20% have Fetal Dysmaturity Syndrome

Contradictions To Induction
Classical uterine incision Placenta Previa Malpresentations Nonreassuring Fetal Status Medical Conditions

Relative Contradictions To Induction

Grand Multiparity (5 or more) Multiple Pregnancy Suspected CPD Inability to adequately monitor the fetal heart rate during labor

Risk Of Elective Induction

Cesarean Delivery
-Two fold increase risk compared with spontaneous labor -Nulliparous (50% risk of failure if bishop score <5) Neonatal Respiratory Morbidity -Surfactant deficiency

Induction Criteria
Well established ovulation date Basal body temperature chart Clomiphene induction of ovulation Artificial insemination or in vitro fertilization Examination of patient by the 14th week Sonographic estimation of fetal weight performed prior to 20 weeks Bishop pelvic score of 6 or more

Bishop Scoring System

Bishop Scoring System

Usually successful if >9 Score of <4 indicates need for a cervical ripening agent

Risk of Elective Induction

American Journal of Obstetrics and Gynecology (Jan, 2004) Risk of cesarean delivery in nulliparous women at greater than 41 weeks gestational age with an unengaged vertex Objective -unengaged vertex significantly increased the risk of cesarean delivery in nulliparous >41 weeks

Risk of Elective Induction

Study Design - Birth logs from Jan. 1999 to May 2002 at Kaiser Permanente Medical Center in Santa Clara, Calif. -448 nulliparous women who were >41 weeks -Spontaneous and induced labors were included -Multivariate analyses was used to compare the influence of admission fetal station verses induction of labor on the risk of cesarean delivery

Risk of Elective Induction

Patient Characteristics
Station at -5 Admission No. 1
(0.2%)

-4

-3

-2

-1

+1

+2

39

148

164

70
(15.6%)

23

(8.7%) (33.0%) (36.6%)

(5.1%) (0.4%) (0.2 %)

Comparison of engaged and unengaged group

Unengaged Group
Initial dilation (mean[SD]) Initial effacement (mean[SD]) Spontaneous labor Induced labor Vaginal delivery Cesarean delivery

1.3 cm 41% 12% 88% 42% 50%

Engaged Group 3.5 cm 86% 70% 30% 79% 5%

Risk of Elective Induction

Results -62% of patients underwent induction -significant increase in cesarean rate compared with station
Station -4
% delivered cesarean delivery

-3 43%

-2 20%

-1 6%

77%

Risk of Elective Induction

Results -78 of the 94 c-sections in the unengaged were for arrest of descent or dilation -Patients with an unengaged vertex had a 12.4 times higher risk of cesarean delivery -A multivariate analyses showed that fetal station was more predictive of c-section than induction of labor

Histology of Cervical Ripening

Cervical Composition
-Collagen (Type I, III, and IV) -Smooth Muscle

Prior to Labor -Collagen content decreases by 30-50%

-Increase in nonelastin proteins and water

Cervical Ripening
Increase production in cytokines -TNF-alpha, IL-1beta, IL-6, IL-8 Extravasation of neutrophils into cervical stroma Proteases released from neutrophils Apoptosis of smooth muscle cells

Cervical Ripening Agents

Prostaglandin E2 (Cervidil, Prepidil) Misoprostol (Cytotoc) Balloon Catheters Laminaria

Cervical Ripening Agents

Oxytocin Extraamniotic Saline Infusion Sexual Intercourse Castor oil Nipple Stimulation

Cervical Ripening Agents

Prostaglandin E2 (dinoprostone) -Prepidil - FDA approved in 1992
2.5 ml syringe containing 0.5mg of dinoprostone

-Cervidil - FDA approved in 1995

10 mg of dinoprostone Releases prostaglandin at 0.3mg/h Decrease in time of delivery by 4.5 hours from gel

Mean time to delivery is 22 hours

Cervical Ripening Agents

Misoprostol -Originally approved for use in preventing NSAID-induced ulcers. -April 2002 manufacturer revised drug label to include cervical ripening -May be given orally or vaginally

Misoprostol
The American College of Obstetrics and Gynecology in September 2004 Randomized trial using misoprostol for outpatient cervical ripening Methods -Compared a single 25-ug intravaginal dose of misoprostol

to placebo -Women 40 weeks or greater -Bishop Score of less than 9 -Well dated pregnancy

Misoprostol
After placement of the medication, fetal heart tones were monitored for one hour. The patients were allowed to go into spontaneous labor unless an indication developed Interval of delivery was defined as time from the placement of the medication to the time of delivery

Misoprostol
Results -Thirty-three women assigned to receive misoprostol - Thirty-five women assigned to placebo - Interval of time in the misoprostol group was significantly less. - 4.2 days compared with 6.1 days in the placebo group - no adverse outcomes in either group

Misoprostol
Conclusion -A single 25ug intravaginal dose of misoprostol is effective in decreasing the interval of time to delivery in women with unfavorable cervices.

Cervival Ripening Agents

Mechanical Dilators -Several variations (balloon catheters, extraamniotic normal saline infusions, laminaria) -Abramovici and coworkers (1999)
Superior efficacy with the catheter induction compared with 50 ug of misoprostol q 4 hours in nulliparas with a bishop score <5 85% delivered within 24 hours compared to 55 % on misoprostol

Cervical Ripening Agents

Balloon Catheters
-30 ml balloon retracted against the internal os

Extra-amniotic saline infusion

-sterile saline infused at rate of 40ml/hour

Hydroscopic Dilators (Laminaria)

-absorb moisture and gradually expand the canal

Amniotomy
Used to induce and augment labor One of the most commonly performed procedures in obstetrics Increased incidence of cord compression patterns and chorioamnionits (especially seen with early amniotomy)

Amniotomy
Early vs Late Amniotomy -Mercer and Colleagues (1995) -209 patients were randomized -Early amniotomy at 1-2 cm or late amniotomy at 5 cm -Early amniotomy was associated with a shorter labor by 4 hours -Increased incidence of chorioamnionitis (23%) and cord compression (12%)

Membrane Stripping
Common practice for induction of labor Increase the level of phospholipase A2 and prostaglandin F Spontaneous labor usually occurs within 72 hours No increase risk ruptured membranes, infection, or bleeding. Uncomfortable for patient

Oxytocin
Most common medication in obstetrics Has been used for almost 100 years Approved by the FDA in 1965 for labor augmentation

Oxytocin
Amino-acid homolgy which is similar to vasopressin Can act as an anti-diuretic when infused at high doses Sensitivity to oxytocin increases rapidly after 34 weeks

Oxytocin Regimens
Cervical ripening -Continuous IV infusion of 2 to 4 mU/min for 8-12 hours Augmentation -Stimulation of spontaneous contractions that are considered inadequate

Oxytocin Regimens
Augmentation
Regimen Starting Dose (mU/min)
Incremental Increase (mU/min)

Dosage Interval (min)

Maximun Dose (mU/min)

Low Dose

0.5 - 1 1 1-2 2 6,3,1

30-40 15 15-40

20 40 42

High Dose

Low vs High Dose Oxytocin Regimen

Merril and Zlatnik (1999) -Blinded, randomized study of 1307 women - Low dose regimen began at 1.5 mU/min and was increased by 1.5 mU/min every 30 minutes - High dose regimen began at 4.5mU/min and was increase by 4.5mU/min every 30 minutes

Low vs High Dose Oxytocin Regimen

Results -No difference in cesarean rate -Women in the high dose regimen had a significantly decreased duration from induction to second stage labor and from induction to delivery -No difference in neonatal outcomes

Oxytocin
High dose regimen for Augmentation -Decrease in mean time to delivery -Fewer incidences of chorioamnionitis -Fewer cases of neonatal sepsis -Increase incidence of hyperstimulation

Fetal Surveillance
Fetal Surveillance with PG preparations -Administered at or near a labor and delivery suite -Patient should remain recumbent for 30 minutes -Maternal vital signs should be monitored -Fetal heart rate monitoring should be continued if contractions continue

Fetal Surveillance
Fetal Surveillance with PG Insert (Cervidil)_ -Monitor fetal heart rate and uterine activity for 15 minutes after the insert is removed Misoprostol - Monitor fetal heart rate and uterine activity in hospital setting until further studies evaluate the safety of outpatient therapy

Complications
Uterine contraction abnormalities -Hyperstimulation -Tachysystole -Hyperstimulation syndrome Uterine Rupture -most occur with a previously scarred uterus

Conclusion
Induction of labor is not without consequences , especially in the unripe cervix of nulliparous women Elective Induction is not recommended by ACOG for either convenience or the practitioner or patient

My Three Successful Elective Inductions