AUGMENTATION /

INDUCTION OF LABOUR:
MEDICAL AND SURGICAL
INDUCTION, VERSION AND
MANUAL REMOVAL OF
PLACENTA

PRESENTED BY:
LAMNUNNEM HAOKIP
MSC(N)2ND YEAR
UNDER THE GUIDANCE OF
MS. AASTHA SINGH
ASST. PROF (OBG)
INTRODUCTION

• Prolong labour is an important cause of

maternal and perinatal mortality and
morbidity. Common underlying causes
include insufficient uterine contractions,
abnormal fetal presentation or position,
inadequate bony pelvis or soft tissue
abnormalities of the mother.
 DEFINITION

• Augmentation of labour: is the process of stimulating

the uterus to increase the frequency, duration and
intensity of contractions after the confirmed delay of
established labour in the first or second stages.
• Induction of labour: The initiation of uterine
contractions (after the period of viability) by any
method (medical, surgical and combined) for the
purpose of vaginal delivery.
• Version: It is changing the transverse lie to a
longitudinal one or replacement of the presenting part
by the other.
• Manual Removal of Placenta: A procedure to remove
a retained placenta from the uterus when failure of
placental delivery takes place within 30 minutes after
delivery of the fetus.
 INDICATIONS
&
CONTRAINDICATIONS

PAMPHLETS
PARAMETERS TO ASSESS PRIOR TO INDUCTION OF LABOUR:

Maternal
To confirm the indication Assess Bishop score
for induction of labour. (score >6 is favourable).

Exclude the Perform clinical

contraindication of pelvimetry to assess
induction of labour. pelvic adequacy.

Adequate counselling Confirm the period of

gestation
 Fetal

Ensure fetal
gestational age.

Ensure fetal lung

maturation status.

Ensure fetal
presentation and Confirm fetal
lie. well-being.
METHODS OF INDUCTION

Medical
Method

Combined Surgical
Method Method
 Medical Method

The drugs commonly used in medical methods of

IOL are as follows

• Prostaglandins PGE2, PGE1 : Dinoprostone 0.5

mg and Misoprostol 25µg vaginally or orally.
• Oxytocin

• Mifepristone: RU 486, 200 mg vaginally daily

for 2 days has been found to ripen the cervix and

to induce labour.
 PROCEDURE
• Prior to inserting the medication into the vagina, the
mother may be asked to empty bladder.
• The position of the baby will be confirmed by
palpating (feeling) the abdomen.
• A CTG – recording of the baby’s heart rate and
contractions of the uterus).
• If the bishop’s score is unknown an internal cervical
assessment/vaginal examination must be made.
• The prostaglandin can then be inserted if the bishop’s
score is 6 or less.
• Following insertion the mother should lie on left side for
30 minutes to allow the medication to be absorbed.
• The foetal heart rate and maternal observations will be
checked 4-hourly thereafter.
• If contractions developed, continuous CTG monitoring
should be done.
• A repeat internal exam will be performed six hours post
dose to assess any cervical change. If the change is
minimal then a second dose can be given.
 SIDE
EFFECTS

• Nausea, Vomiting, Diarrhoea, pyrexia,

bronchospasm, tachycardia and chills.

• Cervical laceration may occur (PGF2α) when used

as an abortifacient.
• Tachysystole of the uterus may occur.

• Risk of uterine rupture.

NURSES RESPONSIBILITIES

• Be clear about administration of drugs.

• Administer PGE2 gel 0.5mg before the cervical
ripening.
• Observe cervical ripening.
• Monitor the mother and fetal vitals and drugs given.
• Oxytocin should be started in low dose with interval of
20- 30minutes
• Oxytocin should be administer 2units in 500ml ringer
solution with drop rate of 60/minutes
 SURGICAL METHOD OF IOL

There are two surgical methods of IOL, ARM

and Sweeping / Stripping of Membrane)
• Artificial Rupture of Membrane
(Amniotomy): Amniotomy is performed to
induce labour when the cervix is favourable
or during labour to augment contractions.
• It may be also done to visualize the colour
of the liquor amnii.
There are two types of ARM:

• Low rupture of membrane: It is widely practiced with

high degree of success. The membranes below the
presenting part overlying the internal os are rupture using
Kocher’s forceps/clamps and Amnicot to drain some
amount of amniotic fluid.

• High rupture of membrane: It is a procedure where the

puncture of hind-water above the presenting part is made
with a special instrument called Drew – Smythe catheter.
KOCHER’S CLAMP /
FORCEP
AMNICOT
DREW – SMYTHE
CATHETER
Benefits effects of Amniotomy
• Lowering of the blood pressure in pre-eclampsia and
eclampsia.
• Relieve of the maternal distress in poly-hydramnious.
• Control of bleeding in antepartum haemorrhage.
• Release of tension in abruption placenta thereby
minimizing utero-renal reflex.
Hazards of Amniotomy
• Intrauterine infection, trauma.
• Chance of umbilical cord prolapse (free floating head)
• Bleeding form vessels in membranes, cervix and placenta.
 Stripping Of Membrane

• Stripping of the membranes means digital

separation of chorioamniotic membranes from the
wall of the cervix and lower uterine segment.
• It is use as a preliminary step prior to rupture of
membrane.
• It is also use to make cervix ripe.
 NURSES RESPONSIBILITIES

•  Maintain aseptic techniques

• Provide position

• Vaginal examination with the use of proper aseptic

techniques.

• Clear about the instruments which is used in the

surgical induction of labour.

• Observe by visible escape of amniotic fluid

 VERSION

• It is changing the transverse lie to a longitudinal one

or replacement of the presenting part by the other.

Types of version:

There are three types of version as follows:

• External Cephalic version

• Internal Podalic version

• Bipolar version
 External Cephalic version

• When the breech presentation is

made back to being transverse and
moving the baby’s head and
turning into a cephalic
presentation that is done
externally.
• Done for breech presentation,
transverse lie / oblique lie.
 Techniques
• No anesthesia, as the pain is a safe guard against
rough manipulations.
• The patient evacuates her bladder, lies in a
Trendelenburg position with exposed vulva to
detect any vaginal bleeding.
• The fetal position is determined and FHS is
auscultated.
• One hand is applied externally to the fetal head and the
other on its buttock, the two poles are approximated to
flex the fetus and rotation is done by the two hands
simultaneously to bring the head lower down.
• The FHS is auscultated again, if there is fetal distress
lasting for more than 5 minutes, the fetus is returned back
to its previous position as the cord might be coiled or
entangled around the neck.
• If neither vaginal bleeding nor fetal distress results,
an abdominal binder is applied to fix the new
position and re-examined twice weekly. If the
original presentation returned again, the procedure
of version can be repeated.
Contraindications:
• Fetal distress
• Rupture of membrane

• Maternal disease condition

• Previous placenta previa or abruption placenta with
caesarean section.
 Internal Podalic Version
• A trans-vaginal procedure that converts a difficult fetal
presentation and lie – retained second twin in a
transverse lie, some cases of shoulder presentation to
a vaginally deliverable situation by hand-rotating the
fetus in utero, also known as breech extraction.
• Its only indication being the transverse lie in case of the
second baby of twins. However, it may be employed in
singleton pregnancy to expedite delivery in adverse
condition where the caesarean section facilities are
lacking.
 Techniques

• Lithotomy position, episiotomy in primigravida.

• The hand is introduced through the cervix into the uterus

and grasp the lower foot if the back is anterior and the
upper foot if the back is posterior, so that the back is
kept anterior during delivery.
• The other hand is pushing the head upwards while the
foot is brought downwards.
• The other foot is brought down and breech extraction is
done.
• The birth canal is explored after delivery for possible
 Bipolar Version
• Under the pulled through general anaesthesia.

• At least two fingers are passed through the

partially dilated cervix; the foot is grasped as in
internal podalic version pulled through the cervix
while the other hand is assisting the version
externally.
MANUAL REMOVAL OF PLACENTA

• Manual removal of the placenta is an option for the

treatment of retained placenta, but it carries the risks
for haemorrhage, infection, and genital tract trauma.
 Techniques/Procedures
• Follow precautions common to all intrauterine procedures

and specific precautions for manual procedures.

• Cup the fundus with one hand and hold it down.

• Advance the other hand into the uterus, supinated, directly

to the fundus and locate the cleavage plane between the

uterine wall and the placenta with the fingertips. This hand

is inserted all the way up to the forearm in the genital tract.

• Once the cleavage plane has been located, use the side of the

supinated hand like a spoon to detach the placenta and bring

POST-PROCEDURE CARE

• Observe the woman closely until the effect of IV sedation has

worn off.

• Monitor the vital signs (pulse, blood pressure, respiration)

every 30 minutes for the next 6 hours or until stable. 

• Palpate the uterine fundus to ensure that the uterus remains

contracted.

• Check for excessive lochia.

• Continue infusion of IV fluids.

• Transfuse as necessary
 BIBLIOGRAPHY / REFERENCE
• Annama Jocab, text book of comprehensive text book of
‘MIDWIFY and GYNECOLOGY nursing ‘ JAYPEE
publication 3rd edition page no.285-287.
• D.C. DUTTA text book of obsterical including
perinatary and contraception central publication 7th
edition page no. 583-585.
• Lily Podder, fundamentals of Midwifery and Obstetrical
Nursing, ELSEVIER publication. Page no. 280 – 285.
• Mudaliar and Menon’s. Clinical Obstetrics, Universities
Press 12th Edition. Page no. 408 – 411.
• https://www.ncbi.nlm.nih.gov/books/NBK131965/
• https://pubmed.ncbi.nlm.nih.gov/24099451/
• https://www.thelancet.com/journals/lancet/article/PIIS01
40-6736(02)53518-2/fulltext