Induction of Labour

Induction of Labour
 Induction of Labour

Objectives

• List the indications and contraindications for induction

of labour.
• Use the appropriate methods for induction of labour.
 Induction of Labour

Definition

• Induction is initiation of uterine activity and cervical

change with fetal descent by pharmacological or other
means in a woman who is not in labour.
 Induction of Labour

Cervical Ripening
• promotion of cervical change by pharmacological or
other means
• not primarily intended to induce labour but to
increase the success of subsequent induction
 Induction of Labour

Contraindications to Induction

• Any contraindications to labour

• Placenta or vasa previa or cord presentation
• Abnormal fetal lie or presentation (transverse and
footling breech)
• Prior classical or inverted T uterine incision (always
ensure documentation and confirmation)
 Induction of Labour

Contraindications to Induction (cont)

• Significant uterine surgery (full-thickness myometrium)
(always ensure documentation and confirmation)
• Active genital herpes infection
• Pelvic structural deformities
• Invasive cervical carcinoma

* And absence of indication(s) for induction

 Induction of Labour

Indications for Induction

• When continuation of the pregnancy is a greater risk

to the woman or fetus than the risk of induction and
delivery
• Must be convincing, compelling, fully discussed and
consented to, and documented
 Induction of Labour

Indications – Urgent
• Gestational hypertension with proteinuria and
adverse conditions
• Significant maternal disease not responding to
treatment
• Significant APH
• Chorioamnionitis
• Suspected fetal compromise
• Isoimmune disease at term or near term
 Induction of Labour

Indications – Less Urgent

• Poorly controlled diabetes mellitus

• Alloimmune disease at term or near term
• Intrauterine growth restriction (IUGR)
• Pre-labour rupture of membranes (PROM) at term or near
term
 Induction of Labour

Indications NON-URGENT:

• Post-term pregnancy
• Intrauterine death in a prior emergency
• Intrauterine fetal demise
• Logistic problems (rapid labour, distance to hospital)
 Induction of Labour

Indications - Unacceptable

• Suspected fetal macrosomia

• Absence of fetal or maternal indication
• Physician or patient convenience
 Induction of Labour

Post-term pregnancy

• Definition - gestation of  42 weeks

• Incidence - approximately 6% of births
• Significance
 perinatal mortality,  perinatal morbidity
 operative delivery rates
 Induction of Labour

Risks of Induction

• Failure to achieve labour

• Uterine hyperstimulation with fetal compromise
• Uterine hyperstimulation with uterine rupture
• Increase risk of caesarean section (C/S)
 Induction of Labour

Labour Induction Methods

Likelihood of Successful Vaginal Delivery

MOST MOST
favourable multiparous previous vaginal
cervix delivery

unfavourable
cervix nulliparous previous C/S
LEAST LEAST
 Induction of Labour

• If attempted induction does not achieve

labour reevaluate the indication and
method of induction.
 Induction of Labour

Methods of induction include mechanical

and pharmacological means.

The best choice depends on the cervical

score (A cervix is unfavorable if the Bishop
score is < 6).
 Induction of Labour

Bishop Scoring System

Score
Factor 0 1 2 3

Dilatation (cm) 0 1-2 3-4 >5

Effacement (%) 0 - 30 40 - 50 60 - 70 > 80

Consistency Firm Medium Soft

Position Posterior Mid Anterior

Sp -3 or Sp +1 or
Station Sp -2 Sp -1 or 0
above lower
 Induction of Labour

Effect of Cervical Status on C/S Rate

50 Nulliparous Parous
Caesarean Section (%)

40 34

30 23
20
20 13 12
6
10

0
0-3 >3 Spontaneous Labour
Cervical dilatation at induction
Xenakis Obstet Gynecol (1997) 90: 235
 Induction of Labour

Labour Induction – Unfavourable Cervix

• stripping/sweeping of membranes
• cervical ripening followed by oxytocin
- Foley catheter
- prostaglandins
• vaginal prostaglandins
 Induction of Labour

Mechanical Methods for Cervical Ripening

1. Foley catheter - effective
• no. 14-18, sterile technique, insert past internal os, inflated to 30-
60 cc water
• contraindication: low placenta
- relative contraindications: APH, PROM, cervicitis
2. Hydroscopic dilators - effective
• may be associated with increased risk of infection
• oxytocin is usually needed after cervical ripening
 Induction of Labour

Mechanical Methods for Induction of Labour

• do not appear to be effective on their own

• reduced risk of hyperstimulation compared to PG
• reduced risk of C/S compared to Oxytocin alone
 Induction of Labour

Pharmacological method

• Prostaglandin Preparations
Vaginal preparations are:
- easier to administer
- easier to remove
- less likely to be placed extra-amniotically
- less likely to cause patient discomfort
 Induction of Labour

Prostaglandin E2 (PGE2)
• myometrial contraction
• cervix ripening
- causes collagen breakdown and proteoglycan deposition
• vasodilator
• bronchodilator
• GI motility and secretory effects
 Induction of Labour

Prostaglandin E2 - Route and Dose

• intracervical (Prepidil)
- prostaglandin E2 0.5 mg into cervical canal
• vaginal (Prostin E2 vaginal gel)
- prostaglandin E2 1 or 2 mg into posterior fornix
• vaginal (Cervidil vaginal insert)
- prostaglandin E2 10 mg into posterior fornix
• any formulation may be used for cervical ripening
 Induction of Labour

Guidelines for PGE2 Use

• insertion in hospital by experienced caregiver
• monitor appropriately for FHR and uterine activity
• if labour develops, manage as appropriate
• if no labour, reassess, repeat as necessary or choose
an alternative induction method
 Induction of Labour

Prostaglandin E2 – Advantages

• improved patient acceptance

• lower operative delivery rate
• less need for oxytocin induction
• may be used in PROM
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Prostaglandin E2 - Disadvantages
• adverse reactions
- hyperstimulation
- CVS events
- nausea, vomiting, diarrhea
• gel preparations are difficult to remove
• cost considerations
 Induction of Labour

Precautions with Prostaglandins

• avoid placing PGs adjacent to myometrium
• use cautiously in patients with previous C/S
• do not repeat more frequently than every 6 hours
• wait 6 hours prior to oxytocin infusion following gels
- may be started 30 minutes after Cervidil removal
• do not use for augmentation
• misoprostol (Cytotec®) still being evaluated for term
induction
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Labour Induction - Favourable Cervix

 Amniotomy

 Oxytocin

 Vaginal prostaglandins
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Amniotomy
• creates commitment to delivery
• effective with favourable cervix
• often used in conjunction with oxytocin
• caution in cases of high presenting part (risk of
cord prolapse)
 Induction of Labour

Oxytocin Effects
• myometrial contraction
• cervix - no direct effect
• vasoactive
- hypotension possible with bolus IV administration
• antidiuretic activity
- water intoxication possible with high-dose oxytocin
 Induction of Labour

Oxytocin Guidelines

• cervix should be favourable

• experienced caregivers and resources to manage dystocia
or other emergency (access to c/section)
• intermittent auscultation or EFM depending on indication
and availability
• administration
- Intravenous, rates in milliUnits per minute (mU/min)
- concentrations vary, but avoid large free water load
- Half life is ~5-7 min and steady state in about 30 min
 Induction of Labour

Oxytocin adverse effects

• fetal compromise:
-with hyperstimulation or with normal labour

• maternal:
-discomfort secondary to contractions
-uterine rupture
-water intoxication
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Uterine Hypertonus

• discontinue oxytocin if in use or remove prostaglandin

from vagina
• intrauterine resuscitation
• be prepared for emergency delivery
• nitroglycerin spray sublingual
 Induction of Labour

Goals of Induction

• to avert an anticipated adverse outcome

associated with continuation of pregnancy
• to effect uterine activity sufficient for cervical
change and fetal descent without causing uterine
hyperstimulation or fetal compromise
• to allow as natural a birthing experience as safely
possible and maximize maternal satisfaction
 Induction of Labour

Postpartum Consideration
• if oxytocin was used in labor, postpartum haemorrhage
(PPH) may occur
• for all induced patients, give oxytocin bolus postpartum
(oxytocin 10 units IM 20 units 1L at 100 cc/hr for 2
hours or more
 Induction of Labour

Conclusion
• reasons for induction must be compelling, convincing,
consented to, and documented
• risk and benefits must be discussed with patient
• patient preference must be considered
• ripen the cervix as much as possible
• match the method with the urgency and cervical status
- do not use oxytocin if cervix unfavourable
• don't overestimate your ability to succeed