INDUCTION OF LABOUR

&
PARTOGRAPH
BY
DR. R VIDYA
MODERATOR
DR. DEVDATTA DABHOLKAR
INDUCTION OF LABOUR

• Induction of Labour is the process of artificial initiation of Uterine

Contractions (after period of viability) with an aim to achieve Vaginal
Delivery

• Augmentation of Labour is the process of stimulation of uterine contractions

that are already present but found to be inadequate to achieve vaginal
delivery
GENERAL CONSIDERATIONS

• According to the FOGSI-ICOG guidelines for IOL 2018,

• Induction of labor should be performed only for a specific medical and/or obstetric
indication.
• Expected benefits of shortening the duration of pregnancy should outweigh the potential
harms from continuation of pregnancy with no contraindications for vaginal delivery.
• The indication and process of induction of labor should be discussed with the patient.
• Induction of labor should be done after obtaining informed written
• OBSTETRIC INDICATIONS: • MEDICAL
• Preeclampsia, Eclampsia INDICATIONS:
• Prelabour Rupture of Membranes
• Diabetes Mellitus
• Preterm Prelabour Rupture of membranes
after 34 weeks At 39 wks if controlled on diet

• Post maturity or Prolonged Pregnancy At 38 wks if controlled on

• Fetal Growth restriction
• Abruptio Placentae
• Congenital Malformation in fetus
• Intrauterine Foetal Death
• VBAC ?
insulin/OHA
• Chronic Renal Disease
• Cholestasis of Pregnancy
CONTRAINDICATIONS

• Contracted Pelvis, Cephalopelvic Disproportion

• Malpresentation (Breech, transverse or oblique lie), Umbilical cord presentation
• Previous Classical C Section or inverted T uterine incision
• Uteroplacental Factors: Unexplained vaginal bleeding, placenta previa, vasa previa
• Maternal infections like Active Genital Herpes
• Invasive Carcinoma Cervix
• Previous Uterine rupture
 PARAMETERS TO ASSESS BEFORE IOL
MATERNAL
• Confirm Indication
• Rule out Contraindications
• Assess Pelvis Adequacy
• Assess Favourability of Cervix (Bishops
Score)
• Maternal Consent
• Ensure correct Gestational age and LMP
FETAL
• Ensure Fetal Gestational age
• Ensure fetal lung maturity
• Estimate Fetal Weight (<3.5kg)
• Ensure fetal longitudinal lie and cephalic
presentation
• Confirm fetal well being: NST & BPP
PREDICTIVE FACTORS FOR SUCCESSFUL IOL

• Period of Gestation: Pregnancy near Term or postterm more favourable

• Cervical Assessment: Modified Bishops score ≥ 6
• Young age
• BMI < 30
• EFW < 3.5kg
SCORE ≥ 6

Cervix favourable
For induction

Most Important:
Cervical Dilatation
MODIFICATIONS OF BISHOP’S SCORE
• Calder’s Modification :
Cervical length was used in place of Effacement

• Regression analysis in 2011(Laughon et al) and 2016( Ivars & Raghuraman)

Used only 3 parameters: Dilatation, effacement and Station
omitted Position and Consistency
Though not come into official guidelines yet, these studies state that using
only 3 components gives the same or improved PPV/NPV
 METHODS OF INDUCTION

PHARMACOLOGIC NON
AL PHARMACOLOGICAL
COMPONENTS OF IOL:
MECHANIC SURGICAL
• CERVICAL RIPENING AL
• STIMULATION OF
UTERINE
CONTRACTIONS
 PHYSIOLOGY OF CERVICAL RIPENING
• Cervical Ripening is the softening of the cervix before onset of labour in order
to ease the passage of the fetus.
• It involves a series of complex
biochemical processes
that ends with rearrangement
and realignment of collagen molecules
• Some of them being increase in hyaluronic acid content, decrease in dermatan
and chondroitin sulphate which leads to less bridging between collagen fibres
and increase in water molecules that intercalate between the collagen fibrils
PHARMACOLOGICAL METHODS
3 Classes of Drugs can be used for Pharmacological Induction of
Labour:

• Oxytocin
• Prostaglandins: PGE1 & PGE2
• NO Donors: Isosorbide Mononitrate & Glyceryl Trinitrate
OXYTOCIN

• Oxytocin is an endogenous Uterotonic that acts to stimulate uterine

contractions
• Effective for IOL in case of a ripe cervix. Not a good agent for cervical
ripening
• Receptors for Oxytocin increase in the uterus to 100 fold at 32 weeks and
300 fold at onset of labour
OXYTOCIN: MECHANISM OF ACTION

1. OXTR Receptor Mediation

2. Voltage Gated Ca Channels
3. Prostaglandin Production
• Half Life: 3-5 min
• Plasma Steady State Concentration: 40 min
OXYTOCIN: DOSING REGIMEN
• Oxytocin is administered via a controlled intravenous infusion either with a
drip set or an infusion pump
• LOW DOSE REGIMEN:
Infusion is started with 2 units Oxytocin added to 500ml RL solution at a rate of
1-2 mIU/min and increased by 1-2mIU/min every 20-30 minutes until optimal
uterine contractions are achieved- {3 contractions/10 min/40-45 seconds}
At this contraction rate, the same infusion rate is to be continued unless there is
any fetal compromise or uterine tachysystole.
OXYTOCIN: DOSING REGIMEN
• HIGH DOSE REGIMEN:
High dose regimen starts with 4-6mIU/min drip rate and is increased by 4mIU/min every 20 min
Risk of uterine tachysystole or hyperstimulation is more in this regimen
Studies state that low dose regimen/ physiological dose regimen is equally effective as high dose
regimen in inducing labour without increasing induction-delivery interval or incidence of c
sections
• MAXIMUM DOSAGE:
Usually adequate contractions are achieved at a dose of 10-12mIU/min.
Maximum accepted dosage or the upper limit is 40mIU/min for a live fetus in 3 rd trimester
OXYTOCIN : POTENTIAL COMPLICATIONS
• Uterine Tachysystole: > 5 contractions every 10 min or >7 contractions in 15 minutes.
• Uterine Hypertonus: Contractions lasting for >120 seconds
• Uterine Hyperstimulation: Tachysystole/ Hypertonus with non reassuring FHR changes
In case of tachysystole or hypertonus, Oxytocin drip must be stopped immediately. The contractions
will reduce automatically as the half life is only 3-5 minutes
• Water intoxication: At a dose of >20mIU/min Oxytocin affects the renal free water clearance and
due to administration of fluids along with Oxytocin there are chances of Water intoxication that
may lead to convulsions, coma and death.
Hence in case Oxytocin has to be given for longer duration, a higher concentration solution must be
used instead of giving more low concentrated solution
OXYTOCIN: POTENTIAL COMPLICATIONS

• Uterine Rupture: The risk is very low in case of nulliparas and also in parous
women. Though the chances are higher in cases of Grand multiparas

• FHR Changes/ Fetal Distress:

FHR should be monitored closely while administering oxytocics. Continuous
monitoring is ideal, otherwise FHR should be recorded every 30 minutes
immediately after a contraction.
 PROSTAGLANDINS : PGE2 {DINOPROSTONE}
• Dinoprostone is a synthetic analogue of PGE2 and is used mainly for Cervical Ripening.
• MOA: Stimulation of IL-8 leading to local inflammatory response and functional
withdrawal of Progesterone. It has collagenolytic properties and also sensitizes the
myometrium to Oxytocin.
It is available in Gel and Time release vaginal insert formulations
• Dinoprostone Gel: For intracervical administration (Prepidil)
0.5mg Intracervical Application is the Gold Standard for Cervical Ripening
Woman must remain supine for 30 min post application. Dose may be repeated after 6 hrs
upto a maximum of 3 doses in 24 hrs.
Oxytocin should not be given for at least 6 hrs post last dose of PGE2 Gel to prevent
Tachysystole
 PROSTAGLANDINS: PGE2 {DINOPROSTONE}
• Dinoprostone Time release Vaginal Insert (Cervidil)
10mg Vaginal insert is also used for Cervical Ripening
Provides a slower release of PGE2 – 0.3mg/hr
Used as a single dose placed transversely in the post vaginal fornix
Following insertion woman must remain recumbent for 2 hrs
The insert is removed after 12 hrs or at onset of labour at least 30 min before
starting oxytocin infusion
PGE2: COMPLICATIONS &
CONTRAINDICATIONS
• Uterine Tachysystole: 1-5% women develop Uterine tachysystole by vaginal use of PGE2.
Seen especially in case Prostaglandins are used in women with preexisting spontaneous labour
and hence such use is not recommended.
• Contraindications:
• Not recommended in case of ruptured membranes as there is higher chances of
chorioamnionitis
• H/o Asthma or Glaucoma: Although studies have shown that there isn’t any significant
exacerbation of asthma in case of use of PGE2, it is still considered a relative contraindication.
• h/o Dinoprostone Hypersensitivity
• H/o 6 or more previous term pregnancies
• Women already receiving Oxytocin
• H/o previous C section or uterine surgery
PROSTAGLANDIN PGE2: EFFICACY

• Most metanalyses of Dinoprostone efficacy show a reduced time to delivery

within 24 hrs.
• But it doesn’t significantly reduce the rates of caesarean sections
• Reduced Caesarean section rates are seen only in cases with an unfavourable
cervix with intact membranes
PROSTAGLANDINS: PGE1 {MISOPROSTOL}
• Misoprostol or synthetic PGE1 is a drug that can help in both cervical ripening
and stimulation of uterine contractions.
• It can be used via oral, buccal, sublingual or vaginal routes of administration
• It is a cheap drug that can be stored at room temperature
• Studies have shown that induction with vaginal misoprostol is more effective than
intracervical dinoprostone in achieving vaginal delivery and also reduces the need
for Oxytocin infusion. But the rates of uterine tachysystole and incidence of MSL
are higher with misoprostol.
• Comparison of oral misoprostol with intracervical dinoprostone and oxytocin
showed a significant decrease in caesarean section rates for oral misoprostol
PROSTAGLANDINS: PGE1 {MISOPROSTOL}
• Dosage:
Vaginal Route: WHO recommends low dose of 25 mcg P/V application 6 hrly
for induction of labour upto a maximum of 6 doses
Oral Route: WHO recommends a dose of 25mcg 2 hourly p/o for Induction.

Although Vaginal route is considered more effective than oral, there are some
systematic reviews that state that Oral and vaginal route have similar efficacy
and that oral misoprostol was associated with a higher apgar score and lesser
incidence of PPH.
PROSTAGLANDINS: PGE1{ MISOPROSTOL}

• Misoprostol has a higher incidence of uterine tachysystole and higher

chances of uterine rupture and is hence contraindicated in women with
Previous caesarean section or uterine surgeries.
• Oxytocin infusion if needed must be started at least 4 hrs after giving
Misoprostol.
• Electronic fetal monitoring to be done for 30 minutes post giving misoprostol
and for 60 minutes after a uterine tachysystole.
NON PHARMACOLOGICAL METHODS

• MECHANICAL METHODS:
They primarily act by giving mechanical pressure on the cervix leading to release of Prostaglandins
• Hygroscopic Dilators like Laminaria tents or
Synthetic variant-Dilapan
They act by absorbing water from endocervix and
surrounding tissues and swell up to dilate the cervix
Not commonly used anymore
MECHANICAL METHODS
Intracervical Foleys Catheterisation :
Foleys catheter is introduced inside the cervix and the balloon is inflated with 30cc
normal saline to put mechanical pressure on the cervix. Downward tension/traction
is created by strapping it to the thighs. Left in situ for 24 hrs or till it gets expelled
spontaneously.
• It causes less uterine hyperstimulation as compared to prostaglandins but does
not reduce cesarean rates.
• Transcervical Foley catheter is safe, cheap, easy to store and preferred in cases
of scarred uterus and unfavorable cervix provided there are no signs of infection.
• It is contraindicated in placenta previa and should be avoided in women with
ruptured membranes and undiagnosed vaginal bleeding.
MECHANICAL METHODS
• STRIPPING OF MEMBRANES:
Stripping or Sweeping of membranes is digital separation of the
chorioamniotic membranes from the wall of the cervix and lower uterine
segment.
• It acts by endogenous release of prostaglandins
• Also activates release of Oxytocin by Fergussons reflex
• Usually done prior to Artificial Rupture of membranes
ARTIFICIAL/LOW RUPTURE OF MEMBRANES
• Widely practiced procedure in which the membranes below the presenting part
overlying the internal os are ruptured to drain the liquor amnii.
• Mainly used for Augmentation of labour
• MOA:
Stretching of Cervix
Separation of Membranes – release of PG
Reduction of Amniotic fluid volume
• EFFICACY: Depends on state of Cervix and station of presenting part. It is more
effective if combined with Oxytocin infusion
ARTIFICIAL/LOW RUPTURE OF MEMBRANES
• ADVANTAGES:
High success rate
Chance to observe liquor for blood or meconium
Access to fetal scalp to place electrode or for scalp blood sampling
• DISADVANTAGES/COMPLICATIONS:
Once done, no scope of retreating from decision of delivery
Umbilical cord prolapse: Avoided by pushing the head down to fix it to the pelvic inlet
Amnionitis: Aseptic precautions to be taken
Abruptio Placentae
Accidental injury to placenta, cervix or uterus
Amniotic fluid Embolism: RARE
ARTIFICIAL/LOW RUPTURE OF MEMBRANES
• PROCEDURE:
With complete aseptic precautions the membranes underneath the presenting part are burst
using an Amnihook to drain out the liquor.
• CONTRAINDICATIONS:
Woman with HIV Infection
Woman with any local perineal infection
Chronic Hydroamnios due to risk of cord prolapse
• Fetal Heart Rate to be monitored before and
after the procedure for 2 minutes
INDUCTION OF LABOUR
• Has to be done only in cases where indicated with consent from the patient
after explaining all risks and consequences to her
• Although various methods of induction are available mostly a combination of
medical and surgical methods is used for induction in practical setting
• In case of failure of induction:
• Maternal and fetal wellbeing should be reassessed.
• i. Another attempt to induce labor with a different method can be considered
after discussion with the patient but it depends on the nature and urgency of the
clinical situation (indication of the induction of labor)
• ii. Cesarean delivery.
PARTOGRAPH
PARTOGRAPH
• It is a composite graphical record of of key data (maternal and fetal) during
labour, entered against time on a single sheet of paper
• COMPONENTS OF WHO MODIFIED PARTOGRAPH(2000)
• Patient identification:
• NO LATENT PHASE: Charting starts at 4cm dilatation of cervix.
• Fetal heart rate recorded at every 30 minutes
• State of membranes and color of liquor to mark I for intact membranes, 'C' for
clear and M for meconium stained liquor and B for Blood Stained Liqour
PARTOGRAPH
• Vaginal examination: This should be done no less than every 4 hours to
assess cervical dilatation, descent of the fetal head, and moulding of skull
bones. More frequent examination is only undertaken if indicated. Charting
starts at 4 cm of cervical dilation.
• Moulding mentioned:
• bones are separated and sutures can be easily felt - (0)
• bones touching (1+)
• bones overlapping but can be reduced(2+)
•bones severely overlapping and irreducible (3+).
PARTOGRAPH
• Uterine contractions-the squares in the vertical columns are shaded according
to duration and intensity
• Drugs and fluids;
• Blood pressure (recorded with an arrow) at every 4 hours and pulse at every
30 minutes
• Oxytocin: Concentration in the upper box and dose (mIU/min) in lower box
• Urine analysis
• Temperature record every 4 hrs
PARTOGRAPH
• Alert line reflects the average rate of cervical dilation of the slowest quintile
of term primigravidae, if dilation slows or ceases, the partograph plot will
cross the alert line.
• Alert line: at 4 cm dilation and expected dilation of 1 cm/hour.
• Action line is 4 hours after the alert line, which prompts interventions to
accelerate labor or perform cesarean delivery.
• Higher rates of perinatal mortality are associated with delays of 4 hours or
more after the alert line.
• WHO Composite Partograph: It is same as modified except for it has latent phase and
charting done at 3 cm

• WHO Simplified Partograph: WHO further modified the partograph for use by skilled
attendants in health centers. This simplified partograph is colour coded.

• • The area to the left of the alert line in the cervicograph is coloured green, representing
normal progress.
• • The area to the right of the action line is coloured red, indicating dangerously slow
progress in labour.
• •The area in between the alert and action line is coloured amber, indicating the need for
greater vigilance.
Partogram
showing
prolonged active
stage of labour
Partogram showing
obstructed labour
PARTOGRAPH: USES AND ADVANTAGES

• It is a proper Objective documentation of progress of labour

• Synergistic with IOL and should be plotted in all cases
• Easier to alert Neonatologist or Anaesthesiologist at an early stage
• Can be used to diagnose obstructed labour and fetal malpositions
• Can be utilised in Telemedicine
THANK YOU