LABOR INDUCTION

AND
CERVICAL RIPENING
PRESENTED BY; DR. SEBLE / I /
MODERATED BY; DR. MESFIN /R2 /

02/20/2024
OUTLINE

 DEFINITIONS
 INDICATIONS & CONTRAINDICATIONS
 RISKS & COMPLICATIONS
 PREREQUISITES
 CERVICAL FAVORABILITY AND PRE-INDUCTION RIPENING
 TECHNIQUES
 MECHANICAL METHODS OF CERVICAL RIPPENING AND INDUCTION
 PHARMACOLOGIC METHODS OF CERVICAL RIPENING AND
INDUCTION
 AUGEMENTATION
 REFERENCE
02/20/2024
DEFINITIONS

 Induction of labor- artificial stimulation of uterine contractions before the

spontaneous onset of labor, with or without ruptured membranes to achieve
vaginal delivery.
 Augmentation- enhancement of spontaneous contractions that are
considered inadequate because of failed cervical dilation and/or poor fetal
descent.
 Cervical ripening is the use of pharmacological or mechanical means to
soften the cervix.

02/20/2024
…

 When the cervix is closed and uneffaced, labor induction is often preceded
by cervical ripening. The cervical ripening agent may also initiate labor. If
not, oxytocin can be used for induction.

 Generally, cervical ripening and induction of labor are on a continuum and

not all women undergoing induction of labor need cervical ripening.

02/20/2024
INDICATIONS

 Hypertensive disorders of pregnancy

 Maternal medical complications (DM, severe cardiac disease, etc...)
 Term PROM, Chorioamnionitis
 Abruptio placenta
 IUFD
 Post term
 Fetal growth restriction, Oligohydraminos

02/20/2024
CONTRAINDICATIONS

Absolute:
 placenta previa, vasa previa,
 abnormal lie, malpresentations,
 previous uterine scar (e.g. myomectomy, CS),
 contracted pelvis, macrosomia, twin pregnancy,
 invasive cervical cancer, active genital herpes infection,
 severe IUGR with confirmed fetal compromise.

Relative:
 Bad obstetric history, grand multiparty

02/20/2024
RISKS AND COMPLICATIONS

INTRA-PARTUM POST-PARTUM
 Failed induction  Atonic PPH
 Increased risk of CS

 Iatrogenic prematurity
 Uterine hyper stimulation
 Fetal sepsis associated with
 Uterine rupture/with scared uterus
 Placental abruption
ascending Infections
 Precipitated labor with Its
consequences

 Fetal distress, fetal demise

 Cord prolapse, fetal bleeding in ARM
02/20/2024
PRECONDITIONS

Maternal
 Confirm the indication for induction.
 Review contraindications to labor and/or vaginal delivery.
 Perform clinical pelvimetry to assess the shape and adequacy of the bony
pelvis.
 Assess the cervical condition (assign Bishop score) and determine
favorability
 Review risks, benefits, and alternatives of induction of labor with the
patient.

02/20/2024
…

Fetal/neonatal
 Confirm gestational age.
 Assess the need to document fetal lung maturity status.
 Estimate fetal weight, either by clinical or ultrasound examination.
 Determine fetal presentation and lie.
 Confirm fetal well-being.

02/20/2024
…

 Get informed consent.

 Document your decision
 Continuous FHR monitoring preferably electronic or ONE TO ONE
 Ascertain availability of labor ward staff and the capacity to do emergency
CS

02/20/2024
FACTORS AFFECTING INDUCTION SUCCESS

Favorable factors include;

 Multiparity
 favorable cervix, and
 birthweight <3500 gm
 younger age
 body mass index (BMI) <30

02/20/2024
CERVICAL FAVORABILITY

02/20/2024
…

 As favorability or Bishop score rises, the rate of induction to effect

vaginal delivery also increases.
 A Bishop score >8 conveys a high likelihood for a successful
induction, and
 a score ≤6 is considered unfavorable (American College of
Obstetricians and Gynecologists, 2019a).

02/20/2024
…

OBS STG 2021

 Interpretation of the Bishop’s score:

 Score ≥ 6: Favorable - cervical condition and induction is likely to succeed.
There is no need for cervical ripening. Induction using oxytocin can be
planned.
 Score ≤ 5: Unfavorable - cervix is unlikely to yield for induction;
 cervical ripening is needed for success with induction; postpone induction
for next week if possible or use cervical ripening and plan induction for next
day.

02/20/2024
TECHNIQUES FOR CERVICAL RIPENING

PHARMACOLOGIC/MEDICAL
1. PG Analogues
2. Oxytocin

MECHANICAL/SURGICAL
3. Balloon catheter and osmotic dilators
4. Hydroscopic dilators
5. Membrane stripping
6. Amniotomy / For Induction and Augmentation

02/20/2024
MECHANICAL METHODS
FOR CERVICAL RIPENING

 Mechanical agents work by directly causing cervical dilation, and by

releasing endogenous prostaglandins and oxytocin.

02/20/2024
…

1- TRANS-CERVICAL CATHETER

Also called Balloon / Foley catheter is placed through the internal cervical os,
and downward tension is created by taping the catheter to the thigh.

02/20/2024
…

 Leave the Foley catheter until it is spontaneously expelled or keep it in place for at least 12
hours, or until contractions begin.

 Following priming with catheter, most women require further induction of labor with
oxytocin and/or amniotomy. Oxytocin infusion can be started with a balloon catheter in
place or after it has been removed.

 CONTRAINDICATED IN
• ruptured membranes
• obvious vaginal infection

02/20/2024
…

2-HYGROSCOPIC CERVICAL DILATATION

 Osmotic cervical dilators are hydrophilic agents that absorb water and thus
gradually expand within the cervical canal, which in turn causes the cervix
to dilate (E.g. laminaria).
 Placement generally requires a speculum and positioning of the woman on
an examination table.
 Intuitive concerns of ascending infection have not been verified, and their
use appears to be safe.

02/20/2024
…

3-MEMBRANE STRIPPING

For Labor Induction

Several studies have suggested that membrane stripping is safe and lowers the
incidence of post term pregnancy without consistently raising the incidence of
ruptured membranes, infection, or bleeding

Downsides are discomfort and associated bleeding

02/20/2024
…

4-ARTIFICIAL RUPTURE OF MEMBRANES / AMNIOTOMY

Amniotomy is a non-pharmacological method where the amniotic

membranes can be ruptured artificially to induce or augment labor.

For labor induction, artificial rupture of the membranes— sometimes called

surgical induction. For labor augmentation, amniotomy is commonly
performed when labor is abnormally slow.

Amniotomy alone or combined with oxytocin was superior to oxytocin

alone.
02/20/2024
…

 Amniotomy may be contraindicated in pregnancy with

• Known or suspected vasa previa,

• Any contraindications to vaginal delivery or
• Unengaged presenting part (although this obstacle may be overcome with
the use of a controlled amniotomy or the application of fundal or suprapubic
pressure). This is in fear of possible cord prolapse.

02/20/2024
…

Early amniotomy was associated with a 4-hour reduction in labor

duration. With early amniotomy, however, the incidence of
chorioamnionitis was elevated.

Regardless of the indication, amniotomy is associated with a risk of

cord prolapse. To minimize this risk, disengagement of the fetal head
during amniotomy is avoided

02/20/2024
PHARMACOLOGIC METHODS FOR
CERVICAL RIPENING AND INDUCTION

 PROSTAGLANDIN ANALOGUES

1. PGE1/ Misoprostol
2. PGE2/ Dinoprostol

 OXYTOCIN

02/20/2024
PROSTAGLANDIN ANALOGUES

1- PGE1/ Misoprostol

Vaginal- 25 mcg, repeat after 6 hours.

Oral: 25 mcg; if required repeat after 3 hours.
 If 25 mcg is not available, dissolve one 200 mcg tablet in 200 mL of water
and administer 25 mL of that solution as a single dose.
 Patients with PROM, oral route of administration is preferred for priming
and induction

02/20/2024
…

 Discontinue misoprostol and begin oxytocin infusion if:-

 Membranes rupture or cervical ripening has been achieved; or
 12 hours have passed since the first dose of prostaglandin.

 Misoprostol is associated with a greater rate of uterine tachysystole,

particularly at higher doses.

02/20/2024
PROSTAGLANDIN ANALOGUES

2- PGE2/ Dinoprostol

 A 3 mg pessary is placed high in the posterior fornix of the vagina and may
be repeated after six hours if required.

02/20/2024
OXYTOCIN

 Oxytocin - has been used for labor induction for more than 70 years
 In women with intact membranes, amniotomy should be performed
where feasible before starting oxytocin induction.
 Allow a delay of six hours after administration of the last dose of
vaginal prostaglandins before commencing oxytocin.

02/20/2024
…

 During induction, monitor and record rate of infusion of oxytocin,

duration and frequency of contractions, maternal pulse and fetal heart
rate every 30 minutes (never leave her alone).
 The effective dose of oxytocin varies greatly among women.
Cautiously administer oxytocin in IV fluids;
 gradually increase the rate of infusion until adequate contraction is
achieved.
 Oxytocin induction can be done either by oxytocin infusion or with
infusion pump.

02/20/2024
…

OXYTOCIN INFUSION

 Use 0.9% N/S or R/L for infusion. To ensure even mixing, the bag must be
turned upside down several times before use.
 The initial infusion rate should be set at 1 to 2 milli units / minute.
 The infusion rate is increased every 30 minutes up to a maximum of 40 mU /
min (250 ml/hour).
 For induction of a primigravid woman only, oxytocin with starting dose of
3.0 to 6.0 mU / min can be used.

02/20/2024
…

 Aim to maintain the lowest possible dosage consistent with adequate uterine
contraction which is 3-5 contractions in 10 min, each lasting 40-60 sec.
 Label the bag and keep timely record of the drops used. Monitor and record
maternal and fetal conditions, and labor progress according to the labor
protocol.
 Continue the oxytocin infusion for at least one hour after delivery

02/20/2024
…

A 1-mL vial contains 10 units of oxytocin.

A typical infusate consists of 10 or 20 units, which is 10,000 or 20,000 mU,

respectively, mixed into 1000 mL of crystalloid or dextrose solution.

This mixture results in an oxytocin concentration of 10 or 20 mU/mL,

respectively.

02/20/2024
02/20/2024
02/20/2024
…

 Discontinue Oxytocin
 Number of contractions more than five in a 10-minute period or
 more than seven in a 15-minute period or
 persistent nonreassuring fetal heart rate pattern.
 Oxytocin discontinuation nearly always rapidly lowers contraction
frequency. When oxytocin is stopped, its concentration in plasma rapidly
falls because the half-life is approximately 3 to 6 minutes

02/20/2024
…

 Unless the uterus is scarred, uterine rupture associated with oxytocin

infusion is rare, even in parous women.
 When infused at doses of 20 mU/min or more, renal free water clearance
drops markedly.
 If aqueous fluids are infused in appreciable amounts along with oxytocin,
water intoxication can lead to convulsions, coma, and even death.

02/20/2024
FAILED INDUCTION

 Failure to achieve regular (e.g. every 3 minutes) uterine contractions and

cervical change after at least 6 - 8 hours of the maintenance dose of oxytocin
administration, with artificial rupture of membranes if feasible.
 If the induction is not for an emergency condition and the fetal membranes
are intact (e.g. IUFD with unruptured membranes), the induction can be
postponed.
 If the pregnancy has to be terminated on the day of the induction or the
membranes are ruptured, cesarean section is the only available option .

02/20/2024
…

Text-books however say that no universal standard exists for what

constitutes a failed induction.
Likely strongly influenced by
•the induction duration,
•Favorability of cervix

Associated with
• Higher BMI
• DM

02/20/2024
U TERIN E HYPER STIMULATION

 six or more contractions in 10 min and / or durations of contractions of 60 or

more seconds.

 This could be with or with out NRFHRP.

02/20/2024
…

Management: Stop the infusion, put the woman on left lateral position
and assess the FHR:
 If the FHR is abnormal, manage for non-reassuring fetal heart rate
pattern attempt Intrauterine resuscitation methods and relax the uterus
using tocolytics If feasible.
 If the FHR is normal, observe for improvement in uterine activity and
monitor the FHR. If normal activity is not established with in 20
minutes relax the uterus using betamimetics.
 Observe for improvement in uterine activity, and monitor the FHR: If
both mother and fetus are in good condition, restart at half dose of the
last dose causing uterine hyper stimulation.
02/20/2024
AUGMENTATION: WHAT’S DIFFERENT?

 The main indication for augmentation is weak and ineffective uterine contractions leading
to abnormal progress of labor.

 Contraindications are same as Induction plus secondary hypotonic contractions due to

obstructed labor

 The methods for augmentation are ARM and oxytocin. If there is no urgency to expedite
delivery, oxytocin infusion is initiated one hour after ARM and if the ARM failed to correct
the weak contractions
NOTE: prostaglandin analogues have high risk of uterine hyper stimulation incase of an
already established uterine contractions or oxytocin use. Not used for labor augmentation.

02/20/2024
REFERENCES

 WILLIAMS OBESTETRICS 26TH EDITION

 GABBE OBESTETRICS 8TH EDITION
 OBESTETRIC MGT PROTOCOL 2021
 DC DUTTAs TEXTBOOK OF OBESTETRICS 8th EDITION
 UPTODATE 2023

02/20/2024
THANK YOU!!!

02/20/2024