Induction of labour

Definition
• Induction of labour (IOL) is the initiation of uterine contraction before
the spontaneous onset of labour, with the aim of accomplishing
vaginal delivery.
• Indicated when the benefits of delivery outweigh the risks of
continuing the pregnancy
Indications
• Maternal indications
- Post date
- Preterm Prelabor Rupture of membrane (PPROM)
-> happen before 37 week
-> If before 34 weeks of gestation, induction should not be done unless indicated
(eg infection or fetal compromise)
- Prelabor Rupture of Membrane (PROM)
-> after 37 weeks
-> IOL recommended approximately 24 hours after PROM, reduce risk of infection
- DM,HTN, renal disease, chronic pulmonary disease, antiphospholipid syndrome
- twin pregnancy >38 weeks without complications
• Foetal indications
- IUGR
- Oligohydramnios
- Reduce fetal movement at term
- Previous history of intrauterine death
- History of antepartum haemorrhage
- Fetal demise
 Bishop score
• To assess whether cervix is favorable and to determine whether the
patient needs cervical ripening or to proceed with augmentation
• 0 1 2
Cervical dilatation 0cm 1cm 2cm or more
Cervical length 2cm 1cm Effaced
Consistency Firm Soft Soft and
stretchable
Station -2 -1 0
Position Posterior Axial Anterior
• An unfavorable cervix has been defined as having a Bishop score of ≤4
• A Bishop score of ≥8 denotes that the cervix is “favorable” or ripe,
increasing the chance of a spontaneous labor or successful labor
induction
Methods
1) Pharmacotherapy
- Prostaglandin E2 (Prostin)
* Effective agent for ripening of cervix and labor induction if cervix is
unfavorable
• May be given in various routes but local administration in the vagina is the
route of choice due to fewer side effects and acceptable clinical response
• Max: 3 doses, if previous scar: 2 doses
• Post insertion:
-CRIB for 1 hour, CTG post prostin 1hour, NRVE 6 hours, Time
contraction/LPC
- Misoprostol
* A synthetic Prostaglandin E1 analog
* Oral or vaginal route is recommended for induction of labor in women with non-
scarred
*Contraindicated in women with previous cesarean section
- Oxytocin
* Intravenous (IV) Oxytocin has been widely used for induction and augmentation
of labor
* Use of Oxytocin has not been shown to be effective in ripening the cervix but is
the preferred pharmacologic agent for inducing labor when the cervix is favorable
or ripe
* Amniotomy should be done when feasible prior to the start of Oxytocin infusion
in women with intact membranes
2) Mechanical Methods
Promote cervical ripening and/or labor induction through mechanical
pressure and release of endogenous prostaglandins from the
membranes and maternal decidua
- Membrane sweeping
* Place the finger through the internal os and sweep in a
circumferential motion separating the amniotic membrane from the
lower uterine segment
* increasing the local Prostaglandin F2-α production and releasing it
from the decidua and adjacent membranes
- Amniotomy/ artificial rupture of membranes(ARM)
* It is the deliberate perforation of the chorioamniotic membranes
performed in multiparous women with favorable cervix during labor
induction
* Oxytocin should be given early after amniotomy to establish labor
(amniotomy alone should not be used for labor induction)
* Should not be used as a primary method of labor induction except in
cases where PGE2 cannot be employed (eg risk of uterine
hyperstimulation)
- Balloon Devices
* Inflated bulb of a Foley catheter exerts pressure to the internal os of
the cervix which then stretches the lower uterine segment and
stimulates release of prostaglandin (PG)
Contraindication
• Active genital herpes infection
• Placenta or vasa previa
• Umbilical cord prolapse
• Oblique or transverse fetal lie or footling breech
• Cephalopelvic disproportion
• Previous uterine rupture
• Invasive cervical cancer
• Previous uterine surgery
Complication of IOL
• Maternal
1. Uterine hyperstimulation
2. Rupture Uterus
3. Chorioamnionitis
4. Amniotic fluid embolism
5. Water intoxication
• Fetal
1. Fetal distress
2. Cord Prolapse
3. Infecton
4. Iatrogenic prematurity
Failed IOL

• Cervical ripening with prostaglandins over a period ranging from a

single dose to several doses or mechanical methods over 1-2 days
prior to oxytocin administration.
• Failure to generate regular contractions approximately every 3
minutes and cervical change after at least 24 hours of oxytocin
• After AROM, may consider failed IOL if regular contractions and
cervical change do not occur after at least 12 hours of oxytocin
administratio.
IOL in special circumstances
1. Prev C+S
• Not a contraindication for IOL
• Cervical ripening can be done using PGE2 gel
• Misoprostol is a absolute contraindication
• Oxytocin can be safely use in low doses with close FHR monitoring
and Uterine contraction monitoring
2. PROM
• Use of PGE2 gel 2 doses 6 hours apart is not associated with highrer
risk of infection
• Misoprostol can be used in low dose 25mcg
• Oxytocin infusion should be closely monitored
• Beware of hyperstimulation

3. IUD
• Oxytocin is efferctive for IOL near term with favourable cervix
• All prostaglandins can safely be used in recommended dosages for
cervical ripening remote from term
Counsel the Patient
1. Discuss the indication for induction
2. Introduce the agents and methods od labour stimulation
3. Acknowledge the possibility of need for repeat induction or cesarean
delivery
4. Set expectations for length of process