Induction of Labour

Obstetric and Maternity Nursing NUR-306

Group (1)
 Definition of Induction of Labour
Induction of labor is the artificial initiation of labour mechanism prior
to its spontaneous onset. The term Induction of Labour is
abbreviated IOL.
Augmentation refers to the stimulation of spontaneous contractions
that are considered inadequate because of failed cervical dilation
and fetal descent.
Indications for Induction of Labour
Broadly speaking, an IOL is performed when the risks to the fetus
and/or the mother of the pregnancy continuing exceeds those of
bringing the pregnancy to an end. These include:
• Post-term – If the pregnancy time passed the estimated date of delivery
or is about 41-42 weeks the health practitioner(s) may induce labour.
• Complication – Sometimes conditions like preeclampsia, diabetes,
gestational diabetes, issues with the placenta or problems with amniotic
fluid (low levels or Infection) make it risky to continue the pregnancy
• Rupture membrane – If the amniotic sac membrane ruptures and
contraction does not start on its own labour may be induced.
• Fetus inactiveness – If the fetus is making fewer movements, showing
changes in its heart rate, or not growing well labour may be induce
depending or the gravity of the situation.
• Multiple pregnancies – If the woman is pregnant with more than one
baby (twins or triplex) continuing beyond 36 weeks labour may be induced.
• Social reasons
 High Priorities for Induction of Labour
• Preeclampsia >37 weeks
• Significant maternal disease not responding to treatment
• Significant but stable antepartum hemorrhage
• Chorioamnionitis
• Suspected fetal compromise
 Contraindications for Induction of Labour
1. Major degree of placenta praevia
2. Vasa praevia
3. Previous classical uterine incision
4. Significant prior uterine surgery (e.g. full thickness myomectomy)
5. Cephalopelvic disproportion because of malpresentation or abnormal
pelvic bone structure.
6. Active genital Herpes infection
7. Invasive cervical carcinoma
8. Hypersensitivity to cervical ripening agents
Bishop System of Cervical Scoring
Assessment Dilation Length of Foetal Consistency Position
score (cm) cervix (cm) station*
or
Effacement
(%)
0 0 >2cm -3 Firm Posterior
0 to 30
1 1 to 2 2cm -2 Medium Mid
40 to 50
2 3 to 4 1cm -1, 0 Soft Anterior
60 to 80
3 5 to 6 <0.5cm +1, +2, +3 -- --
90 to 100

• Each score is awarded 0 - 3 and the range of scores

is 0 - 13.
• A total score of six or over is favorable.
• However a score of nine or more will have a safe,
successful induction with an estimated length of
labor of less than four hours.
 Bishop Score
This score is use to quantify how far this process had progress prior to the
IOL. High scores (a ‘favourable’ cervix) are associated with easier delivery,
shorter indication that is less likely to fail. Low score (an ‘unfavourable’
cervix) point to a longer IOL that is more likely to fail and result in caesarean
section. Women with a score of > 9 are equally likely to deliver vaginally
whether induced or allowed to labour spontaneously and could be delivered
within 4 hours and most within 24 hours. A favourable preindication Bishop
score of > 6 successful vaginal delivery. The rate of failed induction are likely
for women with a low Bishop score (0 to 3).
 Time Place and Preparation for Induction of Labour
• Time of induction: preferably early morning
• Place of induction: where facility for intervention and fetal monitoring is
available
• Preparation of patient: enema may be given to patients prior to
induction.
 Factors to Assess Prior to Induction
 Maternal
• To confirm the induction
• Exclude the contraindications
• Assess pelvic adequacy
 Fetal
• Ensure fetal gestational age
• Ensure fetal presentation
• Confirm fetal well-being
 Methods for Induction of Labour
Below are the various methods that are used for induction of labour.
1. Membrane sweeping
2. Use of prostaglandins
3. Use of oxytocin
4. Amniotomy – artificial rupture of membrane (surgical method of
induction)
5. Use of cervical Foley catheter ballon
 Membrane sweeping:
• Sweeping amniotic membranes stimulates production of prostaglandins
which induce labour
• It is possible only if the cervix has ripened to allow the passage of one
finger.
• Insertion of a gloved finger through the cervix and it rotates against the
wall of the uterus.
• It strips of the chorionic membrane from the underlying decidua –
releasing prostaglandin (PGS).
• Placenta praevia should be excluded
• Accidental amniotomy is disadvantage and can be uncomfortable for the
woman.
 Prostaglandins:
• Prostaglandins may be used to greatest advantage in prelabour and
latent labour, prior to amniotomy.
• Prostaglandins are classified as PGE1 (Misoprostol) and PGE2
(Dinoprostone).
 Local applications of PGs cause cervical ripening by:
• Alteration of extracellular grounds substance of cervix by increasing
collagenase, elastase, and glycosaminoglycans.
• Relaxation of smooth muscle of cervix.
 Contraindications
• Previous uterine scar is relatively contraindicated
• Established uterine activity
• Asthma
• Severe hepatic or renal impairment
• Known hypersensitivity to prostaglandins
• Active vaginal bleeding
 PGE1: Misoprostol
Misoprostol is a synthetic PGE1 analogue which have been used as in
pregnancy as a cervical ripening agent.
 How to Use Misoprostol?
• Dose of 25 micro gram every 4hrly to a maximum of 6 doses can be
given intravaginally into the posterior vaginal fornix.
• Dose 50 micro gram every 3hrs to a maximum of 6 doses can be given
orally.
• Dose of 25 micro gram every 2hrs can be given orally.
 Other routes of administration:
1. Buccal
2. Rectal
3. Sublingual
 Oxytocin
• It is synthetized in the hypothalamus.
• Half-life of 3-4 mins and duration of action 20 mins
• Oxytocin is used very commonly to achieve induction of labour.
• The objective is to produce uterine contractions that effectively produce
cervical change and descent of the presenting part.
 Mode of Action
1. It acts through the receptor and voltage gated calcium channel causing
myometrial contraction.
2. It stimulates amniotic and decidual PG production.
 Routes of administration
• IV infusion
 Complications of Oxytocin Use in induction of labour
• Hypertonic uterine contraction causing fetal distress
• Tetanic and tumultuous contractions, which can result in abruptio placenta
• Birth injury due to rapid expulsion of the baby
• Mother may develop hypertension with frontal headache
• Uterine rupture
Oxytocin administration
• Rupture membranes
• Infuse oxytocin 2.5 units in 500mls of dextrose or normal saline
at 10 drops per minute. (this is approximately 2.5mIU /min).
• Increase the infusion rate by 10 drops per minute (dpm) every
30 minutes until the patient has a good contraction pattern of 3
contractions in 10 minutes each lasting 40 seconds or maximum
of 60drops/min is reached. Maintain this rate until delivery
• If a good contraction pattern is not established with an infusion
rate of 60dpm, increase the oxytocin concentration to 5units in
500 mls of dextrose or normal saline and adjust the rate to 30
dpm
• If a good contraction pattern is still not reached: in multigravida
and in women with a previous scar, the induction has failed and
delivery should be by Caesarean section.
• In primigravida, one can increase the concentration of oxytocin
to 10 units in 500 mls of dextrose or saline. If good contractions
are not established with the maximum dose, deliver by
caesarean section
 Amniotomy
Ideally amniotomy or ARM (artificial rupture of membrane is performed when
the cervix is effaced and 2 cm dilated but it can be performed with minimal
cervical dilatation.
 Steps of ARM:
• Auscultate the FHR
• Evaluate the cervix and station of the head. The cervix should be well
applied to the head
• Introduce two fingers into the cervix, sweep away the membranes from
the cervix
• Pass and Allis or Kocher’s forceps in between the groove of your two
fingers, hook the membranes and rupture them; look for the clarity of liquor.
 Risk:
Cord prolapse
FHR deceleration
Bleeding through vasa praevia
Fetal injury
Maternal and fetal infection
 Advantages:
- It shortens duration of labour
- Allows for early diagnosis of meconium staining of amniotic fluid,
especially in high risk pregnancy
- Facilitates invasive fetal monitoring
 Balloon Devices: Foley Catheter
• For a single balloon catheter, a no. 18 Foley is introduced under sterile
technique into the intracervical canal past the internal OS. The bulb is then
inflated with 30-60 cc of water. The catheter is left in place until either it falls
out spontaneously or 24hrs have elapsed.
• Low-lying placenta is an absolute contraindication to the use of a Foley
catheter
 Complications
1. Premature delivery
2. Postpartum Sepsis
3. Fetal distress
4. Failed induction and Caesarean section
5. Hyper stimulation of uterus causing severe pain
6. Umbilical cord prolapse
7. Uterine rupture
 Reference
Jomannah A. Hmood (April 4, 2016). Induction of labour. Retrieved from
http://www.slideshare.net/mobile/jomanahadnan/induction-of-labour-
61286232