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INDUCTION OF

LABOUR
NUR HANANI BINTI MOHD KHAN
0313883

DEFINITION
Induction of labour = artificial stimulation of uterine contractions prior
to the spontaneous onset of labor.
Augmentation of labour = process of stimulating the uterus to increase
the frequency, duration and intensity of contractions after the onset
of spontaneous labour
The aim of IOL is to eliminate the potential risks to the fetus with prolonged
intrauterine existence while minimizing the likelihood of operative delivery

MATERNAL INDICATIONS
INDICATIONS

WHEN TO
INDUCE

REASONS

Maternal DM, twin


pregnancy

38 weeks/
earlier

- Prevent intrauterine fetal distress

Pre-eclampsia /
maternal
hypertensive
disorder

37-38 weeks

- Can cause placenta insufficiency


- very preterm gestations (<34 weeks)/
fetal distress C-section is indicated
- impending eclampsia, IUGR and placental
abruption may require early induction --Corticoid therapy between 30-34 weeks

Placenta abruption

37 weeks with
close
monitoring

- Severe bleeding can cause haemorrhagic


shock.
- To some extent maternal death and fetal
demise can occur

Prelabour rupture
membrane (PROM)

Immediate
(within 48
hours) (if

- Delay Risk of infections (chorioaminitis,


neonatal infections)
- 34-37 weeks risks and benefits need to

FETAL INDICATIONS
INDICATIONS

WHEN TO INDUCE

REASONS

Prolonged pregnancy

41-42 weeks

- Beyond 41 weeks, placenta


insufficiency may occur
- risk of stillbirth, fetal
compromise, meconium aspiration

RH incompatibility

as soon as lung
matured

- RH iso-immunization exposes the


fetus to jaundice and kernicterus .

Intrauterine growth
restriction (IUGR)

- Depends on
biophysical profile

- Can cause fetal asphyxia

Intrauterine death
(IUD)

- immediate

- To avoid infection and


disseminated intravascular
coagulation pregnancy with dead
fetus

CONTRAINDICATIONS
ABSOLUTE

RELATIVE (need precaution)

- Major placenta previa


- Malpresentation breech,
transverse or oblique
- if ECV is also contraindictaed
- Cord prolapse emergency
cesarean section
- Contracted pelvis
- Cephalopelvic disproportion
- Fetal distress emergency
cesarean section
- Hypersensitivity to cervical ripening
agents

- Scarred uterus
- Previous C-section uterine rupture
- Preterm gestation at <34 weeks
higher risk of failure & C-section is
more preferable
- Multiple pregnancy
- Polyhydramnios
- Grand multiparity
- Maternal heart disease
- cannot use hormonal method
of IOL
- Abnormal fetal heart rate that is not
requiring emergency cesarean
section

BREAST STIMULATION
Stimulation of nipples release of oxytocin from
posterior pituitary helps uterine contraction to start
-

- Only works in woman with favourable cervix


- Should not be used in highrisk woman
- Reduces postpartum haemorrhage

MEMBRANE SWEEP
- Circular sweeping of the cervical os Digital separation of chorionic
membrane from the underlying decidua increase local production of
prostaglandins initiate labour
- prior to rupture of membrane
- simple, safe and beneficial for IOL
- Sweeping membranes from 38 weeks of pregnancy onwards reduces the
rate of prolonged pregnancy
- uncomfortable & possible if cervix is beginning to dilate & efface
- only done at term

OXYTOCIN
IV infusion after rupture of membranes
starting infusion rate is low and defined increments follow every 30 mins until
3-4 uterine contractions are achieved every 10 mins, each lasting 40-60s
MOA
initiate myometrial contractions
stimulates amniotic & decidual prostaglandin production

Side Effects

uterine hyperstimulation abnormal fetal heart rate pattern


uterine rupture
water intoxication ADH effect in high doses
fetal distress

SYNTOCINON
- Synthetic derivative similar in action to oxytocin
- has longer half life (5-12 minutes) than natural oxytocin
- often as an adjunct to rupture of membrane with favourable cervix
- given intravenously as a constant low dose at less than
10milliunits/min
- brand name : pintocin
*continuous CTG monitoring to avoid risk of uterine hyperstimulation

PROSTAGLANDINS
- Used for cervical ripening and induction of labour
- commonly used are Prostaglandin E2 (dinoprostone) and
Prostaglandin E1 (misoprostol)
- Contraindications : hypersensitvity, uterine scar, active cardiac,
pulmonary, renal, hepatic disease, bronchial asthma
- Side effects:
pyrexia, vomiting, diarrhea, headache,
chills and
Dinoprostone
Misoprostol
exacerbation of severe asthma
- inserted vaginally into posterior
- Transvaginal (25mcg fourfornix as tablet/gel, 2 doses with
hourly) / oral (should not
at least 6 hrs apart
more than 50mcg)
- a controlled-release pessary left
- SE: tachysystole,
in place up to 24 hrs
meconium passage, uterine
- Higher rate of uterine
rupture
hypertonus / hyperstimulation

MIFEPRISTONE
- is a progesterone receptor blocker
- inhibitory effects of progesterone on the uterus sensitize myometrium
to prostaglandin-induced contraction contraction of the uterus
and ripens the cervix
- widely used in 2nd semester termination of pregnancy
- combination of mifepristone and misoprostol currently used in the UK only
to induce labour following IUD

EXTRA AMNIOTIC FOLEYS


CATHETER
- Promote the cervical ripening and the onset of
labour by stretching the cervix and / or
stimulating the release of prostaglandin
- Foleys catheter is introduced into the cervical canal
under sterile technique past the internal os and
the balloon is inflated with 30-60 cc of water.
- The catheter is then left in place until it
spontaneously falls out
- Risks:
- Infection
- maternal discomfort
- antepartum bleeding
- PROM

LAMINARIA TENT and


HYGROSCOPIC DILATORS
- It is introduced into the cervical canal under sterile technique past the
internal os / into extra amniotic space.
- It absorb cervical and local tissue fluids, causing the device to expand
within the cervical canal, providing controlled mechanical pressure
- Promote the cervical ripening and the onset of labour by stretching
the cervix
- Stimulate release of prostaglandin.

LAMINARIA TENT

HYGROSCOPIC
DILATORS

ARTIFICIAL RUPTURE OF
MEMBRANE (ARM)
- Artificial rupture of membrane initiate inflammatory response release of endogenous prostaglandins cervical
ripening & uterine contraction
- also use to observe amniotic fluid for blood or meconium
- Cannot be employed in an unfavourable cervix (long, firm cervix with closed os). Cervix should be at least 1cm
dilated.
- Usually started with oxytocin to reduce fetal & maternal risk of sepsis

- Advantages
1.
b/p in pre-eclampsia
2.
Relief maternal distress in hydramnios
3.
Control bleeding in APH
4.
Relief of tension in placenta abruption & initiation of labour
- Disadvantages
5.
Umbilical cord prolapse
6.
Amnionitis
7.
Accidental injury
8.
Liquid amnii embolism
.-

COMPLICATIONS
pain and use of epidural and analgesia
Long labours
haemorrhage

augmented

with

oxytocin

uterine

atony

Postpartum

PGs & oxytocin uterine hyperstimulation fetal distress/fetal bradycardia*


emergency C- section
ARM performed while fetal head is high cord prolapse emergency C-section
Previous C-section/uterine scar uterine rupture
Failure of IOL attempt induction again in the future/ C-section
Fetal iatrogenic prematurity
Intrauterine infection with prolonged IOL

A contraction frequency of > 5 per 10 mins should be treated by stopping oxytocin


and administration of a tocolytic drug (subcutaneous injection of B2 agonist
terbutaline)

REFERENCES
Dutta, DC (2013)DC Dutta's Textbook of Obstetrics, 7th ed., New Delhi: Jaypee Brothers
Medical Publishers (P) Ltd.
Collins, Sally., Arulkumaran, Sabaratnam., Hayes, Kevin., Jackson, Simon., Impey,
Lawrence. (2015)Oxford Handbook of Obstetrics and Gynaecology, 3rd ed., page 57,
Great Clarendon Street: Oxford University Press.
N Baker, Philip., C Kenny, Louise (2011)Obstetrics by Ten Teachers, 19th ed., Great
Clarendon Street: CRC Press.
NICE guidelines (2016)Inducing labour,Available
at:https://www.nice.org.uk/guidance/cg70/chapter/1-Guidance(Accessed: 22nd April
2016).
Kavanagh J, Kelly AJ, Thomas J. Breast stimulation for cervical ripening and induction of
labour. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003392. DOI:
10.1002/14651858.CD003392.pub2.

THANK YOU