Kakamega County General Hospital

KAKAMEGA COUNTY REFERRAL HOSPITAL: DEPARTMENT OF OBSTETRICS & GYNAECOLOGY

Presenter: Dr. Samantha Mukonjia

CME: 24/11/2023
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2.
Scope 3.

4.
I

Disclosures
Multiple Protocols exist in the decision & management of Induction of Labour
Here, we utilize:
World Health Organization Recommendations - informed by ACOG, RCOG etc
Kenya National Guidelines on Quality Obstetrics & Perinatal Care (February 2022)
Peer Reviewed Literature - esp. on Mx. in low resource settings (as a mirror of
what is happening “kwa ground” - Identify gaps & solutions
Facility recommended practices (Prior presentations/ Facility Protocol) (Kwa
Ground Ile Kabisa)
Need for consultancy & hospital specific guidelines
Standardization of practice improves outcomes ; reduces harmful
events¹ Kakamega County General
Hospital
I BACKGROUND

I: Introduction

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Hospital
I INTRODUCTION

Induction of Labor: Background

Definition: Stimulation of contractions before the spontaneous onset of labor, with/ without ruptured

membranes.

When the cervix is closed and uneffaced, labor induction will often commence with cervical ripening, a

process to soften and ripen the cervix.

Up to 25% of women will have labor induced. The rate of induction of labor doubled between 1990 and 2006

and has continued to trend upwards.

Kenya? Paucity of data, but IOL is not uncommon

IOL is indicated where the benefits to mother and/or fetus of discontinuing the pregnancy >> outweigh

the risks of awaiting spontaneous onset of labor.

Induction of labor has a large impact on the health of women and their babies and so needs to be

compelling, convincing, clinically justified and consented to.

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Hospital
I INTRODUCTION

Definition of Terms
Labour: Is a physiological process characterized by uterine contractions, cervical effacement and dilatation leading to
expulsion of products of conception.
Successful induction: a vaginal delivery within 24 to 48 hours of induction of labour. (SOGC)
Elective induction: the induction of labour in the absence of acceptable fetal or maternal indications (exception rather
than the rule).
Tachysystole: refers to > 5 contractions per 10-minute period averaged over 30 minutes. This is further subdivided into
two categories, one with and one without fetal heart rate changes
Augmentation of labour: the use of oxytocin to increase the frequency, intensity and duration of uterine contractions in a
patient whose labour has commenced spontaneously but is proceeding slower than acceptable as per partograph.
Cervical Ripening: process used to improve cervical parameters prior to induction of labour. It is the thinning, softening,
and opening of the cervix prior to active labour. Whether or not a patient needs cervical ripening should be determined
using the Bishops Score.
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I INTRODUCTION

Why 39 weeks in High Risk Pregnancies?

Associated increase in Adverse Neonatal Outcomes at 37 - 38 Weeks of Gestation

Neonatal death

NICU admission

Newborn sepsis

Respiratory distress syndrome

Transient tachypnea of the newborn

Treated hypoglycemia

Hyperbilirubinemia

Exceptions?
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I INTRODUCTION

...what about low risk pregnancies?

Why are we scared to reach the edge of the
cliff... EDD?
What are our Fears/ What Sharks are we scared of?

What is the risk of stillbirth if someone declines induction and waits for spontaneous labour?

39 WEEKS - 4 PER 10,000 In reality, what does this mean?

40 WEEKS - 7 PER 10, 000
41 WEEKS - 17 PER 10.000

At 39 weeks, out of 10,000, 4 will habe a stillbirth, 9996 wont have a still birth!

Need to induce 2499 pregnant women @ 39weeks to reduce 1 stillbirth!! Kakamega County General
Hospital
I INTRODUCTION

Do not do a blanket Induction @ 39 Weeks!!

Would a week make a difference?

Inconvenience to the mother/ obstetrician of

LOW RISK
continuation of pregnancy
PREGNANCY?
YES ! WE Implications including cost & resources?
Counsel her, Tell Her
SHOULD GO
BEYOND EDD Risks of Elective Induction

Benefits of Expectant Management

Special Considerations?
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Hospital
I INTRODUCTION

Induction has its Risks!!

Induction of labor using various methods may be associated with an increased risk of:
Delayed breastfeeding, low APGARS and need for NBU
Failure to achieve labor
admission.
Caesarean section
Operative vaginal delivery
Tachysystole with or without FHR changes
Chorioamnionitis
Cord prolapsed with ARM Explain indication, risks,
benefits, mode of induction,
Iatrogenic Prematurity - Inadvertent delivery of preterm/low expected timeframe
.
birth weight infant in the case of inadequate dating
Uterine rupture in scarred and unscarred uteri
II INDICATIONS & CONTRAINDICATIONS

II: Indications & Contraindications

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Hospital
II INDICATIONS & CONTRAINDICATIONS

Labor Induction: Maternal Indications

Induction is indicated when the benefits to either mother or fetus outweigh those of pregnancy
continuation
Logistical problems at term (history of rapid
Post-term Pregnancy (Leading Cause) labour, distance to hospital)
Pre-eclampsia and Eclampsia, high priority Diabetes Mellitus
Chronic Hypertension with signs of end organ Heart Disease, unresponsive to treatment, high
damage priority
Term PROM, high priority Chronic renal disease, unresponsive to
Uncomplicated twin pregnancy more than 38 treatment, high priority
weeks IUFD
Chorioamnionitis, high priority Chronic polyhydramnios with maternal
Abruptio placentae, stable APH respiratory distress

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II INDICATIONS & CONTRAINDICATIONS

Labor Induction: Fetal Indications

Induction is indicated when the benefits to either mother or fetus outweigh those of pregnancy
continuation

Postdates gestation Previous history of unexplained IUFD at term

Rh isoimmunization – Timely intervention

Diabetes Mellitus
Chorioamnionitis at any gestation
Unstable lie after correcting into longitudinal
PROM after 34 weeks
lie
Placental insufficiency
Congenital malformations
Suspected IUGR Abruptio placentae

2. Desai et al., 2018 Kakamega County General

Hospital
II INDICATIONS & CONTRAINDICATIONS

Labor Induction: Absolute Contraindications

Methods to induce or augment labor are contraindicated by most conditions that preclude
spontaneous labor and delivery. The include, but are not limited to the following

Severe hydrocephalus( severe is subjective) •Contracted pelvis

Malpresentation •Placenta previa
Non reassuring fetal status, always confirm •Uterine scar due to classical CS
with EFM •Myomectomy entering the endometrium
Transverse lie •Active genital herpes infection or cervical cancer
Term Breech presentation

2. Desai et al., 2018 Kakamega County General

Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

III: Management of IOL

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Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

Prerequisites & Pre-induction Assessment

Informed written consent
Review of maternal history and profile
Evaluation for indications and rule out any contraindications
Reliable estimation of gestational age, presentation and fetal weight.
Maternal pulse, blood pressure, temperature, respiratory rate and findings on abdominal palpation must be
recorded.
Evaluation of baseline fetal heart rate pattern by auscultation/electronic fetal monitoring.
Maternal pelvis assessment and clinical evaluation for possible cephalopelvic or feto-pelvic disproportion including
fetal macrosomia
Assessment of cervical status using Modified Bishop scoring system to predict the likelihood of success and select
appropriate method of induction of labor.
Kakamega County General

Recent Obstetric Ultrasound Hospital

III MANAGEMENT OF INDUCTION OF LABOUR

To Ripen or Not?

Bishop score parameters must be documented during each vaginal assessment and not just a total
score. Of the Bishop Scores for predicting successful induction, the most important is cervical
dilatation, followed by effacement, station and position with the least important being consistency
Add 1 point for: Pre-eclampsia; Each previous vaginal delivery
• Subtract 1 point for: Postdate pregnancy; Nulliparity; PPROM Kakamega County General
Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

Cervical Ripening/ Induction: Pharmacological

Misoprostol (Vagiprost, Cytotec):

Dosing of misoprostol: ·Give 50 mcg orally (swallowed or sublingual) or give 25 mcg vaginally.

Repeat every 4-6 up to 4 doses hours as long as contractions are absent or non-painful.

Oxytocin can only be used 4 hours after the last dose. May administer oral misoprostol

(50mcg) in case of rupture membranes.

Dinoprostone (PGE2): 3mg in 2.5 mL viscous gel of colloidal silicon dioxide in triacetin, every 6 hrs.

Intracervically or in posterior fornix or 3mg pessary in posterior fornix every 6rs. May repeat for a

total of three doses.

Low dose Oxytocin: 5 units of oxytocin is diluted in 500ml of normal saline and infused starting at 4

drops per minute for 6 - 12 hours. Do not dose escalate for cervical ripening. Kakamega County General
Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

FIGO Guidelines for Misoprostol Induction

Adjustments for
Context?
Your Experiences?

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Hospital

6
III MANAGEMENT OF INDUCTION OF LABOUR

Methods of Cervical Ripening: Mechanical

Foley Catheter:

Size 18/20 Fr catheter is inserted just above the internal os into the extra-amniotic space to

stretch the cervix and promote endogenous release of prostaglandins. (No consensus on the

minimum or max. mills to balloon—30-60mls).

The catheter is left in place until either it falls out spontaneously or 24 hours have elapsed.

Traction not mandatory but not contraindicated.

SAY NO TO CATHETER IN…

Low-lying placenta is an absolute contraindication to the use of a Foley catheter. Relative

contraindications to its use include antepartum hemorrhage, rupture of membranes, and

evidence of lower tract genital infection. Kakamega County General

Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

Sweeping of Membranes
NICE CG70 recommends that prior to formal induction of labour, women should be offered a vaginal

examination for membrane sweeping.

When a vaginal examination is carried out to assess the cervix, the opportunity should be taken to offer the

woman a membrane sweep.

Additional membrane sweeping may be offered if labour does not start spontaneously.

A vigorous digital exam of the cervix is performed by hooking the index finger in the extra amniotic space

just beyond the internal os to promote endogenous release of prostaglandins.

This is repeated every 4 hours.

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Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

Oxytocin (Agent of Choice)

If the patient has undergone cervical ripening using prostaglandins wait at least 4-6 hours after the last dose

before initiating oxytocin or performing Amniotomy.

We can use a low dose oxytocin protocol as follows:

5 units of oxytocin is diluted in 500ml of Normal Saline and infused starting at 4 drops (=2 milliunits) per

minute and escalated by 4 drops per min every 30 minutes.

The dose is escalated until 3 contractions in 10 minutes, each lasting 40 seconds or more, are achieved and

maintained at that rate.

If there are not 3 contractions in 10 minutes at 60 drops per minute, then finish the solution at that rate.

Then start a new bottle with 10 units of oxytocin in 500 mls and start infusing at 30 drops per min and escalate

by 4 drops every 30 minutes as before, to a maximum dose of 40 drops per minute.

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Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

Oxytocin (Agent of Choice)

NOTE: when Oxytocin is running continuously at around 20 -32 drops (10-16 milliunits) majority of

patients are contracting. So only titrate up when assessed again by the doctor.

If Tachysystole(>5 contractions per 10 minutes lasting 40 seconds or more) occurs, stop infusion

and do FM.

Oxytocin is considered a safe uterotonic agent for use in the presence of a scarred uterus, but it

should be used with due care and diligence (SOGC, clinical practice guidelines No. 155)

Our Facility Protocol??

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Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

Amniotomy
NOTE: Amniotomy is not mandatory prior to initiation of oxytocin

Artificial rupture of membranes using Amnihook or Kocher’s artery forceps once contractions have started can

augment the progress of labour and speed the time to delivery in multiparous patients only.

In nulliparous women amniotomy has not been shown to promote a faster time to vaginal delivery.

And is associated with increased risk of chorioamnionitis and change in the FHR patterns on the FM.

In cases of polyhydramnios, the release of amniotic fluid must be controlled to prevent abruptio placentae due to

rapid uterine decompression.

NOTE: Amniotomy should not be performed routinely in patients with HIV or Hepatitis.

However, in patients with prolonged labor amniotomy can be used to promote a smooth vaginal delivery.

With PROM, oxytocin stimulation is more effective than expectant management to reduce maternal infection and

increase vaginal deliveries within 24hours.

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PROM is not a contraindication to prostaglandin use.

Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

What about a previously scarred uterus?

Vaginal birth after cesarean section is acceptable for spontaneous
That face you make when
labor and if the induction with oxytocin and amniotomy alone. you hear a patient with a
previous scar has been
Limitations in many facilities? Equipment for monitoring? Theatre induced with misoprostol
Readiness? Limited Resources
If induction is to be performed with a previous low transverse uterine
scar, then the consultant must review the patient and document the
decision in the medical record.
In these cases the medical officer and or nurse must manage the
induction of labor and must review (not necessarily do VE) every two
hours.
ABSOLUTE CONTRAINDICATION OF PROSTAGLANDINS!!!!

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Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

Patient Monitoring
NOTE: The labour nurse is responsible for monitoring the patient (as listed below), completing the
partograph and advising the Intern, medical doctor of any deviation from expected normal values.
Partograph should be started once the patient is in active labour or started on oxytocin
Blood pressure at least every 4 hours, and every 1 hour in pre-eclamptic/eclamptic patients, Pulse
every 30 minutes
·Abdominal palpation to assess contractions for ten minutes every 30 minutes
Assessment of cervical dilatation at least every 4 hours or more frequently if indicated
Assessment of Fetal heart rate every 30 minutes, listening immediate after a contraction for at least
one minute
Assessment of the color of the liquor, for meconium or blood staining
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III MANAGEMENT OF INDUCTION OF LABOUR

Setting and Timing : IOL is not an Emergency

Decision to induce must be made by a qualified medical doctor/consultant. Documentation of reason for induction
must be clear. The client must consent for this common obstetric intervention. Induction must be done at particular
times (5am - 9am - 1pm - 5pm - 9pm - 1am)
Clients that are induced during the day must be reviewed at night.
Clients who come at night will be induced in the morning unless compelling reasons support beginning the
procedure at odd hours.
Handing over of all patients on induction must be documented in patients file to avoid delays in reviews and
intervention.
All patients on induction lasting more than 24 hours must be reviewed by the consultant on call.
Always indicate time of initiating induction and delivery time.
Always document reason for delay in timely intervention
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Hospital
III MANAGEMENT OF INDUCTION OF LABOUR

So why would an Induction Fail?

Repeat Induction?
WHAT ARM/ Oxytocin?

NEXT? Emergency/ Elective

Caeserian Delivery?

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Hospital
IV CONCLUSION & RECOMMENDATIONS

IV: Conclusion & Recommendations

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Hospital
IV CONCLUSION & RECOMMENDATIONS

Recommendations before & during IOL (Ideal)

Outpatient IOL is not recommended
Fetal surveillance with NST recommended
Intermittent maternal and FHR monitoring should be done every hour initially
Continuous electronic/ more frequent intremittent FHR monitoring should be started in active labour
Progress of labour is monitored using partograpoh/ WHO labour guide
Close watch is kept for temperature, Pulse rate, blood pressure, FH pattern, Vaginal Bleeding, Uterine
Hperstimulation, uterine rupture and scar dehiscence in women with previous caeserian deliveryy

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Hospital
IV CONCLUSION & RECOMMENDATIONS

Recommendations at the Level of the Health System

Adequate skill mix staff

Importance of screening and history taking

Ascertain gestation where applicable before induction

Correct use of Partograph/WHO Labour guide

Ensure availability of all supplies and equipment before induction

Close Monitoring of client during induction

Administration of Correct dosages of drugs

Emergency preparedness in case of failed induction

Emphasis on INDICATIONS AND CONTRAINDICATIONS

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Hospital
Discussion
Any Questions?