INDUCTION OF LABOUR

Prepared by;
Sharmila
Sita
Sisam
Upasana
Urmila
 Induction of Labour

Induction of labour means deliberate termination

of pregnancy beyond 28 weeks (period of viability) by
any method which aims at initiation of labour and a
vaginal delivery.
 Incidence

The incidence of induced labour varies in different

hospital, but generally showing a rising trend.

It is about 10-15% in India.

Purpose of induction

When the risk of continuation of pregnancy either to

the mother or to the fetus is more, induction is
indicated.

Induction of labour is indicated when the benefits of

the termination of pregnancy to the mother or the
fetus outweigh those the continuing the pregnancy.
 Indications

The indications are broadly grouped into:

a) Fetal
b) Maternal
c) Combined
a) Fetal: Continuations of pregnancy may adversely affect the fetal
prognosis.

i. Post maturity.
ii. Previous history of unexplained intrauterine death.
iii. Chronic placental insufficency leading to growth
retardation of the fetus.
iv. Rh-isoimmunization.
v. Unstable lie after correcting into longitudinal lie.
vi. Malformation of the fetus.
vii. Diabetes mellitus.
viii. Other indication:- multiple pregnancy, elderly
primigravidae.
ix. Intrauterine death of fetus.
b) Maternal : condition of pregnancy may affect
maternal health.

i. Chronic polyhydramnious with maternal distress.

ii. Congenital malformation of the fetus:- For

psychological reason and to minimize the pregnancy
condition to occur.
c) combined: continuation of pregnancy affects
both mother and baby.
i. Pre-eclampsia and eclampsia.
ii. Minor degree of placenta previa.
iii. Abruptio-placenta. (very minor)
iv. Premature rupture of the menbrane.
v. Chronic hypertension and PIH.
vi. Chronic renal disease.
Contraindication

Contracted pelvis and major degree of cephalo-pelvic

disproportion.
Persistent malpresentation.
Pregnancy with previous caesarean section.
Pregnancy following repair of vesico-vaginal fistula.
Elderly primigravidae with associated complication.
Carcinoma of cervix.
Presence of active hepatic genital lesion.
Heart disease.
High risk pregnancy with compromised fetus.
Pelvic tumor.
Assessment of suitability of induction

before the undertaking induction of labour, the following

factors have to be considered carefully:

i. The period of gestation

ii. Assessment of the cephalopelvic disproportion is
important, malpresentation; pelvic tumor etc. may
caused mechanical difficulty during labour.
iii. The state of cervix and the station of presenting part
serve as a prognostic index for the success of induction.
A score of 9 and above is highly favourable .
Below 5 is considered unfavourable.

Cervix dialatation and station of the presentind part are

more important than the rest of the parameters.

High score commonly reffered to as “Ripe Cervix”

Success of induction depends on:

I. Period of gestation.

II. Case profile: more success in parous woman or in

cases with premature rupture of the membranes.

III. Sensitivity of the uterus.

IV. Pre-induction scoring.

Methods of induction

i. Medical induction

ii. Surgical induction

iii. combined
i. Medical induction

drugs are commonly employed to medicate induction.

The following are the condition where medical condition
is specially indicated.
a) Intrauterine fetal death.
b) Premature rupture of membrane.
c) In combination with surgical induction.
Drugs used
I. Oxytocics

II. Prostaglandin
Oxytocin
oxytocin is the hormone released from posterior
pitutary gland.

It acts, at cell level, on smooth muscle and released in

pulsed manner in response to stimulation. Receptor tp
oxytocin are found in mayometrium and increase in
number towards term and throughout labour.
Principle of induction of labour
1. The oxytocin should be started at low dose but escalated
by quickly where there is no response besause of its
erratic response.
2. When optimal response are achieved the particular
concentration I mu/per minutes is to be continued. This
is called oxytocin titration techniques.
3. The objective of oxytocin administration is not only
initiate effective uterine contraction but also to maintain
normal pattern of uterine activity til delivery and at least
30-60 minutes beyound thah.
Regime of oxytocin
Ordinarily a multigravidae uterus or the uterus which is
already contracting is much more sensitive to
oxytocin.
In this respect, the primigravidae uterus is less
responsive because of wide variation, in response, it is
a sound practice to start with low dose (2.5 units) and
to escalate quickly if there is no response. The patient
should preferably lie on one side or in semi-fowler’s
position to minimize venacaval compression.
1. First regime
Mix 2.5 unit syntocin in 500ml of dextrose and start at
10drops/minute to evaluate the individual secsetivity of
the patient to the drug. Thereafter the rate of the
infusion is increased gradually with 10drops in every 30
minutes up to 60 drops per minutedepending on the
response that is frequency and atrength of the uterine
contraction. If satisfactory uterine contraction is not
obtained, the contraction may be increased to 5 units in
500ml dextrose start from 30 drops per minute.
2) Second regime
5 units of oxytocin added to 500ml of dextrose give
approximately 0.5mu in one drop of infusion. The
starting dose should be low 5mu per minutes
(30drops/min) increasing at intervals of 30 minutes at
every 10drops, according to the strength and frequency
of the uterine contraction, to a maximum of
30mu/minute (60 drops/min).
Time Oxytocin Drops/min Approx. Volume Total
concentration dose ( m IU infused volume
min) infused
0.00 2.5 units in 500ml 10 3 0 0
dextrose or RL(5ml
IV/ml)
0.30 Same 20 5 15 15

1.00 Same 30 8 30 45

1.30 Same 40 10 45 90

2.00 Same 50 13 60 150

2.30 Same 60 15 75 225

3.00 5 units in 500ml 30 15 90 315

dextrose or R/L
(10mIU/ml)

3.30 Same 40 20 45 360

4.00 Same 50 25 60 420

4.30 Same 60 30 75 495

Observation during oxytocin infusion
I. The mother should never use left alone when the
oxytocin infusion is running.
II. Always start the drop with 10drops/min and increase
10 drops in every 30 minutes.
III. Rate of flow of the infusion should be observed and
properly adjusted especially when the drop is
regulated by counting the drops per minutes.
IV. Response to uterine contraction should be keenly
observed by noting the hardening of the uterus on
abdominal palpation,
Note the tonus of the contraction by using ‘finger tip’
palpation.
5. fetal heart rate should be noted every 15 minutes
interval, continuous fetal monitoring, if available is
specially for high risk cases, cardiotocographic equipment
can record FHR and uterine contraction simultaneously.
6. Use partograph to assess progress of labour.
7. Mternal condition should assess frequently by checking
pulse, blood pressure hourly, amount of urine should be
recorded if oxytocin dose is exess of 20mu/minute.
8. Progress of labour should be assess by abdominal and
vaginal examination by noting descent of head,
dialatation of the cervix, status of membrane, colour
of liquor, station, etc.
9 Keen observation on any sign of complication and
hazards e.g. fetal distress, cord prolapse after
membrane rupture, tonic contraction, tetanyuterus,
etc.
Indication of stopping the infusion
1. Nature of uterine contraction
a) abnormal uterine contractions occcuring frequently
(every 2 minutes or less) or lasting more than 40sec.
b) increase tonus in between contractions.

2. Evidence of fetal distress.

3. Appearance of untoward maternal symptoms.
Prostaglandin
prostaglandin is most commonly administered by
the intravaginal route, alyhough other preparation is
also available.
Prior to prescribing and using prostaglandin,
Bishop’s scoring should be assessed .
Indication
Medical termination of pregnancy (induction of
abortion).
Termination of abnormal pregnancies.
i. missed abortion.
ii. major fetal abnormalities- anencephaly.
iii. intrauterine fetal death

iv. molar pregnancy

Pre-induction cervical ripening
Induction and acceleration of labour.
Cont…
Control of post partum hemorrahage
Routes of administration
1. Vaginal route:- prostaglandin gel containing 2-3 mg
pessary of PGE2 administered vaginally 12 hours prior to
induction of labour is highly successful in ripening of
the cervix. The gel is administered in the cervical canal
and on the cervix (posterior fornix of the vagina) taking
care that the membranes remain intact and the
application is intra-cervical rather than extra amniotic.
Prostaglandin E2 administered locally to the cervix is
absorbed, resulting in changes which can be assessed on
vaginal examination, increasing bishop’s score.
2. Oral route:- prostaglandin may be administered
orally for induction of labour, the prostaglandin
analogue PGE2 is used. Tablet containing o.5mg of
PGE2 are given at 30 minutes to and 2 hours intervals.
The doc=se may be doubled and a maximum of 30mg
may be used.
ii. Surgical induction
The initiation of labour is attempt by surgical method
and is almost exclusively done by rupture of
membranes.
Indication
1. Exclusive :
a) APH
b) chronic polyhydramnious
c) severe pre-eclampsia and eclampsia

2. In isolation or as an adjunct to medical induction

(common)
Contraindication

Intra-uterine fetal death

Methods
i. Artificial rupture of the membrane
-low rupture of membrane (LRM)
- High rupture of membrane (HRM)

ii. Stripping of the membrane

Artificial rupture of membrane (amniotomy)

Amniotomy is the artificial rupture of the membranes

resulting in drainage of liquor. It is commonly
abbreviated to ARM.
ARM is performed to induce labour when the cervix is
favorable or during labour augment contractions. A
full fitting presenting part is essential to prevent cord
prolapse. ARM may also be carried out to visualize the
color of liquor.
Cont…
rupture of the menbranes allows the presenting part
to descend. Amniotic fluid is expelled, prostaglandin,s
are produced (stimulating factors) & uterine
contraction begin or become stronger.
Procedure
ARM is carried out during vaginal examination by
maintaining the strict aseptic technique;
Consent should be taken from mother.
Mother is kept in lithotomy position and using
aseptic care, the index or the middle finger is inserted
through the cervical OS.
The membranous are stripped off, the lower uterine
segment and the bag of membranes are ruptured by a
sharp pointed instrument (kocher’s forceps).
Cont..
Liquor starts draining, as the fore waters rupture the
color of the liquor observed, it may be clear or
meconium stained.
After ARM, listen FHS, if abnormal, suspect fetal
distress.
if membranes have been ruptured for 18 hours, give
prophylactic antibiotics to reduce infection to
neonate.
Ampicillin 2g I/V 6 hourly untill delivery.
There is no sign of infection after delivery, discontinue
antibiotics.
Cont…..
If good labour is not establish one hour after ARM
begin, start oxytocin infusion.
Hazards of ARM
1. Intrauterine infection, particularily iatrogenic from
digital or instrumental contamination.
2. Early decceleration of the fetal heart.
3. Cord prolapse.
4. Bleeding from sources: fetal vessels in the
membranes (vasa previa); the friable vessel in the
cervix, or a low lying placental site (placenta previa).
5. Liquor amnii embolism.
Contraindication
1. Moderate to severe degree CPD
2. Lie is other than longitudinal.
3. Previous caesarean section.
4. Pelvic tumor.
5. Cardiac diseases.
Advantage of low ARM
1. An easy maneuver.

2. Effective when combined with oxytocin infusion,

80% patients are in labour within 8 hours.
Disadvantes
1. the ‘unripe’ cervix with a closed cervical os make the
procedure difficult.
2. Risk of prolapse cord, if the head is high or there is
polyhydramnious.
3. Risk of intrauterine infection and chorio-amniotis.
Stripping the membranes
stripping the membrane off from its attachment from
the lower segment is an effective procudure for
induction when cervical score if favorable.
it is used as a preliminiary step prior to rupture
of membranes.
it is also used to make the cervix ripe.
Stretching of the cervix and liberation of endogenous
prostaglandins either help in ripening the cervix or at
times, initiation of labour.
iii. Combined method
The combined medical and surgical methods are
commonly used to increase the efficacy of induction by
reducing the induction delivery interval.
The oxytocin infusion is started either prior to or following
rupture of the membranes depending mainly upon the
state of cervix and head brim relation.
With the head non- engaged, it is preferable to induce
with prostaglandin gel or to start oxytocin infusion
followed by ARM.
The advantages of thecombined method are:

I. More effective than any single procedure.

II. Shorten the induction delivery interval and thereby

minimizes the risk of infection and lessens the
period of observation.
Risks of induction
1. Failure of induction-20%.
2. Prematurity: due to mistaken of LMP and wrong
calculation of EDD.
3. Abnormal uterine action.
4. Infection for both maternal and fetal .
5. Fetal hypoxia.
6. Amniotic fluid imbolism.