2. • Induction of labor (IOL) means initiation of
uterine contractions after the period of viability
by any method (medical, surgical or combined)
for the purpose of vaginal delivery.
• This includes both women with intact
membrane and women with spontaneous
rupture of membranes but who are not in labor.
Induction of labor
3. • Pre-eclampsia and eclampsia
• Maternal medical complications like diabetes
mellitus, chronic renal disease, cholestasis of
pregnancy
• Post-maturity
• Abruptio placenta
• Intrauterine growth restriction
Indications
4. • Premature rupture of membrane
• Fetus with a major congenital anomaly
• Intrauterine death of fetus
• Oligohydramnios, polyhydramnios
• Unstable lie
• Lesser degree of placenta previa
• Rh-isoimmunization
5. • Contracted pelvis
• Cephalopelvic disproportion
• Malpresentation
• Previous caesarean section or hysterectomy
• High risk pregnancy with fetal compromise
• Heart disease
• Pelvic tumor
Contraindication
6. • Elderly primigravida with obstetric or medical
complications
• Cord prolapse
• Cervical carcinoma
• any contraindication for vaginal delivery
• Uteroplacental factors: unexplained vaginal
bleeding, vasaprevia, placenta previa
9. • Induction of labor should be performed only
when there is a clear medical indication for it
and the expected benefits outweigh its potential
harms.
• In applying the recommendations,
consideration must be given to the actual
condition, wishes and preferences of each
woman, with emphasis being placed
General principles related to the practice
of induction of labor
10. • On cervical status, the specific method of
induction of labor and associated conditions such
as parity and rupture of membranes.
• Induction of labor should be performed with
caution since the procedure carries the risk of
uterine hyper stimulation and rupture and fetal
distress.
• Wherever induction of labor is carried out,
facilities should be available for assessing
maternal and fetal well-being.
11. • Women receiving oxytocin, misoprostol or
other prostaglandins should never be left
unattended.
• Failed induction of labor does not necessarily
indicate caesarean section.
• Wherever possible, induction of labor should be
carried out in facilities where caesarean section
can be performed.
12. Rating
Factor 0 1 2 3
Dilatation (cm) Closed 1-2 3-4 More than 5
Length of cervix (cm) More than 4 3-4 1-2 Less than 1
Consistency Firm Average Soft -
Position Posterior mid Anterior -
Descent by station of head
Descent by abdominal
palpation
-3
4/5
-2
3/5
-1, 0
2/5
+1, +2
1/5
Assessment of cervix for induction of labor
13. • Medical: oxytocin, prostaglandin,
• Surgical:
● Artificial Rupture of Membrane (ARM)
➢ Low rupture of Membrane (LRM)
➢ High Rupture of Membrane (HRM)
● Stripping the membrane
• Combined method
Methods
14. Prostaglandin:
Prostaglandin act on the cervix to enable
ripening of cervix.
➢ Prostaglandin E2 (PGE2) or cerviprime is
inserted in the posterior fornix of vagina,
usually in the form of 2-3 mg gel or 3mg
pessary, every 6 to 8 hours as one, two or three
doses as required.
Medical induction
15. ➢ Misoprostol (PGE1) is being used either
transvaginally or orally for IOL.
A dose of 25 mcg in the posterior fornix of the
vagina or orally 50mcg is found as effective for
cervical ripening and labor induction. It is
administered about 6 to 8 doses as necessary.
Contd…
16. Oxytocin:
Oxytocin causes contraction.
2.5 units of oxytocin usually mixed with 500ml
of dextrose or normal saline is given
intravenously.
Starting the infusion as 10 drops per minute,
infusion rate is increased by 10 dpm every 30
min until a good contraction pattern is
established, not exceeding 60 drops.
19. • Prostaglandins:
Prostaglandin act on cervix
to enable ripening by a no. of different
mechanisms. PGE2 is primarily important for
cervical ripening and myometrial contraction.
PGE2 (dinoprostone - 0.5mg ; 6hrly
3-4 doses) increases the activity of collagenase
and also sensitizes myometrium to oxytocin.
20. They cause increase in elastase,
glycosaminoglycan , dermatan sulfate and
hyaluronic acid levels in cervix causing relaxation
of cervical smooth muscle that facilitates dilatation.
Misoprostol (PGE1 ) used tansvaginally or
orally (25µg ; 4hrly) is found to be either superior
or similarly effective to PGE2 for cervical ripening
and labor induction.
21. Advantages:
• Effective method in IUD or unfavourble cervix.
• No anti-diuretic effect.
• Highly effective in ripening the cervix during
induction of labor.
22. Disadvantages :
• Requires fetal monitoring for 1-2hrs
• Risk for sustained contraction
• Sometimes causes vaginal soreness
• Nausea, vomiting or diarrhoea may be seen
• Very occasionally cause uterine
hyperstimulation affect FHR pattern
• Uterine rupture may occur with Misoprostol
thus is contraindicated in previous caeserian
section.
23. • Oxytocin :
Oxytocin is an endogenous uterotonic that
stimulates uterine contraction. Receptor
concentration increases during pregnancy and
labor. Oxytocin acts by :
a) Receptor mediation
b) Voltage-mediated calcium channels
c) Prostaglandin production
It is effective for induction of labor when
cervix is ripe as it is less effective as ripening
agent.
24. Advantages :
• Wider availability
• Less systemic effects
• Major catastrophe is rare
• Cheaper
Precautions:
• Never give oxytocin IM before delivery
• If FHR <100 bpm, stop the infusion
• Assess contraction 1/2hrly if hyperstimulation occurs
• Water intocication with high or prolonged use
• Rupture may occur in multigravida and previous c/s.
25.
26. • Mifepristone :
( Progesterone receptor antagonists )
It blocks progesterone and corticosteroid
receptors. 200mg vaginally daily for 2days has
been found to ripen the cervix and to induce
labor.
Progesterone inhibits contraction of the
uterus, while mifepristone counteracts its
action.
27. SURGICAL INDUCTION
● Artificial rupture of membrane (ARM)
• Low rupture of membrane ( LRM)
• High rupture of membrane (HRM)
● Stripping of membranes
28. ● Artificial rupture of membrane (ARM )
• Low rupture of membrane ( LRM):
It is a procedure where the puncture or rupture
of the membrane below the presenting part
overlying the internal os to drain some amount
of amniotic fluid.
29. Indications:
• Abruptio placenta
• Chronic hydraminos
• Severe pre eclampsia/eclampsia
• In combination with medical induction
• To place electrode for fetal monitoring
30. Contraindications:
• Intra uterine fetal death
• Cephalo pelvic disproportion
• Prematurity
• Maternal AIDS or active genital herpes infection
• Oblique or transverse lie
• Contracted pelvis
• Pelvic tumor
31. • High rupture of membrane (HRM) :
It is the procedure in which puncture of the
hind waters above the presenting part, is made
by a special instrument named “drew smythe
catheter”.
32. Indications :
obselete these days. However used in chronic
hydraminos where regulated escape of liquor
amnii facilitates settling down of presenting
part.
Contraindications:
• Antepartum hemorrhage
• Severe preeclampsia/eclampsia
33. Mechanism of onset of labor by ARM:
• Stretching of cervix
• Separation of the membranes
• Reduction of amniotic fluid volume
Advantages of amniotomy:
a) High success rate
b) Chance to observe the amniotic fluid
c) Access to fetal scalp for electrode or scalp
blood sampling.
34. Immediate beneficial effects of ARM:
• Lowering of b.p in eclapsia; pre-eclampsia
• Relief of maternal distress in hydraminos
• Control of bleeding in APH
• Relief of tension in abruptio placenta and
initiation of labor
35. Hazards of ARM:
• Chance of cord prolapse
• Amnionitis
• Accidental injury
• Amniotic fluid embolism
36. • Stripping the membranes:
Stripping of the membrane means digital
seperation of the chorion and amnion from the wall
of cervix and lower uterine segment.
Effective method in uncomplicated pregnancy.
Prostaglandins are rapidly produced in the
procedure thus is used in cervical ripening as well.
It is safe simple and beneficial
37. Criteria for membrane stripping:
a) The fetal head must be well applied to the
cervix
b) The cervix should be dilated so as to allow
the introduction of examiner’s fingers
[ It is done prior to rupture of membrane as well ]
38.
39. COMBINED METHOD
The combined medical and surgical methods
are used to increase the efficacy of induction
by reducing the induction-delivery interval.
The oxytocin infusion is given either prior to
or following rupture of membranes depending
mainly upon the state of the cervix and head
brim relation.
With non-engaged head, induction with
40. Advantage of combined methods:
• More effective than any single procedure
• Shortens the induction delivery interval
• Minimizes the risk of infection
• Lessens the period of observation
41.
42. • Stimulate the uterus during labour to increase the
frequency, duration and strength of contractions.
• It involves stimulation of uterine contraction to
produce delivery after the onset of spontaneous
labor.
• It is officially indicated when SBA diagnoses
“hypotonic uterine dysfunction” i.e. contractions
ineffective at producing cervix dilatation.
Augmentation of labor
[Active Management of Labor]
43. Aims:
To expedite delivery within 12 hours without
increasing maternal mortality and pernatal hazards.
Indications of augmentation:
• Labor is prolonged without any evident cause.
• Uterine contraction is ineffective and inefficient
• To prevent risk of hypoxia from prolonged labor.
44. Contraindications of augmentation:
• When labor is progressing normally
• Woman isn't in true labor
• Cephalopelvic disproportion
• Mechanical obstruction (complete placenta
previa)
• Abnormal presentation
45. • Grand multipara
• Previous uterine operation scar
• Fetal distress
• Cord prolapse and fetus is alive
• Multiple gestation
Contd..
46. • Advantages of AMOL:
➢ Less chance of dysfunctional labour
➢ Shortens the duration of labor
➢ Fetal hypoxia can be detected early
➢ Low incidence of caeserian section.
➢ Less analgesia
➢ Less maternal anxiety.
47. Essential components of AMOL:
• Antenatal education about purpose and
procedure of AMOL.
• Woman is in true labor
• Partographic monitoring of labor
• Amniotomy with confirmation of labor
• Oxytocin augmentation if cervical dilatation
(1cm/hr)
48. • Delivery is completed within 12hrs of
admission .
• Epidural anaesthesia is needed.
• Fetal monitoring by intermittent auscultation or
by continous electronic monitoring
• Active involvement of the consultation
obstetrician.
49. • Definition :
It is a conduction of spontaneous labor in a
moderate degree of cephalo -pelvic
disproportion , in an institution under
supervision with watchful expectancy ,hoping
for vaginal delivery .
Trial labor
50. • Aims:
Trial labor aims at avoiding an unnecessary
cesarean section and delivering a healthy baby.
51. • Associated mid pelvic and outlet contraction.
• Presence of complicating factors like elderly
primigravida , malpresentation , postmaturity ,
post cesarean section pregnancy ,pre – eclamsia ,
medical disorders like heart disease ,diabetes ,
tuberculosis , etc.
• Where facilities of cesarean section are not
available round the clock .
Contraindications
52. • The management of trial labor requires careful
supervision and consideration . The following
guidelines are prescribed :
- the labor should ideally be spontaneous in
onset . But in cases where labor fails to start
even on due date , induction of labor may be
done .
Conduction of trial labor
53. • Oral feeding remains suspended and hydration
is maintained by intravenous drip. Adequate
analgesics is administered .pethidine 50 – 100
mg intramuscularly .
• The progress of labor is mapped with
partograph
• To monitor the maternal health routine check
up includes
54. (a)to record 2 hourly pulse , blood pressure and
temperature .
(b)to observe the tongue periodically for
hydration .
(c)To note the urine output , urine for acetone ,
glucose and
(d)IV fluids , drugs.
55. • If there is failure to progress due to inadequate
uterine contraction , augmentation of labor
maybe done by amniotomy along with oxygen
infusion . On no account should the procedure
be employed before the cervix is at least 3cm .
• After the membranous rupture , pelvic
examination is to be done
56. • to exclude cord prolapse
• To note the color of liquor.
• To assess the pelvic once more
• To note the condition of cervix including
pressure of presenting part on the cervix .
Contd..
57. • Degree of pelvic contraction
• Shape of pelvis : flat pelvis is better than
android or generally contracted pelvis
• Favorable vertex presentation – anterior parietal
presentation with less parietal obliquity is
favorable
Successful outcome depends on:
58. • Intact membranes till full dilatations of cervix
• Effective uterine contractions .
• Emotional stability of women .
59. • Appearance of abnormal uterine contraction
• Cervical dilatation <1cm per hour (protacted
active phase )inspite of regular uterine
contractions
• Arrest of cervical dilatation and non descent of
fetal head inspite of oxytocin therapy
Unfavorable features
60. • Early rupture of membranes
• Formation of caput and evidence of excessive
moulding
• Fetal distress.
61. • It is indeed difficult to set a arbitrary time limit
which is applicable to all cases . One should be
individualized the case .
• So long the progress is satisfactory (evidence
by descent of head and progressive cervical
dilatation ) and maternal and fetal condition
remain good ,trail may be continued safely .
How long the trial to be continued
62. • However , if any ominous features appears ,trial
is to be terminated forthwith .
• Nowadays there is tendency to shorten the
duration of trial .inspite of adequate uterine
contractions , if there is arrest of uterine
dilation of cervix for a reasonable period (3-
4hrs ) in the active phase, labor is terminated
by cesarean section
Contd..
63. • The methods are anyone of the following :
- spontaneous delivery :with or without
episiotomy (30%)
- forceps or ventouse (30%) :difficult forceps
delivery is to be avoided .
-cesarean section : judicious and timely decision
foe cesarean delivery is to be taken . However
,is significant cases , the section is done even
before full dilations of cervix , the indication
being uterine inertia or fetal distress
Termination of trial labor
64. • A trial is successful ,if a healthy baby is born
vaginally , spontaneously or by forceps or
ventose with the mother in good condition .
Delivery by cesarean section or delivery if dead
baby ,spontaneously or by craniotomy is called
failure of trial labor .
Successful trial
65. • It eliminates unnecessary cesarean section
electively decided upon .
• It eliminates injudicious use of premature
induction of labor with its antecedents hazards
• A successful trial ensures the woman a good
future obstetrics .
Advantages of trial labor
66. • Test of disproportion remains unproven when
cesarean delivery is done due to fetal distress
or uterine dysfunction
• Increased perinatal morbidity or mortality due
to asphyxia or intracranial hemorraghage when
the trial is prolonged and / or ends in difficulty
delivery
Disadvantages
67. • increased maternal morbidity due to effects of
prolonged labor and / or operative delivery.
• Increased psychological morbidity when the
trial ends with a traumatic vaginal delivery or
in cesarean delivery .
Contd..
