induction of labour

1. 6/7/1441
1
Induction of labour
By
Ahmed Elbohoty MD, MRCOG
Assistant Professor
of
Obstetrics and Gynecology
Ain Shams University
Contents
2/29/20 ELBOHOTY 2
Basic definitions
indications and contraindications for induction of labour
methods of induction of labour
complications of induction of labour
counsel women about induction of labour.
describe management of labour after induction

2. 6/7/1441
2
2/29/20 ELBOHOTY 3
The spontaneous onset of labour is a robust and effective
mechanism which is preceded by the maturation of
several fetal systems and should be given every
opportunity to operate on its own. We should only
induce labour when we are sure that we can do better
Alec Turnbull, 1976.
Definitions
2/29/20 ELBOHOTY 4

3. 6/7/1441
3
• Induction of labour is the initiation of contractions in a
pregnant woman who is not in labour to help her achieve a
vaginal birth within 24 to 48 hours.
• Successful induction is defined as a vaginal delivery within 24
to 48 hours of induction of labour.
• Elective induction is the induction of labour in the absence of
acceptable fetal or maternal indications.
• Cervical ripening is the use of pharmacological or other
means to soften, efface, or dilate the cervix to increase the
likelihood of a vaginal delivery.
• Tachysystole refers to > 5 contractions per 10-minute period
averaged over 30 minutes.
• Hypertonus refers to excessive uterine contractions lasting >
60 seconds.
• Hyperstimulation refers to excessive uterine contractions
(tachysystole or hypertonus) with abnormal FHR changes.
2/29/20ELBOHOTY5
• Induction of labour (IOL) is performed in over
20% of maternities in developed countries.
2/29/20ELBOHOTY6

4. 6/7/1441
4
To deliver or wait spontaneous onset
?
2/29/20ELBOHOTY7
• It is indicated when interrupting the
pregnancy is thought to be safer for the
mother or the baby than allowing gestation to
continue.
• When discussing IOL the balance between the
potential benefits and potential complications
of IOL should be considered.
• In many circumstances the decision is not
clear cut, and early delivery may be associated
with benefit for the mother but risks for the
baby, or vice versa.
2/29/20ELBOHOTY8

5. 6/7/1441
5
Potential indications for induction
1. Prolonged pregnancy
2. Maternal diabetes (including gestational diabetes)
3. Twin pregnancy
4. Prelabour rupture of membranes
5. Fetal growth restriction and suspected in utero
fetal compromise
6. Hypertensive disorders in pregnancy and other
maternal medical conditions
7. Maternal request
2/29/20ELBOHOTY9
2/29/20ELBOHOTY
Time of elective delivery
10

6. 6/7/1441
6
2/29/20ELBOHOTY
Time of elective deliveryIndication
> 41uncomplicated pregnancies
Around 40 weeksMaternal age > 40 years
< 40 weeks + 6 daysGestational DM
37-38 weeks + 6 daysDM
> 37Twins dichorionic
> 36Twins monochorionic
> 35 csTriplets
32-34 csTwins (monoamniontic)
34+0 and 36+6monochorionic twin pregnancies complicated by TTTS
> 34 except……Severe PET
37Mild PET
> 37PPROM
> 37Cholestasis with BA >40
36-37 CSPlacenta previa (Asymptomatic)
34-36weeks +6 CSPlacenta previa with vaginal bleeding
35- 36 weeks + 6 CSPlacenta previa accreta(Asymptomatic)
37Fetal anaemia reciving IUT
between 34 & 36 weeks CSConfirmed vasa praevia11
Prolonged pregnancy
• A pregnant women is 'at term' when her pregnancy
duration reaches 37 weeks.
• For 5–10% of women, their pregnancies continue
beyond 294 days (42 completed weeks) and are
described as being 'post-term' or 'postdate' .
• Recurrence risk is 30% after one pregnancy and 40%
after two prolonged pregnancies.
• It is one of the most common indications for IOL.
• 40-50% of women will deliver 4-5 days after 42 weeks
2/29/20ELBOHOTY12

7. 6/7/1441
7
2/29/20ELBOHOTY13
Benefits of induction between 41-42 weeks
• Fewer perinatal death
• Lower risk of meconium aspiration
syndrome (after 41 weeks)
• However there was no change in
assisted vaginal delivery rates or
caesarean section rate
2/29/20ELBOHOTY14

8. 6/7/1441
8
GA determination
• Routine ultrasound in early pregnancy
to determine gestation reduced rates of
IOL for post-term pregnancy
–crown–rump measurement from 10
weeks 0 days to 13 weeks 6 days
–head circumference if crown–rump
length is above 84 mm
2/29/20ELBOHOTY15
Recommendation
• Women with uncomplicated pregnancies should be
given every opportunity to go into spontaneous
labour.
• Women with uncomplicated pregnancies should
usually be offered IOL between 41+0 and 42+0
weeks.
2/29/20ELBOHOTY16

9. 6/7/1441
9
Induction declined
• Respect the woman’s decision and discuss further
care with her.
• Offer sweeping of fetal membranes
• From 42 weeks, at least twice-weekly
cardiotocography and ultrasound estimation of
maximum amniotic pool depth.
2/29/20ELBOHOTY17
Age ??
• The increased risk of stillbirth in women ≥40 years
of age and with apparent improved perinatal
outcomes with induction of labour at term without
rising caesarean section rates, there is an argument
for offering induction of labour at 39–40 weeks of
gestation to women ≥40 years of age.
2/29/20ELBOHOTY18

10. 6/7/1441
10
management of women who are 40 years
old or above
• All women should be referred for Consultant care.
• Down syndrome screening counselling should be provided in the
usual way
– If the woman wishes to have diagnostic testing directly without
undergoing screening, she should be referred to the Antenatal Screening
Co-ordinator
• For most women who are fit and well with no co-morbidities, GPs
and midwives in the community can provide the majority of the
antenatal care.
• Offer induction of labour at around 40 weeks gestation to this
group of patients.
• Should the offer of induction of labour not be accepted the
following increased fetal surveillance is recommended;
– alternate day CTG
– weekly liquor volume and cord Doppler studies
– two-weekly biometry
2/29/20ELBOHOTY19
Maternal diabetes
• Overall diabetes complicates 2.5% of
pregnancies
• 87% of which are gestational diabetes with
the remainder being type 1 and type 2
• Induction of labour at term can reduce the
incidence ofstillbirth and shoulder dystocia in
women with pregestational diabetes on insulin.
• However the is lack of benefits in women with
GDM with well controlled DM especially on diet
and have no fetal complication 2/29/20ELBOHOTY20

11. 6/7/1441
11
NICE guideline recommendation
• Advise pregnant women with type 1 or type 2 diabetes
and no other complications to have an elective birth by
induction of labour, or by elective caesarean section if
indicated, between 37+0 weeks and 38+6 weeks of
pregnancy.
• Consider elective birth before 37+0 weeks for women
with type 1 or type 2 diabetes if there are metabolic or
any other maternal or fetal complications.
• Advise women with gestational diabetes to give birth
no later than 40+6 weeks, and offer elective birth (by
induction of labour, or by caesarean section if
indicated) to women who have not given birth by this
time. 2/29/20ELBOHOTY21
When do you offer a CS in a diabetic
woman?!
2/29/20ELBOHOTY22

12. 6/7/1441
12
Twin pregnancy
• 15 per 1000 pregnancies are multiple gestations
• twins 14.4 per 1000
• triplets 4 per 10,000
• The stillbirth rate for women with a twin pregnancy has
been found to be higher than for singletons at each
week of gestational age from 37 weeks of gestation
however monochorinic, triplets are more at risk .
• This has to be balanced against any associated increase
in the risk of caesarean section, as well as the potential
risks for the infant associated with early birth, including
respiratory distress syndrome and need for admission
to the neonatal unit.
2/29/20ELBOHOTY23
NICE recommends
Time of elective delivery
37Twins dichorionic
36Twins monochorionic
35 CSTriplets
32-34 CSTwins (monoamniontic)
2/29/20ELBOHOTY
If elective birth is declined, offer weekly appointments with the
specialist obstetrician.
Offer an ultrasound scan at each appointment (perform fortnightly fetal
growth scans and weekly biophysical profile assessments).
24

13. 6/7/1441
13
Suspected fetal macrosomia (> 4000
grams)
• Macrosomia is defined as a fetus with a birthweight
above 4000 g.
• Fetal macrosomia occurs in about 2–10% of births
at term in the UK.
• Accuracy of estimating fetal weight varies
• From 15-79% using ultrasound
• From 40-52% using clinical judgement
• Comparing IOL and expectant management there
are no significant differences in
• CS rate, Instrumental birth and Perinatal morbidity
2/29/20ELBOHOTY25
Suspected fetal macrosomia
• There is no evidence that IOL is beneficial in women
with suspected fetal macrosomia.
• Suspected fetal macrosomia is not an indication for
IOL.
2/29/20ELBOHOTY26

14. 6/7/1441
14
Guidelines
• Elective caesarean section should be
considered to reduce the potential
morbidity for pregnancies complicated
by pre-existing or gestational diabetes,
regardless of treatment, with an
estimated fetal weight of greater than
4.5 kg (RCOG).
• The American College of Obstetricians and
Gynecologists (ACOG) has recommended that an
estimated fetal weight of over 5 kg should prompt
consideration of delivery by caesarean section,
however inaccuracy of determination is common. ??!!2/29/20ELBOHOTY27
PROM at Term
• Women with PROM at term should be offered a
choice of IOL or expectant management for 24
hours as rate of neonatal infection is 2% in
induction versus 1% in expectant and more than
60% will go into spontaneous onset within 24 hours
• IOL is considered if
• There is any evidence of fetal infection
• Prescence of meconium stained liquor
• A vaginal swab confirming GBS at this pregnancy
• Digital examination has been used to diagnose ROM
• IOL is appropriate for approximately 24 hours after
prelabour rupture of the membranes at term. 2/29/20ELBOHOTY28

15. 6/7/1441
15
PROM at Preterm
• IOL should not be carried out before 37 weeks
unless there are additional obstetric indications (for
example, infection or fetal compromise).
2/29/20ELBOHOTY29
FGR
• Perinatal mortality and morbidity is markedly increased
in FGR fetuses
• Immediate delivery in preterm FGR fetuses showed no
difference in overall fetal mortality compared with
expectant management. However, expectant
management consisted of a mean of 4 days
• Delivery in FGR is indicated; however, timing of delivery
remains unclear
• At 2 years, the overall rate of death and severe
disability was similar to expectant management
• Caesarean section rates were higher in immediate
delivery group compared with expectant management.
2/29/20ELBOHOTY30

16. 6/7/1441
16
FGR
• In approximately 3% of pregnancies there is placental
insufficiency that can compromise fetal wellbeing
• Determination of its cause and type is very important.
• Timing of birth will depend on gestational age, severity
of FGR and results of tests of fetal well being
• Recommend expedited birth for a woman with FGR
diagnosed at term
• Severity affects the decision of the most appropriate
mode of birth
2/29/20ELBOHOTY31
SGA
2/29/20ELBOHOTY32

17. 6/7/1441
17
2/29/20ELBOHOTY33
• The only cure for pre eclampsia is birth
• Consider individual circumstances when
determining timing of birth
• Consider delivery where hypertension initially
diagnosed after 37 weeks
• Consider vaginal birth unless a caesarean section is
required for other obstetric indications
2/29/20ELBOHOTY
Hypertensive disorders
34

18. 6/7/1441
18
Hypertensive disorders
• At term IOL is associated with improved maternal
outcome and should be advised for women with mild
hypertensive disease after 37 weeks.
• Severe pre-eclampsia beyond 34 weeks of gestation is
an indication for delivery.
• Offer birth before 34 weeks (after discussion with
neonatal and anaesthetic teams and, if required, course
of corticosteroids completed) if:
– severe refractory hypertension
– maternal or fetal clinical indication develops as defined in
plan
2/29/20ELBOHOTY35
Obstetric cholestasis
• There is no quality evidence to recommend best management
• It Is associated with increased risk of
– Intrauterine fetal death (IUFD) – 2%
– Preterm birth – 44%
– Meconium staining of liquor – 25-45%
– 90% of fetal deaths occur after 37 weeks
• A correlation has been shown between serum bile acid levels and fetal
complication rates
– Bile acids of less than 40 micromol/L were associated with no increase in fetal
risk
– Ursodeoxycholic acid has been shown to reduce serum bile acid levels. It is
uncertain if this translates to reduced perinatal risk
• CTG and Doppler surveillance have no role in the prediction of perinatal risk
• Decision to deliver should be made on an individual basis
• Based on weak evidence, IOL may be recommended at 37 weeks
• Consider IOL at 35-37 weeks for severe cases with jaundice, progressive
elevations in serum bile acids and liver enzymes, and suspected fetal
compromise (Not in the guideline)
2/29/20ELBOHOTY36

19. 6/7/1441
19
Anticoagulant therapy and maternal
cardiac condition
• For a woman on anticoagulant therapy, IOL is timed around the
medication protocol
• For maternal cardiac conditions, the objective of care is to
minimise the additional load on the cardiovascular system, ideally
through spontaneous onset of labour
• A multidisciplinary team, consisting of an obstetrician, cardiologist
or physician as appropriate, anaesthetist, and midwife is essential
• Involve an intensivist and neonatologist as required
• Develop a plan for peripartum management of anticoagulant
therapy (prophylactic or therapeutic)
• If receiving anticoagulant therapy, wean and cease prior to IOL
• For a woman with a maternal cardiac condition, plan for an IOL
when required:
– Anticoagulant therapy protocol
– Availability of medical staff
– Deteriorating maternal cardiac function 2/29/20ELBOHOTY37
SPD• For most women with SPD, spontaneous vaginal delivery is recommended.
• Induction of labour is occasionally offered to those who are in extreme pain
or who are severely limited in their daily activity or mobility.
• The risks of induced labour often outweigh the benefits.
• There is no evidence that caesarean section is beneficial for women with
SPD. However, very rarely,when hip abduction is severely restricted, this
may be necessary.
• Midwife should encourage the woman to adopt any comfortable position
(more often than not left or right lateral recumbent or kneeling, upright and
supported).
• Use of epidural and spinal anaesthesia have been discouraged on account
of masking SPD pain, although there is no evidence to support this view.
• One-to-one support and the use of birthing pools for pain relief will reduce
the need for epidural analgesia, although specific handling issues may arise.
2/29/20ELBOHOTY38

20. 6/7/1441
20
IUFD
• There is no evidence addressing immediate versus
delayed IOL
• Many women go into spontaneous labour within 2-3
weeks of IUFD
• Risk of coagulopathy is usually only of concern after 4
weeks
• Support the woman's preferences regarding timing of
IOL: Delaying IOL for a few days should be supported, if
desired, provided:
– Membranes are intact
– No evidence of infection
– No medical indication of induction e.g PET
2/29/20ELBOHOTY39
Maternal request
• IOL should not routinely be offered on maternal
request alone.
• Women who are requesting induction of labour before
40+12 weeks should be seen in the antenatal clinic for
further discussions with the obstetrician and should be
told that 30% of primparae and 15% (1in 6) multiparae
who are induced will end up with a caesarean section
• A plan will be written into the notes taking into account
the mothers individual circumstances.
• Under exceptional circumstances (e.g. if the woman’s
partner is soon to be posted abroad with the armed
forces), IOL may be considered at or after 40 weeks.
• Most obstetricians will wish to discuss the available
evidence with women, so that the woman and
obstetrician can jointly come to a decision about IOL.2/29/20ELBOHOTY40

21. 6/7/1441
21
Contraindications to induction of
labour
• placenta praevia/vasa praevia
• transverse lie
• prolapsed umbilical cord
• active genital herpes or 1ry genital herpes in the
last 6 weeks
• previous classical uterine incision
• maternal or fetal anatomical abnormality that
contraindicates vaginal delivery.
2/29/20ELBOHOTY41
Relative contraindications
• triplet or higher order multiple pregnancy
• breech presentation
• two or more previous low transverse
caesarean sections.
2/29/20ELBOHOTY42

22. 6/7/1441
22
Avoid induction:
• If there is severe fetal growth restriction with
confirmed fetal compromise.
• If there is suspected fetal macrosomia with no
other indication.
• To avoid unattended birth if there is a history
of precipitate labour
2/29/20ELBOHOTY43
Previous CS
• It is possible for some women who have previously
delivered by Caesarean section to be induced.
• At the 40 week visit, women should each be assessed
and the findings discussed with the consultant, in order
to determine their suitability for induction.
• This plan should be documented on the “Counselling
sheet for women with one previous LSCS”.
• Counselling women of a 2–3 fold increased risk of
uterine rupture and around 1.5 fold increased risk of
caesarean delivery in induced and/or augmented
labour compared with spontaneous VBAC labour.
• The use of mechanical methods of induction of labour
are thought to be associated with a lower risk of scar
rupture
2/29/20ELBOHOTY44

23. 6/7/1441
23
Preparation
• Evaluate benefits and risks to mother or fetus
• Evaluate the urgency
• Assess the presence of contraindication
• Assessment of gestational age (dating scan is reliable
even in women who are sure of last menstrual period)
• Appropriate counseling including the potential
complication (longer time, more pain, liability to fail,
…..
• Consideration of urgency of IOL
• Book a date and document
• Assess cervix, pelvis, fetal size and presentation
2/29/20ELBOHOTY45
Pre-induction assessment
• Women are admitted to the maternity unit.
• A cardiotocograph (CTG) to ensure the fetus'
wellbeing is performed.
• This is followed by a vaginal examination to
determine the modified Bishop score and act as a
baseline against which to compare subsequent
examinations.
• The state of the cervix is one of the important
predictors of successful IOL
• The cervix is unfavourable if the score is 6 or less
2/29/20ELBOHOTY46

24. 6/7/1441
24
Modified Bishop scoring system
2/29/20ELBOHOTY47
Place
• NICE advise that in the outpatient setting, IOL
should only be carried out if safety and
support procedures are in place.
2/29/20ELBOHOTY48

25. 6/7/1441
25
Maternal and fetal observations
• All women undergoing induction of labour with Propess
will have as a minimum the following observation
carried out between commencement of induction
process and established labour or ARM:
• 4 hourly maternal pulse, BP, temperature, respiratory rate and
MOWS score.
• The FHR will be monitored 4 hourly.
• All women undergoing induction of labour with ARM
will have as a minimum the following observation
carried out between ARM and established labour or
commencement of Oxytocin infusion:
• hourly maternal pulse
• 4 hourly maternal BP, temperature, respiratory rate and MOWS.
• The FHR will be monitored hourly.
• Women that Oxytocin infusions should have continuous
electronic fetal monitoring commenced 2/29/20ELBOHOTY49
Process of Induction of Labour
• Abdominal palpation should be performed to
confirm presentation
• A 20 minute CTG prior to commencing the
induction
• VE to assess the cervix and to calculate the Bishop
score
• Commence the induction of labour integrated care
pathway
• For further observations during the induction
process see appropriate induction guidelines.
• When established in labour, please transfer to
Labour Care pathway.
2/29/20ELBOHOTY50

26. 6/7/1441
26
Methods of induction of labour
• prostaglandin
• oxytocin
• misoprostol
• mechanical methods
2/29/20ELBOHOTY51
Membrane sweep
Risks/benefits
•Membrane sweep reduces the duration of
pregnancy
•It shouldn’t be offered routinely before 40 weeks
•Membrane sweep reduces the frequency of
pregnancy continuing beyond 41 and 42 weeks
•For women who do not have a low-lying placenta,
arrange for a membrane sweep at 40 and 41 weeks
for primigravida women and at 41 weeks gestation
for multigravida.
•To avoid one formal IOL, sweeping of membranes
must be performed in eight women (NNT = 8).
•No increase in the risk of maternal or neonatal
infection
•Discomfort during vaginal examination and other
adverse effects (bleeding, irregular contractions)
more frequently reported by women who undergo
membrane sweep. 2/29/20ELBOHOTY52

27. 6/7/1441
27
Prostaglandins
• The NICE guideline recommends using
prostaglandins in preference to oxytocin in women
with intact membranes, irrespective of parity or
modified Bishop score unless there are specific
clinical reasons for not using it (in particular the risk
of uterine hyperstimulation).
• In women with prelabour rupture of membranes
(PROM), prostaglandins and oxytocin seem to be
equally effective.
2/29/20ELBOHOTY53
Forms
2/29/20ELBOHOTY54

28. 6/7/1441
28
• Tablet
• A 3 mg prostaglandin tablet is inserted into the posterior vaginal fornix
followed by a second dose 6–8 hours later. On rare occasions, and only after
discussion with the woman and her consultant, a third dose of
prostaglandin may be given if it is not possible to perform amniotomy after
two doses of prostaglandin. The maximum dosage is 6 mg in 24 hours.
• Gel
• Prostaglandin gel is available as 1 or 2 mg preparations. The first dose is 2
mg in nulliparous women with a modified Bishop score of <4, while all other
women receive a first dose of 1 mg. The second dose is given 6 hours later
and can be 1 or 2 mg in both the subgroups above. The maximum dose in
24 hrs is 3 mg unless the cervix is unfavourable in a primigravida when the
dose is 4 mg.
• The risk of hyperstimulation is higher with the pessary than with the gel
(4.5% versus 2.4%)67
• Slow release pessary
• Pessaries control release within a retrieval device. Approximately 10 mg of
dinoprostone is released over 24 hours.
• If used for cervical ripening and induction of labour at term, one pessary (in
a retrieval device) should be inserted high into the posterior fornix. It
should be removed when cervical ripening is adequate, labour has become
established or after 24 hours.
2/29/20ELBOHOTY55
Propess
• Propess is a vaginal pessary containing 10mg of dinoprostone
(PGE2, as tablets) which has a tape attached.
• It releases prostaglandins at a steady rate for up to 24 hours. It
decreases the needed Oxytocin.
• The main advantages are that with a single administration in a 24
hour period, less vaginal examinations are required and there
would be no delays between administrations of subsequent
prostin tablets.
• Propess can be used in primigravidae and multigravidae, but
should only be used for those with an unfavorable cervix (bishops
score < 8),
• Propess should not be given where contractions are already
present, or if the CTG is not thought to be reassuring. It should
only be used in the presence of a uterine scar when consultant
approval has been given.
• A management plan must be written in the notes.
• Some women may be offered the opportunity to return home
following propess induction ?!
2/29/20ELBOHOTY56

29. 6/7/1441
29
Administration
• Dinoprostone gel
– Use water soluble lubricants (not obstetric cream)
– Remove from refrigeration and stand at room temperature for at least 30
minutes prior to use
– Insert into the posterior fornix of the vagina
– Not for intracervical administration
– Advise recumbent and left lateral position for 30 minutes after insertion to
facilitate absorption
• Dinoprostone pessary
– Remove from freezer or fridge immediately prior to use
– Can be stored in the fridge for up to one month after removal from the freezer
– Warming is not required
– Open the foil only after decision has been made to use it
– Use water soluble lubricants (not obstetric cream)
– Insert into the posterior fornix of the vagina in transverse position
– Ensure sufficient tape outside vagina to allow removal
– Remain recumbent for 30 minutes
– Advise women to avoid inadvertent removal of pessary and to report if pessary
falls out
2/29/20ELBOHOTY57
Formal induction with vaginal PGE2
• Inform women about the risks of uterine hyperstimulation.
• Induce in the morning.
• Check for low-lying placental site before induction.
• Offer vaginal PGE2 as tablet, gel or controlled-release
pessary:
– tablet or gel: one dose, followed by a second dose after 6 hours if
labour does not start (maximum two doses)
– pessary: one dose over 24 hours.
• Reassess Bishop score 6 hours after each tablet or gel, or 24
hours after controlled-release pessary.
• If woman goes home after tablet or gel, ask her to contact
her obstetrician/midwife:
• when contractions begin
• if she has had no contractions after 6 hours. 2/29/20ELBOHOTY58

30. 6/7/1441
30
Amniotomy
2/29/20ELBOHOTY59
Amniotomy
• Do not use amniotomy, alone or with oxytocin, as a
primary method of induction unless there are
specific reasons for not using PGE2.
• May be used alone especially in a multiparous
woman (may initiate contractions) and Favourable
cervix – Bishop score 7 or more
• Avoid if baby’s head is high.
• To avoid cord prolapse:
– assess engagement of presenting part before induction
– palpate for umbilical cord presentation during
– preliminary vaginal examination (avoid dislodging baby’s
head).
2/29/20ELBOHOTY60

31. 6/7/1441
31
Procedure
• Before ARM:
– Explain the procedure to the woman
– Abdominal palpation to determine descent
– Assess for possible cord presentation
– Consult obstetrician if the head is not engaged or with possible
cord presentation
• Immediately after ARM:
– examine to ensure there is no cord prolapse
– Monitor FHR immediately following procedure
– Document liquor colour and consistency
– Encourage mobilisation to promote onset of uterine contractions
• Following ARM, consider Oxytocin in:
– Multiparous women: if no contractions after 2 hours
– Nulliparous women: immediately following ARM as few women
will commence contractions spontaneously unless the cervical
score is 7 or more 2/29/20ELBOHOTY61
Oxytocin Compared to IOL with vaginal
Prostaglandin:
• Is associated with more failures to achieve vaginal
birth within 24 hours
• Shows no significant difference in caesarean birth
rates
• Increased the need for epidural
• Mobility is restricted
• Maintain fluid balance as water intoxication may
result from prolonged infusion(rare with the use
of isotonic solutions other than glucose)
2/29/20ELBOHOTY62

32. 6/7/1441
32
Oxytocin
• oxytocin alone is more commonly used in the presence of
ruptured membranes, whether spontaneous or artificial.
• Amniotomy with oxytocin should not be used as a primary method
of IOL unless there are specific contraindications to the use of
vaginal PGE2, in particular the risk of uterine hyperstimulation
• Not to be started for at least 6 hours after administration of
vaginal prostaglandin
• The NICE guideline recommends diluting 10 IU of oxytocin in 500
ml, though some maternity units dilute 30 IU of oxytocin in 500 ml.
The infusion starts at a rate of 1–2 mU of oxytocin per minute and
is increased every 30 minutes; the maximum licensed rate is 20
mU per minute though many units go up to 32 mU per minute.
• Oxytocin is given by infusion pump or syringe driver.
• The dose of oxytocin is increased until the women is having three
to four contractions every 10 minutes.
2/29/20ELBOHOTY63
Oxytocin infusion
2/29/20ELBOHOTY64

33. 6/7/1441
33
Mechanical
• NICE published an interventional procedure
guideline in 2015 on the insertion of double
balloon caheters for induction of labour in
pregnant without previous caesarean section
stating that current evidence on its efficacy
and safety was adequate to support its use in
clinical practice.
2/29/20ELBOHOTY65
Failed induction
• If labour cannot be initiated despite use of induction
agents, IOL is said to have failed
• Reassess woman’s condition and pregnancy in general.
• Assess fetal wellbeing with electronic fetal monitoring.
• Provide support, and make decisions in accordance
with woman’s wishes and clinical circumstances.
• Management options include:
– allowing the patient to go home and repeat the attempt at a
later gestation
– waiting for labour to start spontaneously
– scheduling delivery by caesarean section 2/29/20ELBOHOTY66

34. 6/7/1441
34
Management of labour after
induction
• Prostaglandin induction is usually commenced on the
antenatal ward, though the NICE guidelinerecommends that
IOL should not occur on the antenatal ward if the pregnancy
is deemed high risk.
• These women should be induced on the labour ward.
• After prostaglandins are inserted vaginally, the woman is
asked to lie down for half an hour and a cardiotocograph is
performed to establish fetal wellbeing; this is essential once
uterine activity commences.
• Oxytocin is administered on the labour ward with
continuous fetal heart and uterine activity monitoring and
with one-to-one midwifery care.
2/29/20ELBOHOTY67
Intrauterine fetal death
• Offer the woman and her partner/family support, and information
about specialist support.
• If the woman is physically well, with intact membranes and no
evidence of infection or bleeding,
• offer choice of immediate induction or expectant management.
• If there is evidence of ruptured membranes, infection or bleeding,
immediate induction is preferred.
• If the woman chooses induction, offer oral mifepristone, followed
by vaginal PGE2 or misoprostol2.
• If the woman has had a previous caesarean section, reduce
prostaglandin doses to take account of the increased risk of
uterine rupture.
• Misoprostol should only be offered if there is intrauterine fetal
death or in a clinical trial.
• Mifepristone should only be offered if there is intrauterine fetal
death
2/29/20ELBOHOTY68

35. 6/7/1441
35
Complications of induction of labour
• Hyperstimulation
• Fetal distress
• Failed induction
• Caesarean section
• Ruptured uterus
• Adverse effects of drugs used for induction
2/29/20ELBOHOTY69
Hyperstimulation
• Hyperstimulation can be defined either as
tachysystole, that is, more than five contractions in
10 minutes over a period of at least 20 minutes, or
hypertonus, that is, a contraction lasting for more
than 2 mintues in association with changes in the
fetal heart trace.
• It occurs in 1–5% of prostaglandin-induced labour,
and may be more common with the use of
misoprostol. Excessive uterine contractions may
also occur in response to oxytocin infusion, but tend
to be less of a problem because the effects of
oxytocin can be reduced simply by turning the
oxytocin infusion off. 2/29/20ELBOHOTY70

36. 6/7/1441
36
Management
• Attempt removal of any remaining Dinoprostone gel
• Remove Dinoprostone pessary if still in situ
• Stop Oxytocin infusion while reassessing labour and fetal
state
• Position woman left lateral
• Assess BP and FHR (EFM)
• Commence intravenous hydration if not contraindicated by
maternal condition
• Pelvic exam to assess cervical dilation
• If persists use tocolytics:
– Terbutaline – 250 micrograms subcutaneously or
– Salbutamol – 100 micrograms by slow intravenous (IV) injection
• If clinically indicated perform emergency CS 2/29/20ELBOHOTY71
Failed induction
• If labour cannot be initiated despite use of induction
agents, IOL is said to have failed. There is no accepted
definition of this, but if 3 doses of vaginal
prostaglandins have not ripened the cervix sufficiently
for membrane rupture to be performed, then further
doses are unlikely to be helpful.
• The options in this scenario include:
– Review the individual clinical circumstances
– Assess fetal wellbeing using CTG
– Discuss options for care with the woman
– If appropriate consider discharging home for 24 hours
followed by second attempt at IOL
– Caesarean section
2/29/20ELBOHOTY72

37. 6/7/1441
37
Uterine rupture
• Uterine rupture is an uncommon event with
IOL
• Uterine rupture is a life-threatening event for
mother and baby
• If suspected, prepare for an category 1 CS,
uterine repair or hysterectomy
2/29/20ELBOHOTY73
Management of labour after
induction
• Prostaglandin induction is usually commenced on the
antenatal ward, though the NICE guideline
recommends that IOL should not occur on the
antenatal ward if the pregnancy is deemed high risk.
• These women should be induced on the labour ward.
• After prostaglandins are inserted vaginally, the woman
is asked to lie down for half an hour and a
cardiotocograph is performed to establish fetal
wellbeing; this is essential once uterine activity
commences.
• Oxytocin is administered on the labour ward with
continuous fetal heart and uterine activity monitoring
and with one-to-one midwifery care. 2/29/20ELBOHOTY74