This document discusses induction of labor and provides definitions, objectives, indications, contraindications, risks, prerequisites, and methods of induction. It defines grades of evidence and levels of recommendations. The main methods discussed are natural/non-medical, mechanical (laminaria, balloons), surgical (stripping membranes, amniotomy), and pharmacological (misoprostol, mifepristone, oxytocin, prostaglandin E2). It provides details on administration and risks for each method. The goal is to create awareness of appropriate induction techniques and select the best method for each individual patient.

1. Induction of Labour-Evidence Based
Dr Khalid Sait FRCSC
Professor of Obstetrics and Gynecology
King Abdulaziz University Hospital
Jeddah Saudi Arabia

2. Definitions
Grades of Evidence:
-Ia- Evidence obtained from Meta-analysis of multiple RCTs
-Ib-Evidence obtained from a single RCT
-II-1 Evidence obtained from well-designed controlled trials without randomization
-II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably
from more than one center or research group
-II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic
results in uncontrolled experiments could also be regarded as this type of evidence

3. Definitions (Cont.)
-III Opinions of respected authorities, based on clinical experience, descriptive studies, or
reports of expert committees
Levels of Recommendations:
A: The recommendation is based on good and consistent scientific evidence
B: The recommendation is based on limited or inconsistent scientific evidence.
C: The recommendation is based primarily on consensus and expert opinion.

4. Why induction is important?
Transition from passive to active medical role

5. Objectives
At the end of this presentation, you should be:
1-Aware of the indications and contraindications for induction of labor
2-Aware of the different methods of induction of labor
3-Able to select the appropriate method of labor induction for an individual patient.

6. Indications
1-Severe hypertensive disorders of pregnancy
2-Postterm pregnancy and macrosomia
3-Intra-uterine growth retardation
4-Oligohydramnios
5-Premature rupture of membranes
6-Chorioamnionitis
7-Some cases of antepartum hemorrhage
8-Diabetes mellitus with vasculopathy

7. Safety of Elective Induction
9-Congenital fetal malformations incompatible with life
10-Rh incompatibility
11-Maternal diseases. e.g. cardiac disease and T.B.
12-Bad obstetric history
13-Elective inductions: Induction of labor is a medical procedure and should only be carried
out for medical reasons. Induction of labor for social reasons is better avoided as it is hard to
justify should any legal issue arises.

8. Contraindications
1-Placenta previa and vasa previa
2-Abnormal fetal lie / presentation. e.g. transverse lie and breech presentation
3-Umbilical cord prolapse and fetal distress
4-Previous classical Cesarean section or other transfundal uterine surgery
5-Active herpes infection
6-Pelvic Structural abnormality
7-Invasive cervical cancer
8-Contraindicaton specific to the inducing drug used.

9. Risks of Inducing Labour
For the mother:
Distress, fear or anxiety.
Possible failure of labour induction.
Uterine hypotonic inertia or inactive leading to prolonged labour
Hypertonic contractions that could cause rupture of the uterus,
premature separation of the placenta, or tearing of the cervix
Intrauterine infections
Postpartum haemorrhage (following childbirth).
Amniotic fluid embolization (plug).

10. Risks of Inducing Labour
The fetus may be exposed to:
Physical injury
Lack of oxygen (hypoxia)
Premature delivery, if dates are not calculated correctly
Umbilical cord prolapse (falling down).
Infection.

11. PREREQUISITES
Establish indication clearly
Informed consent
Conformation of gestational age
Assessment of fetal size & presentation
Pelvic assessment
Cervical assessment (BISHOPs score)
Availability of trained personnel

12. Factors Influencing positively in
Labour Induction
Cervical ripening -
Uterine sensitivity –
Parity -

13. Factors Influencing positivily Labour
Induction
Mother's age -
Foetal maturity -
Indications -

14. MOD. BISHOPS SCORE
SCORE 0 1 2 3
DILATATION 0 1-2 3-4 >4
EFFACEMENT 0-30% 40-50% 60-70% >80%
STATION -3 -2 -1/0 +1,+2,+3
CONSISTENCY firm medium soft
POSITION posterior mid anterior

15. Selection Criteria For making
Cervical Ripening
unripe cervix.
Bishop score <5

16. METHODS OF INDUCTION
NATURAL
MECHANICAL
CHEMICAL

17. I-Natural-Non Medical methods (Cont.)
1-Relaxation techniques:
2-Visualization:
3-Walking:.
4-Sex:
5-Nipple stimulation:.
6-Bath/Castor oil/Enemas:
7-Foods:
8-Cumin Tea:
9-Several herbs:

18. I-Natural-Non Medical methods (Cont.)
10-Acupressure:
. ( Evidence level B, systematic review of non-RCTs )

19. II-Mechanical methods
1-Hygroscopic dilators
(e.g., Laminaria japonicum) or synthetic osmotic dilators (e.g., Lamicel).
Advantages: 1- Outpatient placement 2- No need for fetal monitoring
Risks: fetal and/or maternal infection
Technique of insertion

20. II-Mechanical methods (Cont.)
2- Placement of Balloon Dilators :
Technique of balloon placement:
Evidence level B, systematic review of non-RCTs

21. III-Surgical Methods
1-Stripping the membranes:
Risks include patient’s discomfort, infection, bleeding from undiagnosed
placenta previa or low lying placenta,and accidental ROM.
The Cochrane reviewers concluded that stripping the membranes, when
used as an adjunct, decreases the mean dose of oxytocin needed and
increases the rate of normal vaginal deliveries. ( Evidence level A)

22. III-Surgical Methods (Cont.)
2-Amniotomy –
Risks of amniotomy:
1- Prolapse of the umbilical cord (0.5%)
2- Chorioamnionitis: Risk increases with prolonged induction delivery interval
3- Postpartum hemorrhage: Risk is doubled compared with women with spontaneous onset of
labor
4- Rupture of vasa previa
5- Neonatal hyperbilirubinemia

23. IV-Pharmacologic Induction of Labor
2- Misoprostol:
Pharmacokinetics:
Route of administration: Oral, vaginal and sublingual route for induction. Rectal route is used
to prevent and treat postpartum hemorrhage.
Bioavailability: Extensively absorbed from the GIT
Metabolism: De-esterified to prostaglandin F analogs
Half life: 20–40 minutes
Excretion: Mainly renal 80%, remainder is fecal: 15%

24. IV-Pharmacologic Induction of Labor (Cont.)
2-Misoprostol:
-Misoprostol (Cytotec) is a synthetic PGE1 analog that has been found to be a safe and
inexpensive agent for cervical ripening.
-Clinical trials indicate that the safe optimal dose and dosing interval is 25 mcg intravaginally
every 4-6 hours. A maximum of 6 doses was suggested. Higher doses or shorter dosing
intervals are associated with a higher incidence of side effects, especially hyperstimulation
syndrome.
-Misoprostol should not be used in women with previous CS because of increased rates of
uterine rupture (- Evidence level B).

25. IV-Pharmacologic Induction of Labor (Cont.)
-The Cochrane reviewers concluded that use of misoprostol resulted in an overall
lower incidence of CS. In addition, there appears to be a higher incidence of vaginal delivery
within 24 hours of application and a reduced need for oxytocin augmentation. ( Evidence
level A).

26. IV-Pharmacologic Induction of Labor (Cont.)
3-Mifepristone:
Mifepristone (Mifeprex) is an antiprogesterone agent which counteracts the inhibitory effect
of Progesterone on the uterus. Few studies with small number of women enrolled, have shown
that women treated with mifepristone in a dose of 600 mg are more likely to have a favorable
cervix and deliver within 48 to 96 hrs when compared with placebo and also they these were
less likely to undergo C.S.
Information about fetal outcomes & maternal side effects is scarse and cannot be used to
recommend the use of mifepristone for cervical ripening.

27. IV-Pharmacologic Induction of Labor (Cont.)
4-Oxytocin:
It is given by IV infusion using an automated pump. Oxytocin has many advantages: it
is potent and easy to titrate, has a short half-life (one to five minutes) and is well tolerated.
Low Dose Protocol:
1-Prepare 5 IU of oxytocin/500 mL 5% dextrose.
2-Start infusion at a rate of 1-1.5 mU/minute (6-9 mL/hr) and increase by 1-1.5 mU/minute
every 30 minutes until adequate labor was established.i.e. 3 contractions in 10 mins, each lasts
between 60-90 seconds 1 mL = 15 drops
3-This protocol have the advantage of less hyperstimulation but with long induction delivery
interval

28. IV-Pharmacologic Induction of Labor (Cont.)
High Dose Protocol:
1-Prepare15 IU of oxytocin/500 mL 5% dextrose.
2-Start IV solution infusion at a rate of 4.5-6 mU/minute (9-12 mL/hour) and increased by 4.5
mU/minute every 30 minutes for a maximum of 40 milliunits per minute.
3-This protocol have the advantage of shorter induction delivery interval but with more
hyperstimulation

29. IV-Pharmacologic Induction of Labor (Cont.)
Oxytocin Protocol
-If infusion volumes were found to be excessive, prepare double strength solution.
-If no progress occurred after 8–12 hours of starting induction, either discontinue the oxytocin
and reapply a cervical ripening agent or re-initiate oxytocin the next day.
-Continuous electronic FHR monitoring during induction is essential to monitor fetal response
to labor and uterine response to the inducing agent. If severe FHR abnormalities or
hyperstimulation occurred, decrease/discontinue the oxytocin infusion.

30. IV-Pharmacologic Induction of Labor (Cont.)
Side effects of oxytocin use:
1-Uterine hyperstimulation and subsequent FHR abnormalities.
2-Abruptio placentae and uterine rupture.
3-Water intoxication may occur with high concentrations of oxytocin infused with
large quantities of hypotonic solutions. Therefore; prolonged administration with doses higher
than 40 mu of oxytocin per minute and infusion of fluids in any 10 hours should not excced
1500 ml. A rapid intravenous injection of oxytocin may cause hypotension.

31. IV-Pharmacologic Induction of Labor
1-Prostaglandin E2: (dinoprostone):. It acts on the cervical
connective tissue and relaxes muscle fibres of the cervix.
The clinical application of Prostaglandins began late 1960s, although their action had
been observed in the laboratory since the 1930s.

32. Vaginal PGE2 is the preferred method of induction of
labour, unless there are specific clinical reasons for not
using it.
PGE2 can cause uterine hyperstimulation, fetal distress and
Cesarean section
In today's clinical practice, Prostaglandins are used
primarily for Labour management, namely cervical
ripening and Labour induction.
Prostaglandins

33. Prostaglandins For Cervical Ripening
& Labour Induction
Prostin E2 Vaginal Gel (1 &2 mg
Dinoprostone):
Prostin E2 Vaginal Tablets (3 mg
Dinoprostone):
Passary ( Propess)

34. Prostin E2 Vaginal Gel Product
Profile
Indications Prostin E2 Vaginal Gel is
indicated for induction of Labour at
term or near-term pregnant women
who have favorable induction
features with bishop scores of 4 to 7.

35. Directions For Use
Introduce the syringe containing 1 mg gel in the posterior vaginal
Fornix and well away from the cervical os, to avoid administration
into the cervical canal.
The mother asked to remain lying on back for at least 30 minutes.
If labour is not established after 6 hours, a second dose of 1 mg or
2 mg may be administered.
The maximum total dose is 3 mg over 6 hours period.

36. Site of insertion
Posterior Fornix
Vaginal Gel
Posterior Fornix

37. Adverse Effects
Tachysystole

38. Failed induction
• If induction fails, healthcare professionals should
discuss this with the woman and provide support.
• The woman s condition and the pregnancy in
general should be fully reassessed.
• Fetal wellbeing should be assessed using
electronic fetal monitoring.

39. The subsequent management options include:
• a further attempt to induce labour (the timing should
depend on the clinical situation and the woman’s wishes)
• caesarean section.
Failed induction

40. Thanks