The document discusses the induction of labor, outlining its purpose, methods, and indications for use, including maternal and fetal conditions. It explains various techniques for induction—natural, mechanical, surgical, and pharmacological—along with considerations like contraindications and monitoring during the process. Additionally, it covers side effects and complications associated with labor induction, emphasizing the importance of careful assessment before and during the procedure.

1. INDUCTION OF
LABOUR
Deepa Mishra
Assistant Professor (OBG)

2. Induction of labour
 An intervention designed to artificially initiate
uterine contractions leading to progressive
dilatation and effacement of the cervix.
 Is the planned initiation of labor prior to the onset
of spontaneous labor.
 It is an obstetric intervention that should be used
when elective birth beneficial to mother and baby.

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

4. Indications for induction of labor
Maternal
• Post-term (main indication] P.I.H
(Timing depend )on the[
severity]
• Diabetes Mellitus (increase risk
of baby loss and mortality rate)
• Medical conditions (as renal,
respiratory and cardiac diseases)
• Placenta insufficiency (as
moderate or sever placenta
abruption but commonly C.S)
• Prolonged pre-labor rupture of
membranes.
• Rheuses isoimmunization
• Maternal request.
Fetal
• Suspected fetal compromise
(I.U.G.R )
• Intrauterine death (I.U.F.D).

5. Contraindications
Placenta previa and vasa previa
Abnormal fetal lie / presentation
Umbilical cord prolapse and fetal distress
Previous classical Cesarean section or other
transfundal uterine surgery
Active herpes infection
Pelvic structural abnormality
Invasive cervical cancer
Contraindicaton specific to the inducing drug
used.

6. Augmentation of labor
 Is refers to
intervention to correct
slow progress in labor.
 Correction of
ineffective uterine
contraction includes
Amniotomy and/or
Oxytocin infusion.

7. Criteria Before Induction
 Sure estimation of weeks of gestation. Evidence of
fetal maturity.
 Absence of cephalopelvic disproportion.
 An engaged head in longitudinal lie.
 Cervix is ready for delivery.
 High score Bishop's score.
Induction with Caution
 Multiple pregnancy. • Hydramnios. • Grand parity.
• Maternal age of >35years. • Previous cesarean
section

8. Bishop’s Score
Cervical feature Modified Bishop score
0 1 2 3
Dilation (cm) < 1 1–2 2–4 > 4
Length
of cervix (cm)
> 4 2–4 1–2 < 1
Station (relative
to ischial spines)
−3 −2 −1/0 +1/+2
Consistency Firm Average Soft –
Position Posterior Mid/anterior – –
High scores (a favourable cervix) are associated with an
easier shorter induction

9. Methods of Induction of Labor
Natural Non
Medical Methods
Mechanical
Methods
Surgical methods
Pharmacological
Methods

10. Natural-Non Medical methods
Relaxation techniques: advise patient to relieve tension and
try to relax then use some visual aids to show how labor
starts.
Visualization: The patient is advised to imagine her uterus
contracting and she is laboring. Hypnosis/self-hypnosis helps.
Walking: The force of gravity pulls the weight of the baby towards
the birth canal leading to dilatation and effacement of the cervix.
Sex: Having sex is known to induce labor. This is related to
prostaglandin content of the seminal fluid and the occurrence of
orgasm which stimulate uterine contractions

11.  Nipple stimulation: The lady moves her palm and applies some
pressure in a circular fashion over her areola and massaging nipple
between thumb and forefingers for a period of 2 minutes alternating
with 3 minutes of rest. The procedure is performed for 20 minutes
 Tea: Used by midwives in Latino cultures. Labor-enhancing herbs
include blue Cohosh, black Cohosh, Squawvine and Dong Quai.
Evening primrose oil also ripens the cervix. It is given internally 5 gel
caps up against the cervix daily.
 Acupressure: One point is located deep in the webbing between
thumb and forefinger. Massaging this point in a circular motion for 1-
5 minutes stimulates labor pain and induce labor.

12. Mechanical methods
 Hygroscopic dilators- They absorb endocervical and local
tissue fluids, causing the device to expand within the
endocervix and provide mechanical pressure. These dilators
are either natural osmotic dilators (e.g., Laminaria japonicum)
or synthetic osmotic dilators (e.g., Lamicel

13. Technique of insertion
 The perineum and vagina are
sterilized with antiseptic sol
& the patient is drapped.
 Using a sterile speculum, the
dilator is introduced into the
endocervix.
 Dilators are progressively
placed until the endocervix
is full.
 A sterile gauze pad is placed
in the vagina to maintain the
position of the dilators.

14. Mechanical methods
 Placement of Balloon Dilators after 42 weeks- A fluid filled
balloon is inserted inside the cervix. The Balloon provide
mechanical pressure directly on the cervix which respond by
ripening and dilation. A Foley catheter (26 Fr) or specifically
designed balloon devices can be used.

15. Technique of Balloon Insertion
The perineum and vagina are
sterilized with antiseptic sol &
the patient is drapped.
Using a sterile speculum, the
dilator is introduced into the
endocervix.
Dilators are progressively
placed until the endocervix is
full.
A sterile gauze pad is placed in
the vagina to maintain the
position of the dilators.

16. Technique of Balloon Insertion (Cont.)
The balloon is inflated with 30 to 50 mL of normal
saline and is retracted so that it rests on the
internal os.
Constant pressure may be applied over the
catheter. e.g. a bag filled with 1 L of fluid may be
attached to the catheter end. An intermittent
pressure may also be exerted on the catheter end
2 -4 times per hour.
Catheter is removed at the time of rupture of
membranes or may be expelled spontaneously
which indicate a cervical dilatation of 3-4
Centimeter.

17. Surgical Methods
 Stripping the membranes
 Amniotomy

21. Before ARM
Informed consent obtain.
Do abdominal palpation to confirm fetal
presentation, position and degree of engagement
of the presenting part.
Fetal heart rate and uterine contraction should be
noted and recorded in patient record.
Apply Aseptic technique

22. After ARM
The midwife or dr should exclude the presence of cord
prolapse.
Note color, odor, consistency, and quantity of amniotic fluid
(to identify if there is any meconium or blood in liquor).
Note presentation, position and station.
Monitor temperature q2h (to detect developing infection)

24. Pharmacological Induction of Labour
 Prostaglandin E2 (Dinoprostone)-
 It is inserted vaginally as a gel (Prepidil), as a removable
tampon (Cervidil) or as a vaginal pessary.
 It acts on the cervical connective tissue and relaxes
muscle fibres of the cervix.
 Dinoprostone should only be administered at hospital and
the patient is expected to stay recumbent and monitored,
at least, for the first 30 minutes after insertion.

25. Pharmacological Induction of Labour
 Prostaglandin E2 (Dinoprostone)-
 Contractions usually start within 60 minutes of
commencing induction and peak within 4 hours. If optimal
response is not achieved by 6 hours, another dose can be
administered. The maximum allowed dose is 3 doses be
administered per 24 hours.
 Cervidil contains 10 mg of dinoprostone and provides a
lower constant release of medication (0.3 mg per hour) than
Prepidil does.
 Cervidil have the advantage of being removed more easily if
uterine hyperstimulation occurs.
 In addition, it does not require refrigeration.
 PGE2 can cause uterine hyperstimulation, fetal distress and
Cesarean section.

26. Before Interventions
 Review patient history before
administration (to ensure there
are no contraindications or any
caution).
 Fetal heart rate and uterine
contractions should be
monitored continuously for 30-
60 minutes after
administration. (there is a risk
of uterine hyper stimulation
and rupture of uterus with or
without fetal distress)
 Instruct woman to pass urine
before administering
prostaglandin (because she will
stay for long time in bed)

28.  The mother should remain in lateral or supine position
with hip tilt for 30 to 60minutes after administration of
gel, for 2 hours after insertion of vaginal tablets. (to
minimize leakage and improve effectiveness).
 Assess cervical dilatation 6 hours after insertion. (If no
cervical response and no adverse effects, the dose may
be repeated).
 Monitor side effects of prostaglandins: Pyrexia, warm
feeling in vagina, vomiting, diarrhea, and back pain.
 It is necessary to allow at least 2 hours to elapse
between the last prostaglandin dose and starting
Syntocinon infusion, (because Prostaglandin increase
the sensitivity of the uterus to Syntocinon).
 If any adverse reactions occur notify doctor to remove
gel or suppository if possible.

29. 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%

30.  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
 there appears to be a higher incidence of vaginal delivery
within 24 hours of application and a reduced need for
oxytocin augmentation

31. 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 scarce and cannot be used to
recommend the use of mifepristone for
cervical ripening.

32. High Dose Protocol- Mifepristone
Prepare15 IU of oxytocin/500 mL 5% dextrose.
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.
This protocol have the advantage of shorter
induction delivery interval but with more
hyper-stimulation

33. Oxytocin Infusion
 Oxytocin infusion in an isotonic solution is used to
stimulate uterine contractions after rupture of the
membranes. The dose and increasing rate depend
on each agency protocols.
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 reinitiate 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 hyper-stimulation occurred,
decrease/discontinue the oxytocin infusion.

34. Side Effects of Oxytocin use
 Uterine hyperstimulation and subsequent FHR
abnormalities.
 Abruptio placentae and uterine rupture.
 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 exceed 1500 ml. A rapid
intravenous injection of oxytocin may cause hypotension.

38. Other Complications may Occur during
Oxytocin Infusion
 In addition to hyper-stimulation
of uterus and fetal distress
those complications may occur:
 Ruptured uterus as a result of
overstimulation if any
cephalopelvic disproportion
present.
 Amniotic fluid embolism is rare
which may caused by strong,
tumultuous contractions.
(usually occur in 3rd stage after
placenta separation and with
tetanic condition of uterus)

39. Signs of Hyperstimulation of the uterus
 Contraction occur more frequently than every 2
minutes.
 Duration of contraction is longer than 90 seconds.
 Elevation of resting tone of uterus is greater than 15 to
20 mmHg over her baseline of intrauterine pressure.
 Blood pressure increases when contractions increase in
frequency, duration, and intensity because of decrease
in utero-placental circulation.
 Client experience increasing pain because of increased
frequency, duration, and intensity of contractions.
 Sustained tetanic contractions occur.

40. Signs of Fetal Distress:
Tachycardia or bradycardia.
Late decelerations, variable decelerations, or
prolonged deceleration.
Loss of variability.
Increased fetal activity.
Excessive moulding or caput-succedaneum
formation.
 Meconium stained amniotic fluid in cephalic
presentation.