Induction of labour RCOG guidelines

1. Dr. Farwa Ashfaq (PGT)
Dr. Lyba Niazi (HO)
Ref. RCOG AND NICE (2008,2021)

2.  Process by which labour is started prior
to its spontaneous onset by artificial
stimulation of uterine contractions
and/or progressive cervical effacement
and dilatation, leading to active labour
and birth.
- The clinical need for IOL occurs when it is
perceived that the outcome of the
pregnancy will be improved if it is
interrupted by induction, labour and birth.

3. - Medical
- Vaginal prostaglandins PGE2: cause myometrial
contraction and cervical ripening, Misoprostol (PGE1)
- oxytocin- uterotonic (stimulates uterine
contractions)
- Mifepristone- progesterone receptor antagonist
- Surgical
. Artificial rupture of membranes (ARM)/ Amniotomy
with oxytocin infusion
Mechanical
- Membrane sweeping
- Hygroscopic dilators
- Foleys balloon catheter

4. MEMBRANE SWEEPING:
RCOG (2008, 2021)
from 39 weeks -42 weeks weekly.
Pharmacological and Mechanical Methods:
BISHOP score(cx ripening) will determine which
method of IOL will be used.(RCOG: 2021)
For Bishop 6 or less:
1. 3.9 : IOL with vaginal PGE2 tab./gel/controlled
released pessaries. [DOSE:vaginal PGE2 tablets (3
mg) 2 doses 6 hrs apart or gel (1–2 mg) at 6-hourly
intervals(max.4mg) or one PGE2 controlled-release
pessary (10 mg) over 24 hours].

5. 1.3.10 : IOL with misoprostol 25mcg if
women prefers oral preparation OR prev
hx of failed IOL with dinoprostone(PGE2)
and she wants other pharmacological
methods(2021).
1.3.11 : IOL with ICF if pharmacological
method is contraindicated
( prev. scar, prev. hx of hyperstimulation)
OR she chooses mechanical method.
For Bishop more than 6:
IOL with Amniotomy and IV oxytocin
Infusion.

6. Pharmacological
 Oral PGE2
 IV PGE2
 Extra-amniotic PGE2/PGF2
 Intracervical PGE2
 Vaginal PGF2
 IV oxytocin alone
 Hyaluronidase
 Corticosteroids
 Estrogen
 Relaxin
 mifepristone(except in case od
IUD)
 Vaginalnitric oxide donors
Non-
Pharmacological
•Acupuncture
•Castor Oil
•Homeopathy
•Hotbaths
•Enema
•Osmotic cervical dialators
•Herbal supplements
•Sexual intercourse(2008)

7. “Speeding up 1st stage of Labour”
It reduces duration by 75mins and risk of CS
by 10%.
 Amniotomy
 Oxytocin infusion
commonly used dose 0.0005- 0.006IU/min
can be exceeded upto 0.004-0.02IU/min.
Increase dose after every 30 min with target
of 3-5/10min palpables.(NICE 2008)

8.  POST-DATE PREGNANCY:
if Woman presents at 41 weeks, then there are 3 options:
1. expectant twice weekly f/up for EFM and scan for Liquor volume.
2. IOL
3. CS
if she presents at 42 weeks  IOL/CS.
 PROM (8-10%):
spontaneous labour  60%
expectant management f/b IOL after 24hrs. (to reduce risk of neonatal sepsis).
 PPROM(3%):
Before or at 34 weeks: no indicators of maternal or fetal compromise wait till
37weeks with weekly f/up. Otherwise immedialtely plan for CS.
B/W 34-37 weeks and evidence of Group B streptococcal infection: immediate
IOL/CS.
 Diabetes: must be started b/w 38-39weeks ( to avoid intrapartum
complications and late stillbirth)

9.  Suspected Fetal Macrosomia:
if fetal weight is more than 4g then timely decide for IOL/CS after 37 weeks.
 Hypertension: at 37 weeks.
 OBS Cholestasis: at 37 weeks to reduce risk of Stillbirth
 Advance Maternal Age: b/w 39-40 weeks.
 Maternal request: not recommended by RCOG/NICE.
 SGA/LGA: at 37 weeks.
 Reduced Fetal Movement: recurrent presentation(2 or more), IOL must
be started at 37weeks.
 Breech Presentation: not generally recommended. Nut if delivery is
indicated and ECV failed and woman chooses not to have CS. (NICE 2021)
 Multiple Pregnancy: TWINS DC 37 weeks
TWINS MC 36 weeks
Triplets 35 weeks

10.  No existing medical condition or Obs complication  IOL
with vaginal PGE2/ mechanical methods.
 Full clinical assessment of women and fetus before
starting Outpatient IOL
 Agree a review plan with women before preeceding.
 Return immediately if :
contractions begin.
SROM.
reduced Fetal Movement.
excessive pain/ Hyperstimulation.
No contractions.

11. - Maternal- confirm indication for iol, exclude
contraindication of iol, adequate counselling
about risks/benefits of iol
- Assess bishop score (score> 6 favourable)
- Placental: localization
- Fetal: ensure fetal gestational age
- Estimate fetal weight
- Ensure fetal presentation and lie
- Confirm fetal well-being

12. Depends on cervical ripening measured by
Bishop score/TVUSG
Success rate is increased:
- if cervix is 1.6 to 3.2 cm in length.
- bishop is 6 or more.

13. • Malpresentation (breech, transverse or
oblique lie)
• Placenta Previa/ vasa previa
• Cord prolapse
• High risk pregnancy with fetal compromise
• Maternal Heart disease
• Cervical carcinoma

14. COMPLICATIONS:
-FAILURE OF IOL (15%):
a) rest period then repeat after 24 hrs.
b) EMLSCS
-HYPERSTIMULATION(1-5%): (contractions
more than 5/10min or exceeding 2mins)
 profound alteration in FHR CS.
 Less severe alteration in FHR tocolysis by
terbutaline 250ug IV/SC. Removal of tablet if
possible (2008).

15. • PAIN RELIEF:
-simple analgesia
-labour in water
- epidural analgesia (2021)

16.  SPECIAL CIRCUMSTANCES:
- A proportion of women who have had a
previous caesarean birth will also have an
indication for IOL in a future pregnancy.
- It is recommended that women who have had
a previous CS may be offered IOL with vaginal
PG, CS or expectant management on an
individual basis. Women should be informed of
the increased risks with IOL, increased risk of
need for emergency CS and increased risk of
uterine rupture.

17. THANK YOU