Induction and augmentation of labor

• Definitions:
• Induction-is the artificial stimulation of uterine contractions before
the spontaneous onset of true labor at 28 or more weeks of gestation
to achieve vaginal delivery.
• Augmentation -is stimulation of the uterus to increase its frequency,
duration and/or strength of spontaneously initiated labor.
• the main indication of augmentation is weak and ineffective power with labor
abnormality.
Induction
• it is done when the benefits of delivery to the fetus or the mother
exceed the benefits of continuing the pregnancy.
• It could be either as:
• Planned (elective)
• Emergency
• Induction methods
− Surgical methods: ARM, ballooned catheter, laminaria
− Medical/pharmacological induction: Oxytocin, prostaglandins
Induction
• Principle: it should be done when the risk of continuing pregnancy outweighs the risk
labor and delivery.
• Can be emergency or elective
• Pre-induction assessment should be made:
• GA, EFW, presentation, BPP,
• Presence of indication(medical or obstetric)
• No contraindications
• Cervical favorability status( Bishop Score); then ripen if unfavorable
• Presence of C/S facility
• Informed consent
• Indications: obstetric and medical indications; E.g
• Post-term
• Term PROM, chorioamnionitis, abruptioplacenta
• Preeclampsia/eclampsia, HELLP syndrome
• Diabetes mellitus
• IUFD…………etc
Indications for Induction of Labor

Maternal Fetal

•Intrauterine fetal death •Congenital anomaly incompatible with

•Pre-eclampsia/Eclampsia life
•Chronic hypertensive disease •RH Isoimmunization
•Antepartum hemmorhage •Fetal growth restriction
•Premature rupture of the membranes •Post term pregnancy
•Diabetes mellitus in pregnancy
•Abnormal fetal well being tests
suggesting chronic intrauterine asphyxia

Indications are classified as maternal and fetal based on the predominant reason for
termination. In most cases maternal and fetal indications overlap and may be difficult
to classify as maternal and fetal.

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• Contraindications
• Prior uterine scar (C/S, myomectomy, repaired uterine rupture)
• Placenta previa, vasa previa
• Transverse lie
• Macrosomia, contracted pelvis
• Cord presentation
• Poor BPP
• Active genital herpes infection
• Invasive Cervical cancer etc.
Techniques of induction
• Two broad categories
• Cervical ripening agents for unfavorable cervix
• Induction methods for favorable cervix-(Bishop score= 9+)
• IV oxytocin drip…..the most common and preferred
• Prostaglandins
• Amniotomy
• Ancillary outpatient measures
• Membrane stripping
• Breast stimulation
Methods of Labor Induction and Augmentation

Medical Surgical Combination of both

1.Oxytocin infusion 1. Amniotomy – artificial 1. Amniotomy with
•Low dose regimen- rupture of the oxytocin induction
beginning at 1mu/min and membranes 2. Stripping of fetal
doubling every 20-30 mins 2. Stripping of the fetal membranes with
to a maximum of 40 membranes oxytocin induction
mu/min 3. Foley catheter method 3. Foley catheter method
•High dose regimen- start with oxytocin induction
at 6mu/min and escalate Surgical methods are often ….. Etc
every 20-30 mins to a used in conjunction
maximum of 42 mu/in with medical methods Most methods of labor
2.Prostaglandin E and not alone for labor induction are also used
1( Misoprostol) induction – induction. for augmentation of
intravaginal or intracervical labor as well.
3.Prostaglandin E 2
( Dinoprostone) – 3 mg
vaginally every 6 hours for
two – four doses

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How can we predict successful induction?

• Bishop score( tradional,modified,simplified)- preferred

• TVUS cervical length measurement
• fFN measurement from cervical fluid
…
• Cervical status based on Bishop score out of 13
• Unfavorable- if 6 and below
• Intermediate- 6-8
• Favorable- if 9+
• Do cervical ripening if Bishop is less than 9.
Techniques of cervical ripening
• Prelabor cervical status is a good predictor of successful induction.
• Favorable cervix- vaginal delivery highly likely
• Unfavorable cervix- failed induction ↑ed; so ripening process is employed prior to
induction
• Cervical ripening is a complex process resulting in physical cervical softening
and dispensability resulting in partial effacement and dilatation
• Remodeling of the cervix involves:
• Enzymatic dissolution of collagen fibrils
• Increase in water content and
• Chemical changes
• These changes are induced by
• Hormones(E,P,R)
• Cytokines
• Prostaglandins and
• N2O synthesis enzymes
Methods of Cervical Ripening
Pharmacological Mechanical
•Prostaglandin E2 (dinoprostone)- •Foley catheter method
intravaginal, intracervical – repeated 3-5 •Stripping of the fetal membranes
mg doses applied until the cervical status •Laminaria insertion into the cervix –
improves or a maximum of three to four hygroscopic dilators that dilate and soften
doses the cervix by absorbing its water content.
•Prostaglandin E1 (misoprostol) – Extracts of laminaria sea weeds.
intravaginal or oral

Un unripe cervix needs to be ripened by these cervical ripening methods in order to

be softened and more ripe. The pharmacologic methods are the most preferred but in
cases where these are not accessible, mechanical agents can also be used to ripen the
cervix.
A ripe cervix indicates a dilated, soft, anterior and effaced cervix that is easily pliable to
uterine contractions.

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Remodeling the cervix
Ripening Methods/techniques: two categories

1. Pharmacological: prostaglandins
2. Mechanical: balloon/ Foley catheters, hygroscopic dilators( luminaria tents),
EASI etc
• Prostaglandins
• Cause dissolution of collagen bundles and submucosal water content rise of cervix
• Preferred method
• May initiate labor
• Prostaglandin E1 and E2( dinoprostone and misoprostol)
• Route- transvaginal route preferred
• Catheters: double balloon /Foley catheters
• Mechanically dilate
• Cause release of prostaglandins F2a and E1
…
• Hygroscopic dilators
• Two types
• Natural sea wood product- luminaria tent
• Synthetic – dilapan
• Mechanism:
• Absorb moisture and gradually expand in the cervical canal= mechanical stretch
• Disruption of choriodecidual interface =prostaglandin release
….
• EASI- sterile saline is infused continuously in to EAS via catheter
• No proven advantage over others
Procedures of Labor induction
Procedure Description Complications
Amniotomy After ascertaining the fetal station •Cord prolapse
and ruling out cord presentation •Infection – chorioamnionitis
membrane is ruptured with an •Abruptio placentae- if
amnion hook or a kocker and sudden decompression of
controlled release of amniotic fluid uterus occurs due to
effected excessive release of amniotic
fluid

Oxytocin An IV line is opened and oxytocin •Uterine hypertonus – fetal

infusion infusion administered gradually by distress; uterine rupture
either a graduated perfusor prepared •Water intoxication – sodium
for the purpose or by IV drip method retention and fluid overload
manually calibrated – dosage •Hypersensitivity reaction to
expressed in mu/min oxytocin
•Higher risk of atonic PPH

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Procedures for Labor Induction
Procedure Description Complications
Prostaglandin Usually applied for cervical ripening Nausea, vomiting,
E1, E2 induction but also used for induction of labor. diahorrea, fever, chills,
Tablet or gel or cream inserted at the respiratory complications
posterior fornix or near the cervix ( rare), uterine hypertonus-
repeatedly at 6 hourly intervals until fetal distress, uterine
labor is established rupture
Stripping of the The membranes are separated from Possibility of placenta
fetal the lower uterine segment by the previa and bleeding.
membranes examining finger for 3-4 cms from the Placenta should be
os and await for labor onset in hours localized before membrane
or days. stripping.
Foley catheter Foley catheter inserted into the uterus Infection
method above the internal os, balloon inflated Membrane rupture
with 30 cc of normal saline and
pressure applied by hanging weight of
1 kg ( e.g. IV fluid bag).

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Techniques of induction…
• Two broad categories
• Cervical ripening agents for unfavorable cervix
• Induction methods for favorable cervix-(Bishop score= 9+)
• IV oxytocin drip…..the most common and preferred
• Prostaglandins
• Amniotomy
• Ancillary outpatient measures
• Membrane stripping
• Breast stimulation
Oxytocin induction:
 A polypeptide which causes periodic uterine contraction
Proven method of labor induction
Half life is 3-5 minutes
Administered in intravenous drip: in 1000 ml crystalloid
Regimen- different protocols
Low dose protocol-
 mimic physiologic approach
 Initiated at 0.5- 1 mIU/min and escalated by 1 mI/mi every 30-40 minutes
 i.e based on that nearly 40 minutes is required for an oxytocin dose to reach steady state
concentration in blood and have maximum contractions
Regimen…
 Alternate low dose
 initiation- 1-2 mIU/min; increase by 1-2 mIU
 Incremental interval- 15-30 min
 High-dose protocol
 High dose oxytocin infusion with shorter incremental interval
 But most labor units do not go beyond 40 mIU/min
 Maximum oxytocin dose is not established
Oxytocin infusion- alternate Low-dose
protocol(Ethiopian FMOH)
• Open IV line using No 18 cannula
• Perform artificial rupture of membranes.
• Start oxytocin infusion, and monitor the dose and rate of infusion
strictly as follows:
• add 2 IU of oxytocin into 1000 ml of N/S or R/L solution and adjust the
number of drops every 30 minutes.
• start with a low dose of oxytocin and increase every 30 minutes till
adequate uterine contraction is achieved or maximum dose is reached.
Schedule for escalating oxytocin
dosage
Cont…
• Monitor mother, fetus and labor according to labor protocol. Record
maternal and fetal conditions and progress of labor.
• Use the partograph once adequate uterine contractions are achieved.
• Continue the oxytocin infusion for at least one hour postpartum.
Indications for oxytocin induction
• − Preeclampsia, eclampsia, chronic hypertension
• − Diabetes mellitus
• − PROM
• − Chorioamnionitis
• − Abruptio placentae
• − Postterm pregnancy
• − Congenital abnormality
• − IUFD
• − Previous stillbirth
• − Rh isoimmunization
• − IUGR , etc
Contraindications for oxytocin
• − Contraindications for labor or vaginal delivery
• placenta Previa, vasa Previa, transverse and oblique fetal lie; breech footling
or extended neck
• CPD, brow presentation, face with mento-posterior, twin pregnancy, extensive
genital wart, cervical cancer, active genital herpes, cord prolapse
• − Contraindications to oxytocin use
• uterine scar (after CS, myomectomy, perforation, ruptured uterus etc),
• meconium stained amniotic fluid, NRFHP or fetal distress
• Relative contraindications to oxytocin use
• breech presentation (e.g., frank,complete), bad obstetric history, grand multi
parity
Prerequisites for oxytocin induction
• Valid indication
• No contraindication
• For Elective induction
• Assess lung maturity
• BISHOP score- if less than 9 –do cervical ripening
• Informed maternal consent
Complications and S/E of oxytocin:
• Tachysystol, uterine rupture, fetal distress
• Amniotic fluid embolism
• Hyponatremia, hypotension, neonatal hyperbilirubinemia
• Failed induction:
• increased risk of cesarean section
• Atonic PPH
• Iatrogenic prematurity
• Chorioamnionitis (prolonged rupture of membranes after ARM and repeated
VE)
• Fetal sepsis and vertical HIV transmission (ARM)
• Cord prolapse (ARM)
• Placental abruption (ARM), water intoxication, amniotic fluid embolism
Failed induction

 Contemporary definition(NIH,SMFM,ACOG):
 Failure to generate adequate contractions and cervical change after at least
24 hours of oxytocin administration for intact membrane; or 12 hours of administration if ARM
done
FMOHE 2010:
 failure to initiate good uterine contraction. It is diagnosed if adequate uterine contractions
are not achieved after 6 to 8 hours of oxytocin administration and use of the maximum dose
for at least one hours.
Managing complications
• Failed induction-
• most important reason is unfavorable cervix
• Pre-induction cervical status assessment is mandatory…….and do cervical ripening for
unfavorable cervix
• Mx- if IUFD with no ROM and elective- postpone and ripen the cervix
- if emergency or ROM – do C/S delivery
• Tetanic contractions-
• Six or more contractions in 10 min and/ or durations of 90 or more seconds
• MX- Stop oxytocin infusion; use tocolytics if available; assess both fetus and
mother for complications
- Restart with half the dose of the tetanic level if fetus and mother are
stable
Augmentation of labor
• The main indication- weak and ineffective uterine contractions
leading to abnormal progress of labor.
• Contraindications- are similar to the contraindications of oxytocin use
as for induction .
• Breech, scared uterus, multiple pregnancy etc. are contraindication for
oxytocin use
• Oxytocin should not be used for secondary hypotonic contractions due to
obstructed labor.
• Methods and procedures(dosing) are generally similar to induction
• Do ARM prior to oxytocin infusion
thank u.