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1. INDUCTION OF LABOUR

2. • Induction of labour involves the use of some
methods to initiate uterine contractions before the
spontaneous onset of labour
• Includes Ripening of cervix.
onset of uterine contractions
• Purpose Achieve vaginal delivery
To avoid operative delivery by cs

3. RIPENING OF CX
• Normal physiological process that precedes
ut.contractions & includes highly complex biochemical
process
• Remodelling of cx occurs towards term
* dissociation of collagen bundles
* increase in water content of cx
* invaded by neutrophils &macrophages(releases
inf cytokines_ IL -1B,IL-8 )

4. MODIFIED BISHOP SCORE
Factor Score
0 1 2
Dilatation <1.5 1.5-3 >3
Effacement(cm) 1.5> intermediat 0.5or less
e
Station -2 or higher -1 0 or
lower
Consistency Firm intermediat Soft
e
Position Posterior Mid Anterior

5. Prerequisites for IOL
 Maternal & fetal risk –benefit analysis
should be assessed before
IOL
 Informed consent
 Maternal pelvis assessed
 Fetal wt. & presentation
 Confirm lung maturity
cx status assessed ---success of induction
& outcome

6. Contraindications to cx ripening
Absolute CI
• Special caution
•pl. preavia
•Vasa preavia – Previous LSCS
• Active genital herpes – Multiple preg.
•Invasive ca cx. – Polyhydramnios
•Previous ut. Surgery – Mat. Heart ds
Classical cs – Severe HTN.
Previous metroplasty
Myomectomy---cavity
opened

7. ELECTIVE INDUCTION
• Induction of labour in the absence of
maternal or fetal indication.
• Convenience of pt. and obstetrician.
• Not encouraged.
• Unripe cx. prolonged labour
failed induction.

8. When to induce ?

9. Methods of cx ripening and labour induction
Mechanical dilators
-Balloon cath
-Laminaria
-Osmotic dilators
Stripping of memb
Amniotomy
Pharmacological Preparation
-PGE2
-oxytocin
-Misoprostol(PGE1 analogue)
-Mifepristone(RU-486)
-Relaxin
-NO

10. Mechanical methods
• Allows slow and controlled dilatation of cx.
• Ideal cx firm, postr.,long and closed
severe FGR, oligamnios,
• Method (EASI)
aseptic precautions foleys catheter
inflated with 30ml distilled water
100ml NS extraamniotic space
spontaneous passage 12hrs
ARM &pitocin
•

11. EASI

12. Stripping of membranes
Release of endogenous PG
Risk ascending infection
bleeding from pl .preavia
accidental rom
Advantage - makes spontaneous onset of
labour more likely.
Reduces the need for formal IOL
When? 39 wks

13. Amniotomy
• ARM is commonly used along with oxytocin infusion
• Shortens the induction –delivery interval
• Ideally ARM done - cx. is favorable
• Spontaneous labour - do only in the active phase
• Delay ARM - occipitoposterior position.
• Oxytocin infusion can be started if ut. Contractions do
not ensue in 2-4 hrs.

14. PROSTAGLANDINS
ONLY When cervix is unripe.
• Action------- dissolution of collagen bundles
increases tissue water content
stimulates myometrium
PG-E2 (dinoprostone)
Preparation and dosages
0.5mg intracervical
2.5mg intravaginal
Kept refrigerated
Brought to room temp. b/f admn.
Contraindications fever
allergy to PG
abn. Vaginal bleed.

15. Mode of admn
• Studies show that intravaginal route is
more superior to IC route (RCOG)
• Rcog(2008) does not recommend other
routes like;
• Oral ,extraamniotic, intracervical PG
Intracervical preparation should not be used for
Intravaginal application.

16. Additional dosage?
• Pv exam done after 6hrs –no cx response
rpt. dose admn.
• Maximum recommended cumulative dose
is 2 doses*24hrs.
• Recommended interval before
administering oxytocin( after PG-E2 )is 6-
12 hrs

17. MISOPROSTOL
• More effective than PG-E2 in producing cx ripening
• Not approved by FDA for IOL at term.
• Advantage inexpensive
easy to store
stable at room temp.
• Risk high incidence of ut. Hyperstimulation
thick meconium
• Low dose regime--25microgm of PGE1
incidence of tachysystole < by 50%
RCOG 2008: PGE1 should only be offered as a method of IOL in IUD
or in the context of a clinical trial.

18. Complications of prostaglandins
• Systemic side effects: nausea,vomiting,diarrhoea,fever
• Ut. Hyperstimulation
» Defined as tachysystole or hypersystole ass. with
nonreassuring FHR pattern.
» tachysystole—def. as 6>more ut. Contractions in 10
mts.
» Hyper systole--- def. as single contraction of at least
2mts duration.

19. Oxytocin
Mechanism of action
binds to OTR in the myometrial cell wall and
increase intracellular ca conc.
increase plasma PG conc.
Dosage
 oxytocin is started as a low dose in normal saline(5U in
500ml NS) and the rate is doubled every 30 mts.
 4 drops/mt=2.5mu/mt
 max dose is 40mu/mt (60 drops/mt)
 ARM before oxytocin

20. Guidelines for oxytocin infusion
• A written protocol for oxytocin admn. should
be available in the labour room.
• Unfavorable cx. ---oxytocin should not be
used as a primary method of IOL.
• All medical personnel who administer
oxytocin should be able to identify and
manage oxytocin complications.
• Once the intensity of contractions increases
oxytocin rate should be reduced or stopped.
• Partogram
• CTG monitoring.

21. Complications
Ut. Hyperstimulation
Mgt stop ,left lateral position ,
O2 inhalation ,iv fluids
terbutaline 250 microgm sc
Water intoxication
• Large dose of oxytocin given for prolonged period
• Sodium poor iv fluids are used
• Hyponatremia-----confusion, convulsions coma death.

22. Rupture uterus
multi ,prev.cs ,
malpresentations
overdistented ut.
Cl.presentation nonspecific and variable
most imp. Warning sign is FHR variation
sudden tearing pain
pp may spontaneously lose station
p/a- abn .uterine contour
shock and referred pain to shoulder---late

23. RCOG recommendations in Special
circumstances
Previous cs
PGE2 & oxytocin is safe in pts .who are candidates for VBAC
.
PGE1 contraindicated.
IUGR - severe FGR with fetal compromise- IOL is not recommended
PPROM-
<34 wks-expectant mgt.
>34wks---intravaginal PGE2
IUD
labour induced with oral mifepristone (200mgdaily *2days) foll. by vaginal PGE2 or PGE1
IUD with previous cs - dosage of PG should be reduced.

24. Summary
• Stripping of membranes at 39 wks.
• ARM only in active phase of labour.
delay ARM op position.
• Foleys catheter long rigid cx, IUGR
• PG ONLY when cx is unripe.
• Misoprostol low dose regime - 25 microgm 6th hrly.
• Oxytocin start as low dose in NS.
do ARM before oxytocin.
• Avoid cocktail regimen.