Induction of Labour SOGC, 2013 WHO, 2011 NICE, 2008

1. Induction of
Labour
SOGC, 2013
WHO, 2011
NICE, 2008
Aboubakr
Elnashar
Benha University Hospital,
Egypt
Aboubakr Elnashar

2. CONTENTS
1. DEFINITIONS
2. SETTING &TIMING
3. INDICATIONS
4. CONTRAINDICATIONS
5. PREVENTION
6. PREINDUCTION ASSESSMENT
7. METHODS
8. MONITORING
9. PAIN RELIEF
10.COMPLICATIONS
Aboubakr Elnashar

3. Aboubakr Elnashar

4. 1. DEFINITIONS
Induction of labour: IOL
initiation of contractions in a pregnant woman who
is not in labour to help her achieve a vaginal birth
within 24 to 48 hs.
Successful induction
vaginal delivery within 24 to 48 hs of induction of
labour.
Elective induction
induction of labour in the absence of acceptable
fetal or maternal indications.
Cervical ripening
use of pharmacological or other means to soften,
efface, or dilate the cervix to increase the
likelihood of a vaginal delivery.
Aboubakr Elnashar

5. Tachysystole
5 C/10 m period averaged over 30 m.
 further subdivided into two categories
one with and one without FHR changes.
Hypertonus
Excessive uterine contractions lasting > 120 sec
without FHR changes.
This term should be abandoned and has been
replaced by tachystole without FHR changes.
Hyperstimulation
Excessive uterine contractions (tachysystole or
hypertonus) with abnormal FHR changes.
This term should be abandoned and has been
replaced by tachystole with FHR changes.
Aboubakr Elnashar

6. 2. SETTING AND TIMING
I. Outpatient:
 If safety & support procedures are in place.
Should be audited continuously.
(NICE, 2008)
 Not recommended for improving birth outcomes.
(who, 2011)
II. Inpatient :
In the morning
{higher maternal satisfaction}.
Aboubakr Elnashar

7. 3. INDICATIONS
1. Must be documented:
reason for induction
method of induction
risks, including failure to achieve labour and
possible increased risk of CS.
(III-B)
2. If IOL is unsuccessful:
indication and method of induction should be
re-evaluated.
(III-B)
Aboubakr Elnashar

8. 3. IOL should not be performed solely for
suspected f macrosomia.
(III-D)
4. IOL should not be performed solely because of
patient or care provider preference.
(III-D)
IOL is indicated when the risk of continuing the
pregnancy, for the mother or the fetus, exceeds
the risk associated with IOL
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9. I. High Priority
•• Preeclampsia ≥ 37 ws
•• Significant mat dis not responding to tt
•• Significant but stable APHge
•• Chorioamnionitis
•• Suspected fetal compromise
•• Term PLROM with maternal GBS colonization
Aboubakr Elnashar

10. II. Other Indications
•• Postdates (> 41+0 w) or post-term (> 42+0 w)
•• Uncomplicated twin pregnancy ≥ 38 w
•• D M (glucose control may dictate urgency)
•• Alloimmune disease at or near term
•• IUGR
•• Oligohydramnios
•• Gestational hypertension ≥ 38 w
•• IUFD
•• PROM at or near term, GBS negative
•• Logistical problems (history of rapid labour, distance to hospital)
•• IUFD in a prior pregnancy (To alleviate parental anxiety, but
there is no known medical or outcome advantage for mother or baby.)
Aboubakr Elnashar

11. Unacceptable Indications
•• Care provider or patient convenience
•• Suspected f macrosomia
(EFWt > 4000 gm) in a non-diabetic
{no reduction in the incidence of shoulder dystocia but twice
the risk of CS}.
IOL at term is not recommended for suspected f
macrosomia
(WHO, 2011)
Gestational diabetes
IOL not recommended before 41 w
(WHO, 2011).
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12. Maternal request
IOL should not routinely be offered.
However, under exceptional circumstances
at or after 40 w
(NICE, 2008).
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13. Breech presentation
•IOL is not generally recommended.
•IOL:
1. ECV is unsuccessful, declined or contraindicated
2. Woman refused elective CS
3. Delivery is indicated
after discussing the associated risks with the woman.
(NICE, 2008)
Fetal growth restriction
If severe, IOL is not recommended.
(NICE, 2008)
Aboubakr Elnashar

14. POST-DATE S INDUCTION
IOL between 41+0 and 42+0 w
{reduce perinatal mortality and meconium
aspiration syndrome without increasing CSR}.
(I-A)
IOL is not recommended in women with an
uncomplicated pregnancy at gestational age less
than 41 w.
(WHO, 2011)
Women who chose to delay induction > 41+0 w
should undergo twice-weekly assessment for fetal
well-being.
(I-A)
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15. 4. CONTRAINDICATIONS
•• placenta or vasa previa or cord presentation
•• abnormal fetal lie or presentation
(e.g. transverse lie or footling breech)
•• prior classical or inverted T uterine incision
•• significant prior uterine surgery
(e.g. full thickness myomectomy)
•• active genital herpes
•• pelvic structural deformities
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16. 5. PREVENTION OF INDUCTION
Routine antenatal US for confirmation of EDD
has been shown to reduce induction rates for
postdates (> 41+0 w) pregnancies after correction
of dates
US in 1st T confirm gestational age.
(I-A)
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17. Routine sweeping (stripping) of membranes
promotes the onset of labour: decreases
induction rates.
{increase of local production of prostaglandins}.
insertion of a digit past the internal cervical os
followed by 3 circumferential passes of the digit:
separation of the membranes from the lower
segment.
An adjunct to IOL rather than an actual method of
IOL.
Aboubakr Elnashar

18. When?
1. Prior to IOL
2. At 40& 41 w in nulliparous
3. At 41 w in parous
4. When a vag exam is carried out to assess the
cervix
5. labour does not start spontaneously.
(NICE, 2008)
Aboubakr Elnashar

19. Massaging around the cervix in the vaginal
fornices
when the cervix was closed, a massage of the
cervical surface with the forefinger and middle
finger for 15 to 30 seconds .
±achieve a similar effect.
(NICE, 2008)
Informed consent should be obtained &
documented.
discomfort and pain
possibility of bleeding postprocedure
Aboubakr Elnashar

20. Quality assurance programs and induction
policies:
safety tools such as checklists, to ensure that IOL
are performed only for acceptable indications.
(II-2B)
An induction committee.
To review each request and enforce the use of
proper indications for induction.
: Reduction in the number of elective inductions
The effect of coitus on promoting labour:
unclear.
Aboubakr Elnashar

21. 6. PRE-INDUCTION ASSESSMENT
1. Fetal well-being (CTG)
 before administration of misoprostol.
 for 30 m after administration of misoprostol
 for 60 m after any tachysystole.
Aboubakr Elnashar

22. 2. Bishop score
 To determine the likelihood of success and
To select the appropriate method of induction.
(II-2A)
 The Bishop score should be documented.
(III-B)
 Induction of women with an unfavourable
cervix is associated with a higher failure rate in
nulliparous patients and a higher CS rate in
nulliparous and parous patients.
(II-2A)
Aboubakr Elnashar

23. Factors influencing success rates of
induction
1. Bishop score
2. Parity (prior vaginal delivery)
3. BMI
4. Maternal age
5. EFW
6. DM.
Elevated BMI (> 40 kg/m2)
Maternal age > 35 y
EFW > 4 kg
DM: increase the CS rate when labour is induced.
Aboubakr Elnashar

24. Burnett modified scoring
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25. Initial studies were limited to parous women, but
the score was later found also to be applicable to
nulliparous women
The most important:
Cervical dilatation, followed by
Effacement,
Station, and
Position,
with the least important being Consistency.
Aboubakr Elnashar

26. > 6: predictive of a successful vaginal delivery.
0 to 3: highest risk of failed induction and CS in
both nulliparous and parous
4 to 6: significantly higher risk of CS than those
with spontaneous labour.
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27. US of the cervix
to predict successful labour induction: conflicting
results.
Rozenberg et al. reported that the Bishop score was
a better predictor of time interval from induction to
delivery.
Fetal fibronectin and TVS
predict successful induction, but neither have been
shown to be superior to the Bishop score.
Aboubakr Elnashar

28. 7. METHODS
FOR CERVICAL RIPENING/INDUCTION
A. UNFAVOURABLE CERVIX
I. Mechanical Options
Foley catheter with and without extra-amniotic
saline infusion that apply pressure on the internal os of
the cervix: stretch the lower uterine segment: increase
release of local PG.
Balloon catheter is recommended for IOL.
(WHO, 2011)
The combination of balloon catheter plus oxytocin
is recommended as an alternative method of IOL
when PG (including misoprostol) are not available
or are contraindicated
(WHO, 2011)
Aboubakr Elnashar

29. Contraindications:
Absolute:
Low-lying placenta
Relative:
Antepartum hge
ROM
Lower tract genital infection.
(NICE, 2008)
Aboubakr Elnashar

30. Steps:
No. 18 Foley is introduced under sterile technique
into the intracervical canal past the internal os.
The bulb is inflated with 30 to 60 cc of water.
The catheter is left in place until either it falls out
spontaneously or 24 hs have elapsed.
Some practitioners apply a small degree of
traction on the catheter by taping it to the inside of
the leg.
Aboubakr Elnashar

31. Advantages:
Simple
Reversible
Reduction in excessive uterine activity
low cost
Not associated with increased rates of
•maternal infection (chorioamnionitis and endometritis)
or
•neonatal infection.
(SOGC, 2013)
Aboubakr Elnashar

32. Foley catheter Vs PG:
•• an increased need for oxytocin
•• much less uterine tachysystole.
•• does not reduce the rate of CS from that of PG.
Intracervical Foley catheters
acceptable agents
(II-2B)
safe both in the setting of
•vaginal birth after CS
(I-B)
•outpatient setting.
(II-2B)
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33. Double lumen catheters
may be considered a second-line alternative. (II-
2B)
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34. II. PHARMACOLOGICAL OPTIONS
1. PGE2
(cervical and vaginal): effective agents of cervical
ripening and IOL for an unfavourable cervix.
(I)
PGE2 reduce CSR of women with an unfavourable
cervix: greater maternal satisfaction.
Vag E2 are preferred to intracervical
{:more timely vaginal deliveries}.
(I)
Care must be taken to avoid the insertion of the higher
dose of vaginal PGE2 (2 mg) into the cervical canal.
•• Uterine tachysystole without FHR changes is more
common
Aboubakr Elnashar

35. PGE2 (cervical and vaginal) should not be used in
the setting of VBAC {increased risk of uterine
rupture}.
(II-2D)
Vaginal PGE2 may be considered with ROM at
term and can be used in this setting.
(I-A)
PGE2 in the setting of ROM had more maternal but
no more neonatal infections.
Aboubakr Elnashar

36. •Regimens:
one cycle of vaginal PGE2 tablets or gel: one dose,
followed by 2nd dose after 6 h if labour is not
established (up to a maximum of 2 doses)
one cycle of vaginal PGE2 controlled-release
pessary: one dose over 24 h.
(NICE, 2008)
Aboubakr Elnashar

37. II. Misoprostol
only in IUFD or in the context of a clinical trial
(NICE, 2008).
Misoprostol can be considered a safe and effective
agent for IOL with intact membranes and on an
inpatient basis.
(I-A)
Misoprostol should not be used in the setting of
vaginal birth after CS
{increased risk of uterine rupture}.
(II-3D)
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38. Duration of actionOnset of actionRoute
∼2 h8 minOral *
∼3 h11 minSublingual
∼4 h20 minVaginal
∼4 h100 minRectal
* After oral administration, uterine tonus develops, which is not
followed by uterine contractions, unless repeated doses are given
Pharmacokinetic Profiles: Key Facts
(Tang et al., 2007)
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39. •• 50 mcg orally with a drink of water (ensure that it
is swallowed quickly to avoid sublingual absorption)
or
25 mcg vaginally.
•• Repeat/4 h as long as contractions are absent or
non-painful.
(SOGC, 2013)
Oral misoprostol (25 μg, 2-hourly)
vaginal misoprostol (25 μg, 6-hourly)
(WHO, 2011)
Aboubakr Elnashar

40. •• The lower vaginal dose (25 mcg) tends to need
more oxytocin stimulation and the higher vaginal
dose (≥ 50 mcg) tends to have more uterine
tachysystole.
•• All doses of misoprostol can cause uterine
tachysystole.
The oral and vaginal routes have a similar
reduction of CS rates.
The oral route needs more oxytocin stimulation but
the vaginal route will have more tachysystole.
Aboubakr Elnashar

41. •• Misoprostol Vs PGE2
More effective to achieve vaginal delivery
less epidural use
More uterine tachysystole.
•• PGE1 and PGE2 both reduce CS rates in an
unfavourable cervix.
Aboubakr Elnashar

42. IUFD
Support {cope emotional& physical consequences}
Immediate IOL or expectant management:
• Woman is physically well
• Membranes are intact
• No evidence of infection or bleeding
Immediate IOL
• Ruptured membranes
• Infection or bleeding
Aboubakr Elnashar

43. Method & dose:
•Oral mifepristone followed by vag PGE2 or
vag misoprostol.
•The choice & dose of vag PG depend on:
 Clinical circumstances
Availability of preparations
 local protocol.
•Previous CS {risk of uterine rupture is increased}:
dose of vag PG should be reduced
In 3rd T, in women with a dead or an anomalous
fetus, oral or vaginal misoprostol are recommended for
IOL
Aboubakr Elnashar

44. Oxytocin can be started
30 m after removal of a dinpoprostone insert
(Cervidil)
6 h after gel (Prostin, Prepidil).
4 h after the last dose of misoprostol.
(III-B)
(SOGC, 2013)
Aboubakr Elnashar

45. B. FAVOURABLE CERVIX
1. Amniotomy
should be reserved for women with a favourable
cervix. Particular care should be given in the case
of unengaged presentation
{risk of cord prolapse}.
(III-B)
After amniotomy, oxytocin should be commenced
early in order to establish labour.
(III-B)
Amniotomy alone is not recommended for IOL.
(WHO, 2011)
Aboubakr Elnashar

46. •• Amniotomy creates a commitment to delivery
and should be
performed when the indication is convincing
documented.
Aboubakr Elnashar

47. 2. Oxytocin
Example of low-dose protocol:
Initial dose of oxytocin..................................1 to 2 mU/min
Increase interval......................................................30 minutes
Dosage increment....................................................1 to 2 mU
Usual dose for good labour.........................8 to 12 mU/min
Maximum dose before reassessment.................30 mU/min
Example of high-dose protocol:
Initial dose of oxytocin..................................4 to 6 mU/min
Increase interval............................................15 to 30 minutes
Dosage increment...........................................4 to 6 mU/min
Usual dose for good labour.........................8 to 12 mU/min
Maximum dose before reassessment.................30 mU/min
Aboubakr Elnashar

48. Term PROM
Oxytocin should be considered before expectant
management.
(I-A)
If GBS +ve: start oxytocin as early as possible
after ROM in order to establish labour within 24 h.
(III-B)
Both high- and low-dose oxytocin may be
considered.
(III-B)
Aboubakr Elnashar

49. Because of the various concentrations, oxytocin
infusion rates should always be recorded in
mU/m rather than mL/h.
(III-L)
Oxytocin induction maybe considered in the
hospital setting of vaginal birth after CS.
(II-3B)
Aboubakr Elnashar

50. Practice Points
•• With PROM, oxytocin stimulation is more
effective than expectant management: reduce
maternal infection and increase vaginal deliveries
within 24 h, but it may increase CS rate.
•• In the setting of PROM, women preferred
oxytocin induction over expectant management.
•If PG are not available, IV oxytocin alone should
be used for IOL
(WHO, 2011)
Aboubakr Elnashar

51. 8. MONITORING
1. CTG: When contractions begin
Once CTG is confirmed as normal: intermittent auscultation
2. Bishop score
-6 h after vag PGE2 tab or gel, or 24 h after vag PGE2
controlled-release pessary
-If a woman returns home after insertion of vag PGE2 tablet or
gel, she should be asked to contact her obstetrician:
when contractions begin
if she has had no contractions after 6 h.
3. Maternal & fetal monitoring
Once active labour is established
Aboubakr Elnashar

52. 9. PAIN RELIEF
Inform woman:
•IOL is likely to be more painful than spontaneous
labour.
•The availability of pain relief options :
Simple analgesics
Epidural analgesia.
Support
labour in water .
Aboubakr Elnashar

53. 10. COMPLICATIONS
I. Ut hyperstimulation (tachystole with FHR
changes).
Tocolysis should be considered
Betamimetics are recommended
Aboubakr Elnashar

54. II. Failed induction
Define:
labour not starting after one cycle of tt
Management
Support.
CTG
Maternal condition
a. Further attempt to induce labour or
b. CS
Aboubakr Elnashar

55. III. Cord prolapse
Prevention:
•Before induction, engagement of the presenting part
should be assessed.
•Palpate for umbilical cord presentation during the
preliminary vaginal examination
•Avoid dislodging the baby’s head.
•Amniotomy should be avoided if the baby’s head is
high.
Aboubakr Elnashar

56. IV. Uterine rupture
If uterine rupture is suspected during IOL:
emergency CS
Aboubakr Elnashar

57. Thank
You
Aboubakr Elnashar