induction of labour , its indicaions , contraindications , methods , drugs , amniotomy, and other methods , and complications.

2.  Induction of labor is the artificial
initiation of labour mechanism prior to its
spontaneous onset.
 Augmentation refers to stimulation of
spontaneous contractions that are considered
inadequate because of failed cervical dilation
and fetal descent.

3.  Broadly speaking, an IOL is performed when
the risks to the fetus and/or the mother of the
pregnancy continuing exceeds those of
bringing the pregnancy to an end.

4.  Prolonged pregnancy
 Fetal growth restriction
 Pre-eclampsia and other maternal hypertensive disorders
 Prelabour rupture of membranes
 Chorioamnionitis
 Placental abruption
 Diabetes mellitus
 Twin pregnancy continuing beyond 38 weeks
 Maternal iso-immunization
 Fetal malformations incompatible with life
 ‘Social’ reasons Risk of rapid labor, distance from hospital,
psychosocial indications

5.  Prolonged pregnancy
 There is evidence that pregnancies extending
beyond 42 weeks gestation are associated with a
higher risk of stillbirth, fetal compromise in labour,
meconium aspiration and mechanical problems at
delivery.
 Prelabour rupture of membranes
 The longer the time delay between membrane
rupture and the delivery of the baby, the greater the
risk of ascending infection (chorioamnionitis) and
neonatal infectious morbidity

6.  Preeclampsia ≥ 37 weeks
 Significant maternal disease not responding
to
 treatment
 Significant but stable antepartum
hemorrhage
 Chorioamnionitis
 Suspected fetal compromise

7. 1. Major degree of Placenta praevia
2. Vasa praevia
3. Previous classical uterine incision
4. significant prior uterine surgery (e.g. full
thickness myomectomy)
5. Cephalopelvic disproportion because of
malpresentation or abnormal pelvic bone
structure.
6. Active genital Herpes infection ,
7. Invasive cervical carcinoma ,
8. Hypersensitivity to cervical ripening agents

8.  to quantify how far this process had
progressed prior to the IOL. High scores (a
‘favourable’cervix) are associated with an
easier, shorter induction that is less likely to
fail. Low scores (an ‘unfavourable’ cervix)
point to a longer IOL that is more likely to fail
and result in Caesarean section.

10.  women with a score of > 9 were equally likely
to deliver vaginally whether induced or allowed
to labour spontaneously and could be
delivered within 4 hours and most within 24
hours.
 A favourable preinduction Bishop score of > 6
successful vaginal delivery.
 The rate of failed induction was higher for
women with a very low Bishop score (0 to 3)

11.  Time of induction: Preferably early
morning
 Place of induction: where facility for
intervention and fetal monitoring is
available
 Preparation of Patient : Enema may be
given to patients prior to induction

12.  Maternal
 To confirm the indication
 Exclude the contraindication
 Assess Bishop score
 Assess pelvic adequacy
 Fetal
 Ensure fetal gestational age
 Ensure fetal presentation
 Confirm fetal well being

15. Prostaglandins
PGE1
Misoprostol
PGE2
Dinoprostone

16. Local applications of PGs causes cervical ripening by:
•Alteration of extracellular grounds substance of cervix
by increasing collagenase , elastase,
glycosaminoglycans ,
•Relaxation of smooth muscle of cervix

17.  Previous uterine scar is relatively
contraindicated
 Established uterine activity,
 asthma,
 severe hepatic or renal impairment ,
 known hypersensitivity to prostaglandins ,
 active vaginal bleeding

18. Intracervical PGE2 gel:
•Contains 0.5 mg of PGE2
•Bring the gel to room temperature before use and
instill in the cervical canal below the internal os
•The patient lies supine for 15-30 minutes after the
insertion .
•If no response occurs in one use a repeat insertion
may be required after 6 hours .
•Maximum of 1.5 mg 24 hours.
•If required oxytocin is to used only after 6- 12
hours of the last insertion.

19. Intravaginal PGE2 gel:
•Vaginal PG E2 gel : - contains 2.5 mg PGE2
- 2 doses 6 hours apart are used
•Vaginal controlled release insert : (Cervidil )
- 10 mg insert which releases 0.3 mg / hr of the
prostaglandin
- The patient should lie supine for 2 hours following the
insertion
- The insert is to be removed after 12 hours or when
active labor begins or in case of hyperstimulation.

20. •Intracervical use is technically more difficult
•Vaginal route ( gel or insert ) is superior to
intracervical route for cervical ripening but it causes
higher uterine activity
•The overall incidence of hyperstimulation is 4.8% -
same as with oxytocin.
•the incidence is more when used in active labor
(12.5 %)
• more with vaginal gel (5%) than intracervical (1%)
and least with controlled release insert

21. •Mioprostol is a synthetic PG E1 analogue which has been used as a
gastric cytoprotective agent since 1988 for patients of peptic ulcer.
•How to give Misoprostol?
 Dose of 25 micro gram every 4hrly to a maximum of 6 doses can
be given intravaginally into the posterior vaginal fornix ,
 Dose of 50micro gram every 3hrs to a maximum of 6 doses can be
given orally
 Dose of 25micro gram every 2hrs can be given orally
 Other routes of administration:
1.Buccal
2.rectal
3.sublingual

22. oral
 Less effective when
compared to vaginal PG
 Chance of fetal
distress is less
vaginal
 More effective when
compared to oral route
 Chance of fetal
distress is more

23.  Cheap & cost
effective
 Stable at room temp
 Costly
 Need refrigeration

24.  It’s synthetised in the hypothalamus.
 Half life of 3-4 mins and duration of
action 20 mins
 Oxytocin is used very commonly to
achieve induction of labour.
 The objective is to produce uterine
contractions that effectively produce
cervical change and descent of the
presenting part.

25. 1.It acts through the receptor and voltage
gated calcium channelmyometrial
contraction
2.It stimulates amniotic and decidual PG
production
Routes of administration:
 I.V infusion
 Intra muscular
 Buccal tablets
 Nasal spray

26. 10 –20 units are dissolved in 1000 ml of balanced salt solution ( Ringer
Lactate solution or Normal saline ) making it as 10-20 mu/ml and it is
preferable to give it through an infusion pump. Further increments are
made according to the low dose or high dose protocol given below :
Regimen Starting dose Incremental dose Dosage interval
(mU/ min) (mU/ min) (min)
Low Dose 0.5 – 1 1 30-40
1 –2 2 15
High dose 6 6 15
6 6, 3*, 1* 20-40
* The incremental increase is reduced to 3 mU/min in presence of
hyperstimulation and reduced to 1mU/min with recurrent
hyperstimulation .

27.  Oxytocin should be used with extreme
caution in multiparous women.
 Oxytocin should not be started for six
hours following administration of vaginal
prostaglandins
 Oxytocin should be used with caution
with a previous uterine scar.
 Oxytocin should always be used in
conjunction with the partogram once in
established labour.

28.  Uterine hyperstimulation:
(>5 contractions in 10mins each lasting for
1min)
 Water intoxication:It due to
anti diuretic action(30- 40IU/ml)
.Manifested by hyponatremia ,confusion
,coma
 Fetal distress
 Uterine rupture

29.  When there is hyperstimulation of uterus
 Fetal distress
 Signs of water intoxication.(Occurs with
the max dose of 100 IU in the interval of
less than 24hrs .clinically Manifested
after 24hrs)

30.  Safe,cheap and
effective
 Unstable at room temp
 Easily titrable
 Chance of fetal
distress is less
 More effective near
term
 Less effective with less
Bishop score and in
IUD
 Tablet form is cheap&
effective
 Stable at room
temp,PGE1-unstable
 Not titrable
 Chance of fetal
distress is more
 Effective irrespective
of gestation

31. Ideally amniotomy or ARM is performed when the cervix is effaced and
2 cm dilated but it can be performed with minimal cervical dilatation.
Methodology of ARM:
•Auscultate the FHR
•Evaluate the cervix and station of head. The cervix should be well
applied to the head
•Introduce two fingers into the cervix , sweep away the membranes
from the cervix
•Pass an Allis or Kocher’s forceps in between the groove of your two
fingers , hook the membranes and rupture them ; look for the clarity of
liquor

32. •Risks: Cord prolapse
FHR deceleration
Bleeding through vasa praevia
Fetal injury
Maternal and fetal infection
Advantages: - It shortens duration of labor
- Allows for early diagnosis of meconium
staining of amniotic fluid,specially in high risk
pregnancy
- Facilitates invasive fetal monitoring

33.  Its possible only if the cervix has ripened to
allow the passage of one finger.
 Insertion of a gloved finger through the cervix
and it’s rotation against the wall of the uterus.
 Its strips off the chorionic membrane from
the underlying decidua releases PGS
 Placenta previa should be excluded,
 Accidental amniotomy is a disadvantage
 and can be uncomfortable for the woman.

35.  For a single balloon catheter, a no. 18 Foley is introduced
under sterile technique into the intracervical canal past
 the internal os. The bulb is then inflated with 30 to 60 cc of
water. The catheter is left in place until either it falls out
spontaneously or 24 hours have elapsed.
 Low-lying placenta is an absolute contraindication to the
use of a Foley catheter.
 Relative contraindications to its use include antepartum
hemorrhage, rupture of membranes, and evidence of lower
tract genital infection.

36.  There is an increased need for oxytocin
when Foley catheters are used.
 In comparison with prostaglandins, Foley
catheters cause much less uterine
tachysystole.
 Foley catheters are not associated with
increased rates of maternal infection
(chorioamnionitis and endometritis) or
neonatal infection.

37.  Hygroscopic dilators: These are
 natural or synthetic rods inserted
 through the cervical os and left in
 situ for a particular time wherein
 because of their osmotic properties they
absorb endocervical and local tissue fluids .
This swelling causes a controlled dilatation of
the cervix along with releasing
prostaglandins.

38. Castor Oil
 It is known to stimulate gut peristalsis and
labor most likely is stimulated due to release
of prostaglandins.
 Other methods like : Nitric Oxide ,
Mifepristone (an anti-progesterone),
Intercourse , Herbal supplements, Acupuncture
and TENS( Transcutaneous electric nerve
stimulation)

39.  1.Greater pain in labour
 2. Long labours augmented with oxytocin
predispose to postpartum haemorrhage
secondary to uterine atony.
 3. Cord prolapse If ARM is performed while
the fetal head is high then cord prolapse may
occur, precipitating the need for emergency
delivery by Caesarean section.

40.  4. Uterine hyperstimulation and fetal compromise :
Fetal compromise is more common during induced labours
and this is due to uterine hyperstimulation caused by the
injudicious use of prostaglandins and oxytocin.
 A contraction frequency of 5 per 10 minutes should be
treated by stopping the oxytocin and the administration of
a tocolytic drug, most commonly the subcutaneous
injection of the β2-agonist terbutaline.
 Uterine hyperstimulation may precipitate a fetal
bradycardia and the need for emergency Caesarean
section if the fetal heart rate fails to resolve promptly.

41.  5. Greater risk of uterine rupture:Women with a
previous Caesarean section scar, or some other form of
old uterine injury, are at greater risk of uterine rupture if
they are induced. The risk of scar rupture increases from
one in 200 in a spontaneous labour, to as high as one in
70 if induction of labour is performed using prostaglandins.
 6. Increased need for Caesarean or instrumental
delivery : The rates of instrumental delivery and
Caesarean section are higher following induction, and not
all of this increase can be explained by the underlying
problems which necessitated the induction in the first
place.

42.  this is said to have occurred if an ARM is still
impossible after the maximum number of
doses of prostaglandin have been given,
 or if the cervix remains uneffaced and less
than 3 cm dilated after an ARM has been
performed and oxytocin has been running for
6–8 hours with regular contractions.

43.  When an induction fails, the options include
 attempting induction again at some point in the
future,
 or performing a Caesarean section.
 Delaying delivery further is only acceptable if
there is no major threat to fetal or maternal
condition.This may be the case with a failed
social induction,for example.
 Failed induction in the setting of preeclampsia
or fetal growth restriction will usually
necessitate Caesarean delivery.

44.  during Induction of Labor,
 B enefits should be weighed,
 Risks should be assessed,
 Alternatives should be considered,
 N ecessity of intervention adjudged &
 D ecision should be taken accordingly
 BUT
 INJUDICIOUS USE of Labor Inducing agents should
be avoided