INDUCTION OF LABOR
ADRIAN SETIAWAN,M.D.
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
FACULTY OF MEDICINE
UKRIDA
Introduction
Induction of labor is one of the most common interventions
practiced in modern obstetrics. It describes the process of
artificially ripening the cervix and stimulating uterine
contractions with the intention of precipitating the active
phase of labor, thus leading to progressive dilatation and
effacement of the cervix with the intention of achieving a
vaginal delivery.
Induction of labor should only be considered in situations
when the balance of risk are such that the mother and baby
will be safer if delivery occurs than if pregnancy is allowed
to continue and when vaginal birth is thought to be
appropriate route of delivery
Induction implies of contractions before the spontaneously
onset of labor , with or without ruptured membranes
Augmentation refers to stimulation of spontaneously
contractions that are considered inadequate because of
failed cervical dilatation and fetal descent.
In general, this limits induction to pregnancies of gestation
greater than the legal limits of viability usually 24 weeks
gestation
Indication
1.
Prolonged pregnancy
2.
PROM
3.
Fetal growth restriction
4.
Hypertension
5.
Oligohydramnion
6.
Diabetes
7.
Social/maternal request
8.
IUFD
Contraindication
1.
Macrosomia
2.
Multifetal gestation
3.
Severe hydrocephalus
4.
Malpresentation
5.
Non reassuring fetal status
6.
Uterine incision type
7.
Contracted or distorted pelvic anatomy
8.
Abnormal placentation
9.
Active genital herpes infection or cervical cancer
Methods of induction of labor
Non-pharmacological methods :
1.
Herbal compounds
2.
Castor oil
3.
Hot baths
4.
Enema
5.
Sexual intercourse
6.
Breast stimulation
7.
Acupuncture
8.
Transcutaneous nerve stimulation
Mechanical methods
1. Transcervical catheter
A foley catheter maybe placed through the internal cervical os.
This causes mechanical stretching of the cervical canal and
also release of endogenous prostaglandins and oxytocin.
2. Hygroscopic cervical dilators
Cervical dilatation can be accomplished using hygroscopic
osmotic cervical dilators. These devices called hygroscopic
dilators origins from the stems of Laminaria digitata or
Laminaria japonica a brown seaweed.
3. Membranes stripping for labor induction
It is a commonly used procedure by midwives and
obstetricians. It causes release of endogenous
prostaglandins from the membranes and the decidua. This
can stimulate uterine contractions as well as ripening the
cervix.
4. Artificial rupture of membranes (Amniotomy)
Amniotomy is a simple procedure, which can be used alone
for induction of labor if the membranes are accessible,
sometimes avoiding the need for pharmacological
intervention.
Amniotomy releases endogenous prostaglandins that can
initiate labor.
There are clinical situations where amniotomy alone may be
considered, such as in grand- multiparous women and
women with previous CS, where the risk of scar rupture with
prostaglandins and oxytocin are higher than if labor starts
spontaneously.
In HIV-positive women, amniotomy should be avoided, with
induction methods that allow the membranes to remain intact
for as long as possible preferred.
Pharmacological methods
1. Oxytocin
Oxytocin is a neuro hormone secreted by the posterior
pituitary. It stimulates the myometrium to contract, and also
causes decidual prostaglandin production.
The sensitivity of the uterus to oxytocin increases as
pregnancy progresses, following rupture of the membranes
and after prostaglandins.
For induction oxytocin (Syntocinon and Pitocin) is given
intravenously to allow the dose to be titrated against
contractions
Oxytocin can be used alone, in combination with amniotomy,
or following cervical ripening with other pharmacological or
non-pharmacological methods.
2. Prostaglandin E2
Local application of prostaglandin E2- Dinoprostone is
commonly used for cervical ripening. Its gel form available in a
2.5 ml syringe for intracervical application of 0.5 ml of
dinoprostone. Doses maybe repeated every 6 hours with a
maximum of three doses recommended in 24 hours.
Prostaglandin preparations should only be administered in or
near the delivery room and uterine activity and fetal heart rate
monitoring should be performed.
The side effects has been reported is tachysystole (defined as
6 contractions in a 10 minute period.
Contraindications to prostaglandin agents is general include
asthma, glaucoma or increased intraocular pressure.
3. Prostaglandin E1
Misoprostol, a synthetic prostaglandin E1 (Cytotec) that was
developed for the prevention of gastric ulcers, is less
expensive and easier to store than other prostaglandin
analogues.
It is commonly used in obstetrics for medical abortion,
cervical priming, induction of labor, and the management of
postpartum haemorrhage.
It can be given orally, vaginally or rectally, with higher plasma
levels occurring with oral administration. Misoprostol has
been used for the induction of labour since 1987
Misoprostol shortened the induction-to-delivery interval, but
is associated with a higher incidence of fetal heart rate
abnormality than PGE2, and this has limited its use.
The risk of hyperstimulation is dose-dependent, and so lower
doses should be associated with fewer problems.
Assessing suitability for induction of labor
Bishop Score
Success of labour induction is related to the state of the
cervix, and therefore it is very important to assess the
cervical status prior to induction of labor.
It has undergone several modifications over the years, and
the most widely used is Calders modified Bishops score
A Bishop score of 9 conveys a high likelihood for a successful
induction, with scores below 6 associated with high failure
rate, prolonged labor, and caesarean section.
A Bishop score of 4 or less identifies an unfavourable cervix
and maybe an indication for cervical ripening.
The Bishop scoring system remains the most costeffective method of evaluating the cervix before labor
induction, and most evidence suggests that newer and
more expensive techniques do not significantly improve
accuracy.
Cervical length measurement by ultrasound
Recently, there have been several studies that have
assessed the predictive accuracy of ultrasound for
successful labor induction.
A study comparing the performance of the Bishop score
and transvaginal ultrasonography in predicting
successful labor induction suggested that cervical length
is a better predictor than the Bishop score
A further study found that transvaginal measurement of
cervical length measurement is better tolerated than digital
examination for Bishop score assessment
Both cervical length and Bishop score seem to be useful
predictors of the need for CS delivery following labor
induction, with a cervical length of more than 20 mm at
labor induction an independent predictor of caesarean
delivery.
Intravenous Oxytocin Administration
The goal of induction or augmentation is to effect uterine
activity sufficient to produce cervical change and fetal
descent, while avoiding development of a nonreassuring fetal
status.
In general oxytocin should be discontinued if the number of
contractions persists with a frequency greater than 5 in a 10
minute period or seven in a 15 minute period or with a
persistent nonreassuring fetal heart rate pattern.
- Oxytocin Dosage
Low dose regimens 0.5 to 1.5 mU/min
High dose regimens 4 to 6 mU/min
The low-dose regimens currently recommended are not
associated with increased operative deliveries,
hypercontractility or precipitate labor compared to high-dose
regimens. Oxytocin should be delivered in a syringe drive or
infusion pump to avoid fluid overload and give accurate
dosage.
Regimen
Starting Dose
(mU/min)
Incremental
Increase
(mU/min)
Interval
(min)
Low Dose
0.5-1.5
2
1
15-40
4,8,12,16,20,25,30 15
High Dose
4
4.5
6
4
4.5
6
15
15-30
20-40
Interval between incremental dosing
Interval to increase oxytocin doses vary from 15 to 40 minutes
The Parkland Hospital protocol starting dose of oxytocin at 6
mU/min increases every 40 minutes
The university of Alabama protocol begins oxytocin at 2
mU/min and increases it as needed every 15 minutes to
4,8,12,16,20,25 and 30 mU/min
Maximal Dose
The maximal effective dose of oxytocin to achieve adequate
contractions in all women is different. Wen and colleagues
(2001) found that the likelihood of progression to a vaginal
delivery decreased at and beyond an oxytocin dosage of
36mU/min.
Risks associated with induction of labor
1. Side effects of prostaglandins
- Nausea, vomiting and diarrhoea,
- Vaginal discomfort with a feeling of warmth or irritation.
- Allergic reactions are very rare, but cases of bronchospasm
have been reported in women with asthma.
- A rise in temperature may be seen (especially with
misoprostol)
- Slight increase in the leukocyte count
2. Hyperstimulation
Uterine hyperstimulation can occur with administration of
prostaglandins and/or oxytocin.
The incidence of hypercontractility with or without fetal
heart rate changes on cardiotocography (CTG) ranges from
1 to 5%.
Signs and symptoms of hyperstimulation include:
five contractions or more in 10 min (or more than 10
contractions in 20 min) without CTG changes;
hypertonus, contractions lasting more than 120 s without
CTG changes
uterine hyperstimulation syndrome excessive uterine
activity (>4 contractions in 10 min) with a non-reassuring
CTG.
3. Uterine rupture
4. Failed induction
Conclusion
Induction of labor is an obstetric intervention that has
become established.
The misuse and mismanagement of the process is likely to
cause compromise to the mother and the fetus/newborn.
The decision to induce should not be taken lightly.
Considerable thought on the part of the obstetrician with
due consideration to indication, parity, cervical score and
other medical issues (e.g. caesarean scar) should help in
the appropriate decision-making.
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