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Induction of Labor

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INDUCTION

OF LABOR
PRESENTED BY:
Ms. Bhagyashree Dash
Here starts
the lesson! M.Sc. Nursing 2nd year
Obstetric & gynecological Nursing
OBJECTIVES
Today’s lesson objectives are-

1. To learn about definition of induction of labor, it's indication and


contraindications.

2. To learn in details on various methods of induction of labor.

3. Also to know about augmentation of labor and research studies


related to induction of labor.
DEFINITION
“Augmentation of labor is the
process of stimulation of uterine
contractions (both in frequency and
intensity) that are already present
but found to be inadequate.”

“Induction of labor (IOL)


means initiation of uterine
contractions (after the period of
viability) by any method (medical,
surgical or combined) for the
purpose of vaginal delivery.”
Elective induction of labor means initiation of labor at term
pregnancy without any acceptable medical or obstetric indication. It
is done for the convenience of the patient, obstetrician or the
hospital.

Induction involves establishing cervical favorability, also called

• cervical ripening and

• stimulating contractions to induce active labor.


INCIDEN
CE
The incidence of induction
of
labor is 15-20% in the UK, 30-
38% in the USA and about 10% in
India. (PubMed, 2023)
INDICATIO
N
Maternal indications Fetal indications

1. Maternal diseases, e.g.: 1. Post maturity (pregnancy > 41 weeks)


(i) Diabetes mellitus 2. Fetal (intrauterine) growth restriction
(ii) Hypertensive diseases 3. Oligohydramnios
(iii) Autoimmune diseases, e.g. 4. Polyhydramnios
systemic lupus erythematosus 5. Rh-isoimmunization
(iv) Renal disease 6. Intrauterine fetal demise
2. Pre-labor spontaneous rupture of 7. Lethal fetal malformations
membranes 8. Corrected unstable lie
3. Pregnancy related conditions:
(i) Pre-eclampsia
(ii) Intrahepatic cholestasis of
pregnancy
(iii) Antepartum hemorrhage
CONTRA-
INDICATI
ONS
Contracted Previous CS or
Malpresentation
pelvis and CPD hysterotomy

Uteroplacental Active genital


Heart disease
factors herpes infection
High-risk
pregnancy with Elderly
Pelvic tumor
fetal primigravida
compromise

Umbilical cord Cervical


prolapse carcinoma
DANGERS OF
INDUCTION OF
LABOR
PARAMETERS ASSESSED PRIOR TO
INDUCTION
Maternal Fetal
 Psychological upset when  latrogenic prematurity
there is induction failure and  Hypoxia due to uterine
cesarean section is done dysfunction
 Tendency of prolonged labor  Prolonged labor
due to abnormal uterine
action
 Increased need of analgesia
during labor
 Increased operative
interference
 Increased morbidity
 Hazards related to individual
BISHOP
SCORE
 Bishop score is a pre-labour scoring system that
helps to assist in predicting whether induction of
labor will be required during parturition.
 It uses several clinically measurable parameters
to calculate a score.
 Given by Edward Harry Bishop in 1964 and
modified in 1991.
1. Field's 10 factor system
2. Burnett's Bishop's
Relationship of date of induction
modification
to EDD, patient's attitude
towards induction, estimated Maximum score of 2 is given to
size of fetus, presence of uterine each category. Effacement
contractions and recent increase instead of length is taken.
in vaginal discharge are
considered.
ASSESSMENT OF CERVICAL FAVORABILITY
Following parameters can be used for assessment of cervical favorability-

1. Cervical status

2. Ultrasound

3. Biochemical

4. Others
PRE-INDUCTION OF
CERVICAL RIPENING
 Induction may be indicated even when the cervix is
unfavorable or unripe (Bishop score <6. In these
cases, techniques for cervical ripening are utilized.

 Cervical ripening is the process of making cervix soft


and pliable by a series of complex biochemical
changes mediated by hormones.
METHODS
OF
CERVICAL
RIPENING
NON-PHARMACOLOGICAL
METHODS
 Sweeping ofSweeping of is
fetal membranes fetal membranes
also called stripping of membranes.
 IT’S digital separation of the chorioamniotic membranes from the wall of the
cervix and lower uterine segment.
 Outpatient procedure.
 Performed only if the cervix is dilated enough to insertion of a finger.
● The sweeping is done by
gently inserting a finger
through the open external
os into the space between
the membranes and the
lower uterine segment.
● The finger is then swept in a
circular motion through 360
degrees.
● Care is taken to keep the
finger close to the uterine
wall.
● The process strips the
amniotic membrane off the
lower uterine segment.
Mechanical method
 Transcervical Foley catheter

A #16 Foley catheter with a 30 mL bulb and with the


tip cut off is used & passed through the cervical canal,
past the internal os, and into the extra-amniotic space.
 Cervical, ripening is usually achieved with this method
and may also result in the onset of labor.
 Transcervical double balloon catheter

Double balloon catheters with one balloon


placed below and the other above the internal os are
available.
 The first (distal) balloon is inserted beyond the
internal os and inflated with 40 mL of saline, and
gentle traction is applied to the catheter.
 The second (proximal) balloon appears below the
external os and is inflated.
Complications of catheter
insertion for cervical
ripening
Rupture of Displacement of
membrane the presenting part

Febrile Significant vaginal


morbidity bleeding in women
with a low-lying
placenta
LAMINARI
A • Laminaria tents used for
pregnancy termination
rather than for preinduction
cervical ripening.
• They are hygroscopic
(absorb moisture).
• Laminaria are removed 12-
24 hours after placement.
PHARMACOLOGICAL
METHODS
Pharmacological agents available for cervical
ripening and labor induction currently include
prostaglandins and misoprostol.
Other pharmacological agents, including
oxytocin, are less commonly used.
PROSTAGLANDINS
 Prostaglandins are most commonly used for cervical ripening in an
unscarred uterus.
 Prostaglandins not only improve the cervical score and cause ripening,
they also initiate labor.
 The need for oxytocin to induce or augment labor is thus reduced.
 The commonly used prostaglandins are prostaglandin E2 (PG*E_{2}) and
prostaglandin E_{1}(PG*E_{1}) for prostaglandin regimens for cervical
ripening.
Intracervical gel Intravaginal insert
 Preloaded syringe comes  This contains 10 mg of
with a plastic insertor,
dinoprostone in a small
which is placed into the
cervical canal under direct white polymer mesh sac
vision. and has an attached tape
 0.5 mg of the intracervical
that helps during removal.
gel administered into the
cervical canal every 6  It is left in the vagina until
hours up to a maximum of active labor starts or for 12
three doses in a 24-hour
hours.
period.
POTENTIAL
COMPLICATI
ON
METHODS
OF
INDUCTIO
N
OF LABOR
TRADITIO SURGICA COMBIN
NAL MEDICAL
L ED
 Castor oil
● PROSTAGLAN ● STRIPPING
 Acupuncture MEDICAL
DINS OF
 Herbal ● OXYTOCINS +
MEMBRANES
remedies SURGICAL
 Breast and
● AMNIOTOMY
nipple
stimulation
MEDICAL METHOD
 OXYTOCIN
 Octapeptide synthetic form.
 Oxytocin was the first poly-peptide hormone to
be sequenced and synthesized and
 won Vincent du Vigneaud a Nobel Prize in 1953.
 Oxytocin is the most common drug used for the
induction of labor.
 It is administered intravenously.
 It is not used orally
 In the presence of a ripe cervix,
induction of labor with oxytocin has
a high rate of success.
 If the cervix is not favorable cervical
ripening will improve the success of
induction.
 When oxytocin is administered,
uterine activity and fetal heart rate
must be continuously monitored.
Low-dose High-dose
regimens regimens
 Low dose of oxytocin  High dose of oxytocin
 Less frequent increases  More frequent dose increases
in dose (every 40 (every 20 minutes)
 Associated with shorter labor
minutes)
 Lower rates of cesarean
 Less occurrence of delivery for dystocia
uterine tachysystole and  Increased rates of uterine
associated fetal heart tachysystole with associated
rate changes fetal heart rate changes
SIDE EFFECTS OF OXYTOCIN

HYPONATREMIA HYPOTENSION NEONATAL


(WATER HYPERBLIRUBINEMI
INTOXICATION) A
SURGIC
AL
METHO
DS
ARTIFICAL RUPTURE OF
MEMBRANES (AMNIOTOMY)

It is of 2 types-
 Low rupture of the membranes (LRM)
 High rupture of the membranes
(HRM/ARM)
ARTIFICIAL RUPTURE OF MEMBRANE

 Mechanism of onset of labor: related with


(a)stretching of the cervix;
(b)separation of the membranes (liberation of
prostaglandins); and
(c)reduction of amniotic fluid volume.
 Effectiveness depends on:
(1)State of the cervix;
(2)Station of the presenting part.

 Advantages of amniotomy:
(a)High success rate;
(b)Chance to observe the amniotic fluid for blood or
meconium;
(c)Access to use fetal scalp electrode or intrauterine
pressure catheter or for fetal scalp blood sampling.
 Indications:
 Patient should be in bed
 Monitoring of uterine contractions
 Monitoring of fetal heart rate
 Monitoring of drug use (Oxytocin dose
increment/Repeat dose for PGs)
Immediate beneficial effects of
ARM
Lowering of the blood pressure in pre-eclampsia,
eclampsia.

Relief of tension in abruptio placentae and initiation of labor.

Relief of maternal distress in hydramnios.

Control of bleeding in APH.


LOW RUPTURE OF THE
MEMBRANES (LRM)
 It is widely practiced nowadays with high
degree of success.
 The membranes below the presenting
part overlying the internal os are
ruptured to drain some amount of
amniotic fluid.
 Contraindications:
i. Woman with HIV infection
ii. Woman with Group B Streptococcus infection
iii. It is preferably avoided in chronic hydramnios, as there is risk of
sudden massive liquor drainage.
COMBINED METHOD
The combined medical and surgical methods
are commonly used to increase the efficacy of
induction by reducing the induction-delivery
interval.
The oxytocin infusion is started either prior to
or following rupture of the membranes depending
mainly upon the state of the cervix and head brim
relation.
INDUCTI
ON OF
LABOR
ACTIVE MANAGEMENT OF LABOR
(Syn: Augmentation of labor)

Active management of labor was introduced


by O'Driscoll and his colleagues in 1968 at
National Maternity Hospital, Dublin.
The term "Active" refers to the active
involvement of the consultant obstetrician in the
management of primigravid labor.
ESSENTIAL COMPONENTS
Antenatal classes

After diagnosis of labor(admission)

One-to-one nursing care

Active involvement of the


consultant obstetrician
Amniotomy with Oxytocin
confirmation of labor augmentation

Delivery is
completed within 12 Epidural analgesia
hours of admission

Fetal monitoring
 Aim:
To expedite delivery within 12 hours
without increasing maternal morbidity and
perinatal hazards.
Active
management
of labor
Objective (a)Early detection of any
delay in labor;
(b)Diagnose its cause;
and
(c)Initiate management.
Advantages and Contraindications of
Active Management of Labor
Advantages Contraindications
• Less chance of dysfunctional labor  Presence of obstetric complication
• Shortens the duration of labor (<12
hours)  Presence of fetal compromise
• Fetal hypoxia can be detected
early  Multigravida (not a routine)
• Low incidence of cesarean birth
• Less analgesia
• Less maternal anxiety due to
support of the caregiver and
prenatal education.
RELATED
RESEARC
H
Prevalence, outcomes and associated factors of labor induction among women delivered
at public hospitals of MEKELLE town-(a hospital based cross sectional study)

AUTHOR:
 Garang Dakjur Lueth,
 Angesom Kebede &
 Araya Abrha Medhanyie

JOURNAL:
BMC Pregnancy and Childbirth volume 20, Article number: 203 (2020)

A hospital based cross sectional study was conducted on 346 laboring mothers who delivered
after induction of labor, from January 1st, to July 31st, 2017. Using structured questionnaire and
quota sampling techniques.

RESULT:
Out of 346, 244 (70.5%) delivered vaginally, 19 (5.5%) were instrumental deliveries and 83
(24%) by Cesarean section, induction was successful in 263 (76%) while the failure rate was 25
(7.2%).
All who failed induction (25) were delivered by cesarean section making a 3.3% contribution of
failed induction into the overall rate of the institutions cesarean deliveries during the study period.
Prolonged rupture of membranes was the commonest indication
Induction of Labour among Pregnant Women in the Department of Obstetrics and
Gynaecology in a Tertiary Care Centre

JOURNAL:
JNMA J Nepal Med Assoc. 2023 Sep; 61(265): 687–690.

Published online 2023 Sep 30. doi: 10.31729/jnma.8255


AUTHOR:

Siddhartha Kumar Yadav, 1 Indra Yadav, 1 Tarun Pradhan, 1 Sabita Jyoti, 2 and Rozy Yadav 3

A descriptive cross-sectional study was conducted among pregnant women in a tertiary care
centre from 3 February 2022 to 31 July 2022.

RESULT:
Among 1355 pregnant women, the prevalence of induction of labour was found to be 135 (9.96%)
SUMMA
RY
CONCLUSIO Induction of labor means
initiation of uterine contractions

N
(after fetal viability) for the purpose
of vaginal delivery.
There is rise in the incidence of
induction of labor globally (US:
23.4%, UK: 21%, Asian countries
12.1%, Sri Lanka: 35.5%)
Induction of labor should be
done when benefits of delivery to
either the mother or the baby
outweigh the risks of pregnancy
BIBLIOGRAPHY
1. Dutta DC. Textbook of Obstetrics:Induction of labor.9 th edition.Nepal:Jaypee
Publishers;2019.page no-487-493
2. Sharma JB. Textbook of Obstetrics:Induction of labor.New Delhi:Avichal Publishing
Company;2018.Page No.-230-237
3. Seshadri L,Arjun G. Essentials of Obstetrics: Induction of labor. New Delhi:Wolters
Kluwer;2016. Page No.-226-237
4. Editor. Bishop score and modified bishop score in obstetrics – medchrome
[Internet]. Available from:
https://medchrome.com/major/gynaeobstr/bishop-score-and-modified-bishop-score/
5. Lueth GD, Kebede A, Medhanyie AA. Prevalence, outcomes and associated factors
of labor induction among women delivered at public hospitals of MEKELLE town-(a
hospital based cross sectional study). BMC Pregnancy and Childbirth [Internet].
2020 Apr 9;20(1). Available from: https://doi.org/10.1186/s12884-020-02862-7
1. Yadav SK, Yadav I, Pradhan T, Jyoti S, Yadav RK. Induction of Labour among Pregnant
Women in the Department of Obstetrics and Gynaecology in a Tertiary Care Centre.
Journal of Nepal Medical Association [Internet]. 2023 Sep 1;61(265):687–90.
Available from: https://doi.org/10.31729/jnma.8255
2. Jacob A.Manual of Midwifery and Gynaecological Nursing:Induction of labor.4 th
Edition.New Delhi: Jaypee Publishcation;2019. Page no-430-432
3. Reeder, Martin, Koniak-Griffin, Raman A V, “Maternity Nursing-Family, New-born and
Women’s Healthcare”,20th edition, page no-343-348
4. Salhan S. Textbook of Obstetrics: Induction of labor.2 nd Edition. New Delhi: Jaypee
Publishcation;2019. Page no-252-258
5. Gary F. Williams Obstetrics: Induction of labor.23 rd edition. London: Mc Graw Hill
education; 1993. page no.-535-539
6. Diane M. Myles Textbook for Midwives: Induction of labor.3 rd edition. New Delhi:
University Press;2014. Page no.-237-242
7. Arulkumaran.S, Gopalan.S, Kumar. P; “Obstertrics & gynecology for post graduates,
universities press private limited, New Delhi; volume 2, 3 rd edition, 2009, page no-
518-528

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