Induction of Labor

Stephen C Busby, MD March, 2005

Case:

Maria is a 22 yo G2P1 Hispanic female whom you have been following over the course of her pregnancy. She is now at 40 1/7 weeks gestation by LMP. She has always had regular periods. Her first child was a term SVD without complications and this pregnancy has gone well also. She asks, How will I know when Im going into labor?
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How a pt can know when labor is beginning:

As opposed to Braxton-Hicks Contractions that are usually felt anterior and in the groin, true contractions usually start in the back and radiate to the front. True contractions usually become regular and increasingly stronger and closer together. Walking causes them to get stronger and laying down generally does not relieve them. A pts water breaking is sometimes her first sign. If the pt thinks any of this is happening, she should call her doctor or come in to be checked.
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What else goes into the assessment?

Cervical changes (dilation, position, effacement, consistency, and station) all combine with the pt history of contractions as a sign of the beginning of labor. This will be further discussed, but generally a pt having contractions will be admitted for labor when cervical dilation is >3cm. If the cervix is closed-3 cm, a trial of walking for 1-2 hours is often tried, though walking itself hasnt been shown to increase rate of cervical dilation. Next Slide

Case:

Maria patiently listens to your explanation, but still seems uncomfortable and concerned. She asks, Are you sure everything is ok with the baby? What are some reasons for a pregnancy to extend beyond 40 weeks?
To Answer

Causes of Post-date Deliveries

Gestational Diabetes CPD, Macrosomia Inaccurate dating Most often, cause is unknown

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Case:

Our pt had EDC by LMP that was 9 days later than the EDC by an 18 week U/S. How do you know which date to go by?

A. Always go by the U/S it is more accurate. B. An U/S in the 2nd trimester is more accurate than LMP, but not in the 1st trimester. C. If the EDC by LMP differs by > 5 days by 1st trimester U/S or 14 days by 2nd trimester U/S, then use the U/S dates. D. Always use the LMP dates if the woman has regular periods. To Answer

Determination of EDC

Answer C: If the U/S was done in the 1st trimester, and the difference between dates is 5 or less days, you stay with the LMP dates. If the U/S was done in the 2nd Trimester, and the difference is 14 or less days, you stay with the LMP dates. Otherwise, the U/S dates are used.
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Case:
Marias EDC has been (correctly) determined by her LMP. This is a normal pregnancy that has progressed beyond the due date. What do you do with her at this point?
A Get an U/S to check fetal size and position. B Schedule for induction.

C Schedule for NST. D Just do a physical exam and see her back in

a week.

Incorrect.
A. It is not necessary to do a huge workup for a pt only 1 day overdue. This occurs often. B. One day overdue is not an indication for induction. C. Perinatal morbidity rises after the due date, but there are no studies that show benefit of NST from 40-42 weeks. However, expert opinion suggests biweekly NST and AFI (or just a BPP) after 41 weeks.
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Correct!

Yes, you should do a physical exam on the pt, and see her back at 41 0/7 weeks if possible. If you cant see her in the first couple days of the 41st week, then schedule an NST and U/S for AFI (just order BPP).
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Case:

The pt returns to clinic a week later and nothing has happened. She is now at 41 1/7 weeks gestation and begging you to deliver her baby. Is an induction indicated?

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Absolute Indications for Induction

Preeclampsia/eclampsia

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Absolute Indications for Induction

Preeclampsia/eclampsia Pregnancy induced HTN

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Absolute Indications for Induction

Preeclampsia/eclampsia Pregnancy induced HTN Maternal medical problems: DM, chronic renal dz, or pulmonary dz

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Absolute Indications for Induction

Preeclampsia/eclampsia Pregnancy induced HTN Maternal medical problems: DM, chronic renal dz, or pulmonary dz Chorioamnionitis

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Absolute Indications for Induction

Preeclampsia/eclampsia Pregnancy induced HTN Maternal medical problems: DM, chronic renal dz, or pulmonary dz Chorioamnionitis Nonreassuring fetal testing

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Absolute Indications for Induction

Preeclampsia/eclampsia Pregnancy induced HTN Maternal medical problems: DM, chronic renal dz, or pulmonary dz Chorioamnionitis Nonreassuring fetal testing IUGR
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Absolute Indications for Induction

Preeclampsia/eclampsia Pregnancy induced HTN Maternal medical problems: DM, chronic renal dz, or pulmonary dz Chorioamnionitis Nonreassuring fetal testing IUGR Postdates pregnancy
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Absolute Indications for Induction

Preeclampsia/eclampsia Pregnancy induced HTN Maternal medical problems: DM, chronic renal dz, or pulmonary dz Chorioamnionitis Nonreassuring fetal testing IUGR Postterm pregnancy (defined at or after 42 0/7 weeks) Placental abruption Next Slide

Gabbe: Obstetrics Normal and Problem Pregnancies, 4th ed., 2002, Table 13-4

Relative Indications for Induction:

Chronic HTN

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Relative Indications for Induction:

Chronic HTN Gestational Diabetes

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Relative Indications for Induction:

Chronic HTN Gestational Diabetes Logistic factors such as risk of rapid labor and distance from hospital

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Relative Indications for Induction:

Chronic HTN Gestational Diabetes Logistic factors such as risk of rapid labor and distance from hospital Premature rupture of membranes

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Relative Indications for Induction:

Chronic HTN Gestational Diabetes Logistic factors such as risk of rapid labor and distance from hospital Premature rupture of membranes Fetal macrosomia

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Relative Indications for Induction:

Chronic HTN Gestational Diabetes Logistic factors such as risk of rapid labor and distance from hospital Premature rupture of membranes Fetal macrosomia Fetal demise

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Relative Indications for Induction:

Chronic HTN Gestational Diabetes Logistic factors such as risk of rapid labor and distance from hospital Premature rupture of membranes Fetal macrosomia Fetal demise Previous stillbirth Next Indication

Relative Indications for Induction:

Chronic HTN Gestational Diabetes Logistic factors such as risk of rapid labor and distance from hospital Premature rupture of membranes Fetal macrosomia Fetal demise Previous stillbirth Fetus with major congenital anomaly Next Indication

Relative Indications for Induction:

Gabbe: Obstetrics Normal and Problem Pregnancies, 4th ed., 2002, Table 13-4

Chronic HTN Gestational Diabetes Logistic factors such as risk of rapid labor and distance from hospital Premature rupture of membranes Fetal macrosomia Fetal demise Previous stillbirth Fetus with major congenital anomaly Unexplained oligohydramnios Next Slide

So, is induction indicated for an otherwise normal pregnancy?

Classically, the gestation at which induction was recommended is 42 weeks (postterm pregnancy). However, more recently, any pregnancy lasting longer than 41 weeks is considered a candidate for induction.
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Case:

Because Maria is in her 41st week, induction may be indicated. Before you answer her question, you consider whether she has any contraindications to induction. Which of these is an absolute contraindication to induction?

A. A Grandmultiparity B. B Active genital herpes C. C Fetal macrosomia, or D. D Gestational hypertension

Answer B is correct.

Genital herpes is an absolute contraindication. Grand multiparity and macrosomia are relative contraindications. Answer D, Gestational HTN, is not a contraindication for induction.
Click here for a list of Contraindications

Contraindications
Absolute:

Relative:

Active genital herpes Serious maternal chronic conditions Absolute CPD (as in pelvic deformities) Malpresentation (transverse or oblique) Extreme fetal compromise Cord prolapse Placenta or vasa previa

Cervical carcinoma Grandmultiparity Uterine overdistention (polyhydramnios or multiple gestation) Malpresentation (breech) Fetal Macrosomia Low-lying placenta Unexplained vaginal bleeding Cord presentation

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Gabbe: Obstetrics Normal and Problem Pregnancies, 4th ed., 2002, Table 13-5

Case:

You do a physical exam on her, focusing on the pelvic exam. Examination of the cervix is essential in guiding you to choose a method of induction.

Heart: RRR, 1/6 SEM Lungs: CTAB Fundus: 41 cm External Genitalia: No lesions FHTs: 150s Vertex presentation by Leopolds, no contractions Cervix: 1/20/-2, posterior and medium consistency

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Case:

No physical abnormalities are noted but you think she may need cervical ripening prior to induction. What might help you decide?

Answer

Bishop Score
Assessment Dilation Score (cm) Effacement (%) Fetal Station Consistency Position

0 1 2 3

0 1 to 2 3 to 4 5 to 6

0 to 30

-3

Firm Medium Soft

Posterior Mid Anterior

40 to 50 -2 60 to 80 -1, 0 90 to 100 +1, +2, +3

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Case:

Marias cervix is not compatible with induction of labor as evidenced by a Bishop score of 3. The ACOG recommends a Bishop score of > 6 before considering a cervix favorable for Induction. She will therefore need cervical ripening. How many methods of cervical ripening can you list?
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Methods for Cervical Ripening and Induction of Labor, Tenore, JL. AFP, Volume 67, May 15, 2003

Methods of Induction
Nonpharmacologic Mechanical Surgical

Pharmacologic
Click on each button to review specific methods of cervical ripening.

Nonpharmacologic Agents

Herbal Supplements, Castor oil, hot baths, and enemas havent been shown to be of use. Sexual intercourse is sometimes recommended, as the cervix is mechanically stimulated and semen contains prostaglandins responsible for ripening. Only one small study has shown this, others have not. Breast stimulation has been shown to cause a release of oxytocin from the pituitary gland, but no studies have supported this. Accupuncture has been brought up as a method of cervical ripening, but there are no RCTs supporting this.

Methods for Cervical Ripening and Induction of Labor, Tenore, JL. AFP, Volume 67, May 15, 2003

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Mechanical Dilators:

Methods for Cervical Ripening and Induction of Labor, Tenore, JL. AFP, Volume 67, May 15, 2003

Hygroscopic Dilators: absorb fluids and expand within the endocervix, causing constant, controlled mechanical pressure. Balloon Dilators: Foley catheter or specifically designed balloon device is placed into the endocervix. Balloon is filled with water at a constant rate to produce dilation. Risks: these methods have an increased risk of infection, bleeding, ROM, and placental disruption.
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Surgical Methods:

Stripping of the Membranes: Causes mechanical dilation as well as increases in phospholipase A2 and Prostaglandin F2a. Associated with increased rate of normal deliveries when used with low-dose oxytocin. Amniotomy: causes an increase in local prostaglandins. Not supported by evidence, and rarely used for cervical ripening.
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Methods for Cervical Ripening and Induction of Labor, Tenore, JL. AFP, Volume 67, May 15, 2003

Pharmacologic Agents

Cervidil: prostaglandin analog that can be inserted into the cervix. It has a string attached and can be easily removed if necessary. Can cost up to $200. Cytotec: synthetic PGE1 effective in cervical ripening, although not labeled by FDA for that purpose. Cost is less than $1. Uterine hyperstimulation is the major side effect of both of these meds. Therefore, Cervidil is used often despite its cost, as it can be quickly and easily removed.
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Case:

Maria is thrilled to hear that you will be inducing her labor. You call the OB floor and arrange for her to be induced the day after tomorrow.

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Case:

On the big day, Maria arrives and her cervical exam is unchanged. You decide to go with Cervidil, placing it into the cervix. In 2 hours, Marias cervix is now 4cm, 50% effaced, 1 station, soft, and mid position. One hour later, you are called by the nurse because she thinks the pt is having uterine hyperstimulation. How would you define this? A B C D
Contractions Contractions Contractions Contractions closer closer closer closer than than than than q1, q2, q1, q2, lasting lasting lasting lasting >60 >60 >90 >90 sec sec sec sec

Answer

Hyperstimulation

Defined as Contractions more often than q2 minutes or lasting longer than 90 seconds each, with accompanying FHR changes (decels). Options: removal of Cervidil, tocolysis if necessary.
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Case:

You continue to watch the strip and Maria has had 2 contractions, 1 minute apart, lasting 90 seconds. What are your options?

What should you do?

For hyperstimulation, either:

Stop induction/augmentation medications: remove Cervidil! Try to stop contractions: SQ or IV Terbutaline.

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Case:

In two hours the cervical exam is now 5cm/50%/-2, soft and midposition. She is contracting every 3-10 minutes on the monitor. Which of these is NOT a good option for management? A Do nothing Start Pitocin B C Amniotomy Start Cytotec D

Answer:

Depending on the situation, any of the 1st three choices are appropriate: no change in plan, start Pitocin, or amniotomy. It would not be wise to try cytotec as we have already had trouble with hyperstimulation. You perform an AROM and decide to start her on Pitocin as the Bishop score is now 9, and you can officially consider the cervix ripe.
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Pitocin

Pitocin is a synthetic oxytocin which stimulates uterine contractions by increasing intracellular calcium levels. The greatest risks of Pitocin include uterine rupture and placental abruption. For this reason, continuous FHR monitoring is used.
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Pitocin

Oxytocin is usually given per a protocol that varies by hospital. The dose can be titrated up or down to adjust the rate of contractions. At MUSC, the protocol starts Pitocin at 1 mU/minute and increases by 1 mU/min every 20 minutes until contractions are 2-3 minutes apart, or lasting 60 to 90 seconds. The max protocol dose is 20 mU/minute.
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Case:

Finally, after 3 more hours, you deliver an 8lb 5oz baby boy with apgars of 9 and 9. End of case.

See References

References
1. Methods for Cervical Ripening and Induction of Labor, Tenore, JL. AFP, Volume 67, May 15, 2003 2. Current Trends in Cervical Ripening and Labor Inductin, Harman, JH and Kim, A. AFP, Volume60, August 1999 3. ACOG Releases Report on Dystocia and Augmentation of Labor, Ressel, GW. AFP, Volume 69, March 1, 2004 4. Gabbe: Obstetrics Normal and Problem Pregnancies, 4th ed., Churchill Livingstone, Inc. 2002 5. Normal Labor and Delivery, Rakel: Textbook of Family Practice, 6th ed., WB Saunders Company 2002, pp 542-544 6. How Will I Know if Im in Labor? DFM Handout, Bolane, JE 7. Postdate Pregnancy, e-medicine, Paul T Wilkes, MD, August 8, 2002

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