Induction and

Augmentation of
Labor
Definitions
Induction of labor: is the artificial
stimulation of uterine contractions before
the spontaneous onset of true labor at 28
or more weeks of gestation to achieve
vaginal Delivery
Augmentation of labor- artificial
stimulation of uterine contractions in
cases of inefficient uterine contractions to
attain required efficiency to effect
delivery
Induction and augmentation of labor can
be achieved through medical and surgical
means or a combination of both
 Induction and augmentation interventions
incur maternal and fetal risks and should be
institute with clear medical indications and
after informed maternal consent
IndicationsofInduction
Labor may be induced for either
maternal or fetal indications.
Induction of labor is undertaken when the
following criteria are met :
Continuing the pregnancy is believed to
be associated with greater maternal or
fetal risk than intervention to deliver the
pregnancy, and
There is no contraindication to vaginal
birth .
Indications for Induction of Labor
Maternal Fetal
Intrauterine fetal death Congenital anomaly
Pre-eclampsia/Eclampsia incompatible with life
Chronic hypertensive RH Isoimmunization
disease Fetal growth restriction
APH (placental abruption) Post term pregnancy
PROM Diabetes mellitus in
Chronic renal disease. pregnancy
Severe cardiac disease. Abnormal fetal well being
DM tests suggesting chronic
Chorioamnionitis intrauterine asphyxia

Indications are classified as maternal and fetal based on the

predominant reason for termination.
In most cases maternal and fetal indications overlap and may
be difficult to classify as maternal and fetal.
Pre requisites for labor induction
Valid indication
Obtain informed consent of the mother
Assure fetal maturity --> 39 completed weeks or
fetal lung maturity tests
Rule out contraindications for vaginal delivery
Assess pelvic adequacy
Assess favorability of cervix by the Bishops Score
Assess presentation ( vertex) and fetal size
Induction to be conducted mostly as an elective
planned procedure with maternal preparation
hemoglobin determination, NPO except fluids etc
Sometimes emergency inductions may also need to
be conducted due to obstetric emergencies such as
eclampsia and abruptio placenta
Contraindications to induction of labor
Fetal distress acute or chronic asphyxia
Gross cephalopelvic or feto pelvic
disproportion
Gross contracted pelvis
Malpresentations
Transverse and oblique lie fetal lie,
Breech with contraindication for vaginal deliver (e.g., footling,
extended neck),
Brow presentation,
Face with mento posterior,
Fundal uterine scars
Multifetal gestations
Uterotonics hypersensitivity
 Absolute
Fetal distress acute or chronic asphyxia
Gross cephalopelvic of feto pelvic disproportion
Gross contracted pelvis
Malpresentations
Fundal (upper uterine segment) uterine scars
2 or more lower uterine segment previous scar
Active genital herps, invasive cervical cancer, major degree
placenta previa, pelvic tumor obstructing the birth canal,
extensive genital wart
Uterotonics hypersensitivity
Relative:-
Multifetal gestations
Grand multiparity
Macrosomia
One lower uterine segment previous scar
Types of induction
Elective planned procedure:- to be
conducted mostly with maternal preparation
Hbn determination, NPO except fluids
Emergency inductions:- conducted due to
obstetric emergencies such as severe
preeclampsia/ eclampsia and abruptio
placenta, ruptured membranes with
chorioamnionitis
Timing of induction:- the point at which
the benefits to the mother &/or the fetus
are greater if the pregnancy is interrupted
than continued & is gestational age
dependent
Predicting a successful induction
Cervical status is one of the most important factors for
predicting the likelihood of successfully inducing labor.
Cervical examination should be performed before
initiating attempts at induction.
The modified Bishop score is the system most commonly
used in clinical practice .
This system tabulates a score based upon the
station of the presenting part and four
Xtics of the cervix: dilatation, effacement,
consistency, and position.
The Bishop score appears to be the best
available tool for predicting the likelihood
that induction will result in vaginal delivery.
Cervical dilatation was the most important
element of the Bishop score .
The Bishop Score
Parameter 0 1 2 3
Cervical dilatation Closed 1-2 3-4 >5
Cervical effacement 0-30% 40-50% 60-70% >80%
Cervical position Posterior Midposition Anterior _
Cervical Firm Medium Soft _
consistency
Fetal station -3 -2 -1,0 +1,+2
TheBishop score indicates the ripening of the cervix for labor
indirectlyindicatingthepossibilityofsuccessofaninduction.
Scores > 9/13 indicate a ripe cervix;
5-8 intermediate cervix and
< 4 an unripe cervixandahigh probability of unsuccessful
induction.
Cervical Ripening
is a complex process that results in physical
softening and distensibility of the cervix, ultimately
leading to partial cervical effacement and dilation
Oxytocin is less successful for labor induction
when used in women with uneffaced and
undilated cervices. Therefore, a ripening process
should be used prior to oxytocin induction when
the cervix is unfavorable.
Cervical ripening methods fall into two main
categories: pharmacologic and mechanical
Pharmacological (misopristone) or surgical means to
soften the cervix (laminaria).
Methods of Cervical Ripening
Pharmacological Mechanical
Prostaglandin E2 Foley catheter method
(dinoprostone) -intravaginal, Stripping of the fetal
intracervical repeated3-5 membranes
mg dosesapplieduntilthe Laminaria insertion into the
cervicalstatusimprovesora cervixhygroscopicdilators
maximumof3to4doses thatdilateandsoftenthe
Prostaglandin E1 cervixbyabsorbingitswater
(misoprostol) 25 mcg four content.Extractsoflaminaria
dose intravaginal or oral seaweeds.
Anunripe cervix needs to be ripened by these cervical ripening
methodsinordertobesoftenedandmoreripe.
Thepharmacologic methods are the most preferred butincases
wherethesearenotaccessible,mechanicalagentscanalsobeusedto
ripenthecervix.
A ripe cervix indicates a dilated, soft, anterior and effaced cervix
that is easily pliable to uterine contractions.
Methods of Labor Induction and Augmentation
Medical Surgical Combination of both
1. Oxytocin infusion 1. Amniotomyartificial 1. Amniotomy with
Low dose regimen- ruptureofthe oxytocin induction
beginning at1mu/min membranes 2. Stripping of fetal
anddoubling every 20-30 2. Stripping of the fetal membranes with
mins to a maximum of 40 membranes
3. Foley catheter method
oxytocin induction
mu/min 3. Foley catheter
High dose regimen- start method with
at 6mu/min and escalate Surgical methods are
every 20-30 mins to a often used in oxytocin induction
conjunction with ..Etc
maximum of 42 mu/in
medical methods and
2. Prostaglandin E 1 not alone for labor Mostmethodsoflabor
(Misoprostol)induction induction. inductionarealsoused
intravaginalorintracervical foraugmentationof
3.Prostaglandin E 2 laboraswell.
(Dinoprostone)3mg
vaginallyevery6hoursfor
twofourdoses

Failed induction: No established labor 6-8hrs after the last oxytocin

dose or no change in Cx dilatation or descent.
 Procedures of Labor induction
Procedure Description Complications
Amniotomy After ascertaining the fetal Cord prolapse
station and ruling out cord Infection
presentation membrane is chorioamnionitis
ruptured with an amnion Abruptio placentae- if
hook or a kocker and sudden decompression of
controlled release of uterus occurs due to
amniotic fluid effected excessive release of
amniotic fluid

Oxytocin An IV line is opened and Uterine hypertonus fetal

infusion oxytocin infusion distress; uterine rupture
administered gradually by Water intoxication
either a graduated perfusor sodium retention and fluid
prepared for the purpose or overload
by IV drip method Hypersensitivity reaction
manually calibrated to oxytocin
dosage expressed in mu/min Higher risk of atonic PPH
 Procedure Description Complications
Prostaglandin Usually applied for cervical Nausea, vomiting,
E1, E2 induction ripening but also used for diahorrea, fever, chills,
induction of labor. respiratory
Tablet or gel or cream inserted at complications ( rare),
the posterior fornix or near the uterine hypertonus-
cervix repeatedly at 6 hourly fetal distress, uterine
intervals until labor is rupture
established
Stripping of the The membranes are separated Possibility of placenta
fetal membranes from the lower uterine segment previa and bleeding.
by the examining finger for 3-4 Placenta should be
cms from the os and await for localized before
labor onset in hours or days. membrane stripping.

Foley catheter Foley catheter inserted into the Infection

method uterus above the internal os, Membrane rupture
balloon inflated with 30 cc of
normal saline and pressure
applied by hanging weight of 1
kg (e.g.IVfluidbag).
(extra-amnionic
saline infusion)
Complications of Labor Induction
Prematurity
Infection- chorioamnionitis;
o Neonatal sepsis; puerperal sepsis
Water intoxication
Uterine hypertonus- fetal distress,
uterine rupture
Hypersensitivity reactions
Side effects of prostaglandins
Post partum hemmorhage risk
Unforeseen cephalopelvic
disproportion
Complications
Failure to initiate labor or achieve good contractions
leading to failed induction leading to increased risk of
cesarean section
Atonic PPH
Iatrogenic prematurity
Uterine hyper stimulation/ tetanic contractions
(oxytocin, PG)
o Uterine rupture
o Fetal distress
Chorioamnionitis (prolonged rupture of membranes
after ARM and repeated VE)
Fetal sepsis and vertical HIV transmission (ARM)33
Cord prolapse (ARM)
Placental abruption (ARM)
Water intoxication (oxytocin)
Amniotic fluid embolism
Failed induction
Definition: Failed induction is failure to initiate
good uterine contraction. It is diagnosed if
adequate uterine contractions are not achieved
after 6 to 8 hours of oxytocin administration and
use of the maximum dose for at least one hours.
Tetanic contractions
Definition: Six or more contractions in 10 min
and/ or durations of 90 or more seconds
Management
o Stop oxytocin infusion
o Use tocolytics if available
o Assess fetal and maternal conditions carefully for
possible fetal distress or ruptured uterus. If there is
fetal distress (e.g. NRFHP, meconium stained amniotic
fluid) or uterine rupture, manage accordingly.
o If both mother and fetus are in good condition, restart at
half dose of the last dose causing tetanic contractions.
Local protocol: Induction
Premi (5IU) & multipara (2.5IU).
Start the drop with 20 drop/min,
increase the drop every 30 till
adequate Ux action.
Start with 2mu/min up to 8mu/min,
then increase by 4mu/min up to
32mu/min.
Drop/min: 20-40-60-80, 50-60-80, 50-
60-80.
Oxytocin mu/min: 2-4-6-8, 10-12-16,
Local protocol:
Augmentation.
Premi (2.5IU) & multipara (1.25IU).
Start with 5mu/min for multi & and
1mu/min for primi-gravida.
Increase every 30` up to max
20mu/min.
Drop/min: 20-40-60-80, 60-80, 60-80,
50.
Oxytocin mu/min:1-2-3-4, 6-8, 12-16,
20.