induction of labour · wherever induction of labour occurs, ... management •iol ~ >24 hours of...

INDUCTION OF LABOURRECENT RECOMMENDATIONS…

DR. ASHA SHASHIDHARA

ST.MARTHA’S HOSPITAL,BANGALORE

Hippocrates‘

original description

-mammary

stimulation

-mechanical

dilation of the

cervical canal.

Soranus

second century AD,

Combination of

procedures+ ARMMoshion &

Casis devised

manual &

instrumental

cervical dilatation

16th century,

Paré , Bourgeois

enemas and

mixtures of folk

medicines.

17th centuries,

mechanical

methods

1943-

OXYTOCIN

(Pituitary

Extract) 1963

PROSTAGLANDINS

*Sanchez-Ramos L, Kaunitz A. Induction of labor. Glob. libr. women's

med.,(ISSN: 1756-2228 ) 2009;DOI: 10.3843/GLOWM.10130

NON MEDICAL METHODS

VISUALISATION/ HYPNOSIS

RELAXATION

WALKING

SEXUAL INTERCOURSE

NIPPLE STIMULATION

CUMIN TEA

FOOD & HERBS

CASTOR OIL/ ENEMA

ACUPRESSURE

MECHANICAL METHODS

NATURAL & SYNTHETIC LAMINARIA

BALLOON TIPPED CATHETERS

AMNIOTOMY

PHARMACOLOGICAL METHODS

PROSTAGLANDINS

NITRIC OXIDE

CYTOKINES

MIFEPRISTONE

MISOPROSTOLDINPROSTONE

RELAXIN

TOCOSAMINE

OXYTOCIN

Why to Induce ?

Anticipated benefits to the mother

Estimated risks to the mother

Anticipated benefits to the fetus

Estimated risks to the fetus

#1. Society of Obstetricians and Gynaecologists of Canada. SOGC Clinical Practice Guideline No 296. Induction of Labor, 2013.

#2. WHO recommendations for induction of labor 2011 Geneva: World Health Organization; 2011.

#3. ACOG Committee on Practice Bulletins – Obstetrics ACOG Practice Bulletin No. 107: Induction of labor. Am J Obstet Gynecol. 2009

#4. National Institute of Clinical Excellence (NICE) clinical guideline 70. Induction of labor. London: NICE; July 2008

#5. Royal College of Obstetricians and Gynaecologists. Induction of Labor. Guideline. No. 9. London, UK: RCOG Press, 2001.

# Society of Obstetricians and Gynaecologists of Canada. SOGC Clinical Practice Guideline No 296. Induction of Labor, 2013

Level Source of Evidence

1++ High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or

RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High-quality systematic reviews of case–control or cohort studies; high-quality case–control or

cohort studies with a very low risk of confounding, bias or chance and a high probability that

the relationship is causal

2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance

and a moderate probability that the relationship is causal

2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant

risk that the relationship is not causal

3 Non-analytical studies (for example, case reports, case series)

4 Expert opinion, formal consensus

#National Institute of Clinical Excellence (NICE) clinical guideline 70. Induction of labor. London: NICE; July 2008

#Royal College of Obstetricians and Gynaecologists. Induction of Labor. Guideline. No. 9. London, UK: RCOG Press, 2001

“

”

CARE DURING INDUCTION OF

LABOR

Information and decision making (At 38 weeks)

Woman-centred care

make informed choices regarding their care or treatment via access to evidence

based information (C)

Place of induction : (C)

uncomplicated pregnancy- antenatal wards, prior to the active phase of labour.

recognised risk factors (including suspected fetal growth compromise, previous

caesarean section and high parity), the induction process should not occur on an

antenatal ward.

#Royal College of Obstetricians and Gynaecologists. Induction of Labor. Guideline. No. 9. London, UK: RCOG Press,

2001

*National Institute of Clinical Excellence (NICE) clinical guideline 70. Induction of labor. London: NICE; July 2008

Uterine hypercontractility with induction agents

Prolonged use of maternal facial oxygen therapy may be harmful to the fetus and should be avoided. (C)

uterine hypercontractility with a suspicious or pathological cardiotocograph (CTG) secondary to oxytocin infusions, the oxytocin infusion should be decreased or discontinued (B)

abnormal FHR patterns and uterine hypercontractility (not secondary to oxytocininfusion), tocolysis should be considered. (betamemtics)

suggested regimen is subcutaneous terbutaline 0.25 milligrams (A) (Q-low, R-weak)

suspected or confirmed acute fetal compromise, delivery should be accomplished as soon as possible - within 30 minutes. (B)

If uterine rupture is suspected during induced labour, the baby should be delivered by emergency caesarean section

#Royal College of Obstetricians and Gynaecologists. Induction of Labor. Guideline. No. 9. London, UK: RCOG Press,

2001

*National Institute of Clinical Excellence (NICE) clinical guideline 70. Induction of labor. London: NICE; July 2008

+ WHO recommendations for induction of labor 2011 Geneva: World Health Organization; 2011

“

”FETAL SURVEILLANCE DURING IOL

Wherever induction of labour occurs, facilities should be available for continuous

uterine and fetal heart rate (FHR) monitoring. (C)

Fetal wellbeing should be established immediately prior to induction of labour. (C)

Following induction of labour with vaginal prostaglandins (PGE2), fetal wellbeing

should be established once contractions are detected or reported. (C)

Uncomplicated pregnancy - following the administration of vaginal

prostaglandins

-initial assessment with continuous electronic fetal monitoring

-once normality is confirmed, intermittent monitoring can be used (C)

With oxytocin - continuous electronic fetal monitoring (C)

“

”

INDUCTION OF LABOUR IN

SPECIFIC CIRCUMSTANCES

PROLONGED/ POSTDATED PREGNANCY

SOGCWHO

(*Q- Quality ofevidence

R- Recommendation)ACOG NICE RCOG

• Offer induction of

labour between

41+0 and 42+0

weeks

-reduce PNM &

MAS

-without increasing

the Caesarean

section rate. (I-A)

• Women who

chose to delay

induction > 41+0

weeks-twice-

weekly assessment

for fetal well-

being. (I-A)

•recommended

for women who

are known with

certainty to have

reached 41 weeks

(> 40 weeks + 7

days) of gestation.

(Q-low, R- weak).

•Not

recommended for

women with an

uncomplicated

pregnancy at

gestational age

<41 weeks.

(Q- low, R-weak)

•USG

measurement less

than 20 weeks

confirms

Gestational age

>39 weeks

•FHR has been

documented as

present for >30

weeks by doppler

•>36 weeks since

UPT+

•offered induction

of labour between

41+0 and 42+0

weeks

•>42 weeks, who

decline IOL

-at least twice-

weekly CTG

USG- AFI

•USG < 20 weeks of

gestation, reduces

the need for IOL

for perceived

postterm

pregnancy (A)

•uncomplicated

pregnancies – IOL

at >41 weeks (A)

•>42 weeks, who

decline IOL

-at least twice-

weekly CTG

USG- AFI (A)

PRELABOUR RUPTURE OF MEMBRANES (PROM)

SOGCWHO



•oxytocin should

be considered

before expectant

management. (I-

A)

•GBS+ women-

start oxytocin

asap- establish

labor within 24

hours. (III-B)

•high- and low-

dose oxytocin

may

considered.(III-B)

*oxytocin

•IOL

recommended for

women with

PROM at term. (Q-

High, R- strong).

REMARK

•Systemic reviews-

IOL initiated <24

hours

•Oxytocin as first

option

•IOL to be initiated

at the time of

presentation, to

reduce risk of

chorioamnionitis

-oxytocin infusion

-intravaginal PGE2

• > 37 weeks, Offer

a choice of

induction of labor

with vaginal PGE2

or expectant

management

•IOL ~ >24 hours of

PROM

•>37 weeks-

choice of

immediate IOL or

expectant

management. (A)

•Expectant

management

shouldn’t exceed

>96 hours of

PROM.(A)

PRETERM PRELABOUR RUPTURE OF MEMBRANES (PPROM)

SOGC WHO ACOG NICE RCOG

• < 34 weeks

-NO IOL unless additional obstetric indication(

Infection/ fetal compromise)

>34 weeks

Discuss

•Risks to the woman (Ex. sepsis, possible need for

caesarean section)

•Risks to the baby (Ex. sepsis, problems relating to

preterm birth)

•Local availability of neonatal intensive care

facilities.

before IOL with vaginal PGE2

DIABETES IN PREGNANCY (GESTATIONAL DIABETES)

SOGCWHO



• Diabetes mellitus

(glucose control

may dictate

urgency)

•IOL before 41

weeks not

recommended if

only GDM+. (Q-

Very low, R-

weak).

REMARK

•IOL when GDM

with placental

insufficiency

-uncontrolled DM

• maternal

medical

conditions for IOL

-- part of future

research

recommendations

-- •offered IOL prior

to their estimated

date for

delivery(C)

FETAL MACROSOMIA

SOGCWHO



•Inductions should

not be performed

solely for

suspected fetal

macrosomia. (III-D)

•IOL not

recommended for

suspected

macrosomia (Q-

low, R- weak).

---part of future

research

recommendations

• no IOL in

absence of any

other indications

•Insufficient

evidence for

recommendation

AT MATERNAL REQUEST

SOGCWHO



• Inductions should

not be performed

solely because of

patient or care

provider

preference. (III-D)

-- -- •not routinely be

offered on

maternal request

alone.

•under

exceptional

circumstances

-woman’s partner

is soon to be

posted abroad

with the armed

forces),

-induction may be

considered at or

after 40 weeks.

• ~Where

resources allow-

consider when

there are

-compelling

psychological or

social reasons

-and the woman

has a favourable

cervix.

INTRAUTERINE DEMISE

SOGCWHO



-- •In third trimester

of pregnancy,

dead or

anomalous fetus,

oral or vaginal

misoprostol are

recommended for

IOL

(Q- low, R- strong).

• <28 weeks

gestation, vaginal

misoprostol

-high dose

oxytocin

infusion(A)

200-400 mcg every

4-12 hours

•>28 weeks- usual

obstetric protocols

• support for

emotional &

physical

consequences

•Offer immediate (

if ruptured

membrane) IOL or

expectant

management.

•Oral Mifepristone

+ vaginal PGE2 or

misoprostol

--

PREVIOUS CAESAREAN SECTION

SOGCWHO



•Prostaglandins E2

(cervical and

vaginal) should

not be used for

VBAC - increased

risk of uterine

rupture. (II-2D)

•Misoprostol should

not be used in the

setting of

Misoprostol should

not be used in the

setting OF VBAC -

increased risk of

uterine rupture. (II-

3D)

•Oxytocin can be

considered(II-3B)

-- • Avoid use of

misoprostol in

previous LSCS/

major surgery of

uterus, due to risk

of rupture

• option of

-Vaginal PE2

-caesarean

section

-expectant

management

•Inform

-increased risk of

LSCS

-uterine rupture

--

“

”

RECOMMENDED MEHODS FOR

LABOR INDUCTION

PREREQUISITES FOR LABOUR INDUCTION

SOGCWHO



•The indication for

induction must be

documented, and

discussion should

include reason for

induction, method

of induction, and

risks, including

failure to achieve

labour and possible

increased risk of

Caesarean section.

(III-B)

•If induction of

labour is

unsuccessful, the

indication and

method of

induction should be

re-evaluated. (III-B)

• Outpatient

induction of

labour is not

recommended for

improving birth

outcomes

•(Q-low, R- weak)

•assess the cervix

(Bishop score) to

determine the

likelihood of

success and to

select the

appropriate

method of

induction. (II-2A)

• Document

Bishop score. (III-B)

• unfavourable

cervix - >> higher

failure rate in

nulliparous

patients+ LSCS

rates. (II-2A)

• --

CERVICAL RIPENING/INDUCTION: MECHANICAL METHODS

SOGCWHO



•Intracervical Foley

catheters are

acceptable

agents (II-2B)

-safe both in the

setting of a

VBAC(I-B)

-in the outpatient

setting. (II-2B)

•Double lumen

catheters may be

considered a

second-line

alternative. (II-2B)

•Balloon catheter

is recommended

for induction of

labour

(Q-moderate, R-

strong)

• balloon catheter

+oxytocin

alternative

method when

prostaglandins

(including

misoprostol) are

not available/

contraindicated.

(Q-low, R- weak)

•Foley’s catheter is

a reasonable and

effective

alternative (A)

• Mechanical

procedures

(balloon catheters

and laminaria

tents) should not

be used routinely.

--

CERVICAL RIPENING/INDUCTION: MEMBRANE SWEEPING

SOGCWHO



•recommended

for reducing

formal induction of

labour.

(Q-moderate, R-

strong)

•Foley’s catheter is

a reasonable and

effective

alternative (A)

• prior to formal

IOL,

recommendation

for PV and

membrane

stripping.

•Additional

membrane

sweeping may be

offered if labour

does not start

spontaneously.

•40-41 weeks in

nulliparous

•41 weeks for

parous

•Prior to formal IOL

(A)

•is not associated

with an increase in

maternal or

neonatal infection

• is associated

with increased

levels of

discomfort during

the examination

and bleeding.

CERVICAL RIPENING/INDUCTION: PHARMACOLOGICAL METHODS

SOGCWHO



•Misoprostol -

with intact

membranes and

on an inpatient

basis. (I-A)

•Oxytocin should

be started no

earlier than 4 hours

after the last dose

of misoprostol.(III-

B)

•After amniotomy,

oxytocin should be

commenced early

in order to

establish labor.(III-

B)

•Oral misoprostol

(25 μg, 2-

hourly)(Q-

moderate, R-

strong)

•Low-dose vaginal

misoprostol (25 μg,

6-hourly (Q-

moderate, R-

weak)

• Low doses of

vaginal

prostaglandins

)(Q-moderate, R-

strong)

•No misoprostol in

prev.LSCS)(Q-low,

R- strong)

•PGE

analogues(A)

•Low and high

dose oxytocin(A)

•T.Misoprostol 25

mcg initial dose, 3-

6hourly(A)

•Intravaginal PGE2

in PROM(A)

•Risk of uterine

rupture with

Misoprotol in

prev.LSCS(A)

•Misoprostol 50

mcg 6th hourly,

↑risk of

tachysystole, FHR

changes (B)

Vaginal

prostaglandin E2

(PGE2)

-tablets or gel- 6th

hourly (max 2

doses)

-controlled release

pessary- one dose

over 24 hours.

Misoprostol- in IUD/

clinical trial

Mifepristone- IUD

•Oxytocin

•Vaginal PGE2



•Oxytocin compared with prostaglandins for induction of labour

-Intact membrane- PG in preference to oxytocin (A)

-Ruptured memb- PG or oxytocin (A)

•Comparison of intracervical and intravaginal prostaglandins

(PGE2)

-intravaginal PGE2 in preference to intracervical -equally

effective and administration of vaginal PGE2 is less invasive (A)

•Comparison of different preparations of vaginal prostaglandin

(PGE2) - vaginal tablets should be considered in preference to

gel formulations. (A)

-Recommended regimens for vaginal PGE2 (C)

- PGE2 tablets: 3 mg, 6–8 hourly. Max 6 mg for all women.

- PGE2 gels: 2 mg in nulliparous + unfavourable cervix (Bishop’s

score less than 4), max 4mg, 2nd dose of 1–2 mg

-1 milligram for all other women, 6 hours later, max 3 mg

•Comparison of different regimens of oxytocin administration



•Oxytocin not start till six hours following administration PGs (C)

• Amniotomy should be performed where feasible prior to

commencement of an infusion of oxytocin. (C)

•recommended regimen for oxytocin (C)

-a starting dose of 1–2 mIU/ min

-increased at intervals of 30 minutes

-maximum dose is 20 mIU/min. If higher doses are used the

maximum dose used should not exceed 32 mIU/min

• be delivered through an infusion pump or via a syringe driver

with a non-return valve. (C)

•Suggested standardised dilutions and dose regimens include:(C)

-30 iu in 500ml of normal saline; hence 1ml/hr = 1milliunits per

minute

-10 iu in 500ml of normal saline; hence 3ml/hr = 1milliunits per

minute.

METHODS NOT RECOMMENDED FOR IOL


Non-pharmacological

methods

Herbal supplements

Acupuncture

Homeopathy

Castor oil

Hot baths

Enemas

Sexual intercourse.

Pharmacological methods

Oral PGE2

Intravenous PGE2

Extra-amniotic PGE2

Intracervical PGE2

Intravenous oxytocin

alone

Hyaluronidase

Corticosteroids

Oestrogen

Vaginal nitric oxide

donors.

“

”

Over recent decades, more and more

pregnant women around the world have

undergone induction of labour to deliver their

babies. In developed countries, up to 25% of all

deliveries at term now involve induction of

labour

THANK YOU

induction of labour · wherever induction of labour occurs, ... management •iol ~ >24 hours of...

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