Induction of Labour(IOL)

Dr.V.Ravimohan

Based on

• NICE guideline on IOL

• IOL guideline from Society of Obstetricians & Gynaecologists of Canada

Basic facts

• 1: 5 pregnancies are induced

• Following pharmacological intervention (whether or not surgical induction was also attempted) – 2/3 delivered without further intervention– 15% had instrumental deliveries– 22% had caesaren section

What could a patient expect ?

• Opportunity to make informed decisions about induction of labour

– in partnership with their healthcare professionals.

• Evidence-based written information tailored to the needs of the individual woman.

What should the patient know ?

– Reasons for induction – Risks and Benefits– Alternative options if the woman declines IOL– induction

– When, Where and How

– Arrangements for • support • pain relief

– IOL could be unsuccessful and then what the options would be.

38 WEEKS VISIT

• Discuss membrane sweep– What a membrane sweep is – It makes spontaneous labour, and the need for

IOL– Possible

• discomfort • vaginal bleeding

• Induction of labour between 41+0 and 42+0 weeks• Explain expectant management.

Prolonged Pregnancy

• induction of labour between 41+0 and 42+0 weeks

• exact timing depends– woman’s preferences – local circumstances.

• If declined– At least twice weekly

• CTG• USS for Maximum Pool depth

Preterm prelabour rupture of membranes

• >>34+0-Consider IOL based on the following– Maternal risks (Sepsis, Caesarean section)– Fetal risks(Sepsis, Prematurity)– Neonatal facilities

Prelabour rupture of membranes(PROM)

• Options:– IOL with vaginal PGE2– Expectant management.

• IOL is appropriate approximately 24 hours after PROM

IOL in Patient with Previous caesaren section

• Options:– Prostaglandins(PGE2)– Artificial rupture of membranes

• Patient should be explained about – increased risk of uterine rupture – Emergency caesarean section

IOL in Intrauterine death

• Indication for early intervention– ruptured membranes– infection – bleeding

• Methods of IOL– Oral Mifepristone– Misoprostol/Prostaglandins

Suspected Macrosomia

• This is not an indication for induction of labour on its own.

Maternal request

• IOL should not routinely be offered on maternal request alone– Unless there is an exceptional circumstance.

(Ex: woman’s partner is soon to be posted abroad with the armed forces)

Membrane Sweep

• If os is open– Pass a finger through the os and separate the

membrane

• If os is closed – massaging around the cervix in the vaginal

fornices may achieve a similar effect.

• Timing:– Primi 40-41 weeks– Multi 41 weeks

Bishop score

Points

Factor 0 1 2 3

Dilatation(cm) 0 1-2 3-4 5-6

Effacement 0-30 40-50 60-70 >80

Station -3 -2 -1 or 0 +1 or +2

Consistency Firm Medium Soft

Position Posterior Mid Position Anterior

Pharmacological Agents

• Prostaglandin E2

– Gel– Tablet– Controlled-release pessary

• Mifepristone & Misoprostol are only IOL in Intrauterine fetal death.

Regimens

• One cycle of vaginal PGE2 tablets or gel: – one dose– followed by a second dose after 6 hours if

labour is not established • up to a maximum of 2 doses

• One cycle of vaginal PGE2 controlled-release pessary: – one dose over 24 hours.

Controlled-release pessary

• Theoretical advantages– the ability of insertion without the use of a

speculum– a slow continuous release of prostaglandin,

only one dose being required– the ability to use oxytocin 30 minutes after its

removal– the ability to remove the insert if required

(such as with excessive uterine activity).

Surgical Methods

• Amniotomy

• Foley Catheter induction– no. 18 Foley catheter – introduced into the intra cervical canal under

sterile technique past the internal os – The bulb is then inflated with 30 to 60 cc of

water– Further research is needed in this area.

Before IOL

• Bishop score should be assessed and recorded

• A normal fetal heart rate pattern should be confirmed using electronic fetal monitoring.

Complications

• Uterine hyperstimulation – Tocolysis should be considered

• Failed IOL(see the next slide)

• Cord Prolapse– Check the engagement of the head– Check for cord presentation prior to

amniotomy

• Uterine rupture

Definitions

• Tachysystole ->5contractions in10 minutes (or more than 10 in 20 minutes)

• Hypertonus - contraction lasting >120 seconds

• Hyperstimulation - excessive uterine activity with a nonreassuring fetal heart rate tracing.

Failed induction

– Options• Further attempt to induce labour

– timing should depend on» clinical situation » woman’s wishes

• caesarean section

Further reading

• NICE guideline

• SOGC guideline

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