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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
#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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
•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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
• 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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
•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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
• 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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
-- •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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
•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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
•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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
•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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
•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
(*Q- Quality ofevidence
R- Recommendation)ACOG NICE RCOG
•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
CERVICAL RIPENING/INDUCTION: PHARMACOLOGICAL METHODS
SOGC WHO ACOG NICE RCOG
•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
CERVICAL RIPENING/INDUCTION: PHARMACOLOGICAL METHODS
SOGC WHO ACOG NICE RCOG
•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
SOGC WHO ACOG NICE RCOG
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