1. INDUCTION OF LABOUR
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.

2. INDUCTION OF LABOUR
Definition
Induction of labour after 28 wks of gestation but
before spontaneous onset of labour with aim of
vaginal delivery.

3. INDICATIONS
 The list of indication has lately been expanded to
cover a large number of maternal and fetal
conditions with the objective of reducing MMR
&morbidity as well as salvaging the babies ----
1.Post date pregnancy Beyond 40 wks of gestation
,placental insufficiency Ch. Fetal asphyxia –fetal
death.
Fetal asphyxia worsens with each weak
of advancing leading to a severely compromised
fetus and IUFD.

4. POST DATED PREGNANCY-----
Reported feta loss ---
0.7% at 37 weeks
5.8% at 43 weeks ( 8-fold increase).
Timing of induction ---controversial---. some prefer to wait
spontaneous onset of labor till week, many other believe
there is no gain in waiting beyond 40 weeks.
CS rate rises sharply after 40 weeks.
Cost and stress of fetal monitoring while waiting for
spontaneous labor to start,
Need for emergency intervention --are the risks of wait &
watch policy.
Good success rate achieved with Induction
with Prostaglandins at40 weeks Prompts many Obstetrician to
intervene if fetal maturity is reached.
.

5. 2. HYPERTENSIVE DISORDER
 Hypertensive disorder of any origin can cause
placental insufficiency, IUGR fetal anoxia
depending upon severity and duration of
hypertension.
 Cerebra-vascular accidents ,eclampsia and
abruptio placenta can endanger maternal life.
 Induction is planned at 37 weeks as fetal maturity is
gained.
 But in state of worsening ---impending
eclapmsia, IUGR and placental abruption may
require early induction ---Corticoid therapy between
30-34 weeks will reduce the risk of RDS in
Newborn.

6. 3.ECLAMPSIA
 Once eclampsia supervenes , maternal and fetal
mortality rises.
 Once the measures for controlling fits are done
and pt is stabilized induction of labour / CS should
be undertaken.

7. 4.DIABETES
 A sudden IUFD is not uncommon in last 6 weeks of
pregnancy complicated by long standing severe
Diabetes.
 Monitoring Biophysical profile at twice week interval and
fetal lung maturity will determine the time and method of
termination of pregnancy.
 Strict control of maternal blood sugar level, avoiding
maternal Ketoacidosis and fetal prematurity and sudden
IUFD must be the aim to be gained.

8. 5.RH INCOMPATIBILITY.
 A pregnancy complicated by RH iso immunization
exposes the fetus to anaemia, jaundice and kernicterus .
 Amniocentasis, cordiocentasis and USG screening done
repeatedly can help to determine severity of fetal
affliction and time of induction.
 Post maturity not allowed.
 Pregnancy should be terminated as soon as lung
maturity is gained/ fetal condition in utero is in state of
impending danger.

9. 6.ANTEPARTUM HEMORRHAGE.
 In placenta praevia nothing is gained by going
beyond 37 weeks as bleeding may start at any
moment .
 Severe bleeding and concealed hemorrhage in
abruptio placenta need immediate termination of
pregnancy.

10. 7.INTRA UTERINE GROWTH RETARDATION.
 IUGR due to any cause results in chronic fetal
asphyxia.
 Further growth is impaired.
 Fetus is worse off in utero than out side.
 The optimal time for induction is determined by bio
physical profile.

11. 8.PREVIOUS INTRA UTERINE DEATH (IUFD)
 It is desirable to terminate the pregnancy one week
before the time when IUFD occurred in last
confinement.
9.Premature rupture of membranes(PROM)—
PROMS leads to infection ,cord
compression, Oligohydramnios and fetal
pneumonia.
If pregnancy is beyond 37 weeks and PROM has
lasted more than 12 hrs without labour pains –
Induction of labour is indicated.

12. 10.DEAD FETUS.
 To avoid infection and DIC Pregnancy wt dead fetus
should be terminated by medical induction.
11.Malformed fetus.
Gross malformation of fetus incompatible with life
necessitates termination.
The routine practice of USG in mid trimester eliminates
the delayed detection of gross fetal malformation in late
pregnancy .

13. 12.UNSTABLE LIE
 Stabilizing induction is sometime recommended in a
multipara. Stabilizing induction may effect vaginal
delivery and avoid a caesarean section.
13.Social Induction –
Also known as elective induction for convenience of
family and obstetrician must be discouraged .Induction
by any method is not 100% successful.
Failed induction may necessitate unneccessary
LSCS.

14. CONTRAINDICATIONS TO INDUCTION OF LABOUR
 Prematurity
 Previous Caesarean scar
 Myomectomy Scar
 Hysterotomy Scar
 Contracted Pelvis
 Uncorrectable Transverse Lie
 Brow Presentation

15. INDICATIONS FOR CAESAREAN SECTION
 Medical/surgical induction is contraindicated, but
early termination of pregnancy is must to save
guard the life of mother and fetus.
 When CS is selected on obstetrical grounds such
as contracted pelvis ,Abnormal fetal presentation/
position, Previous scar of
CS, hysterotomy, myomectomy etc.

16. PRE-INDUCTION EVALUATION
1.Indcation-One must be certain that induction of labour is
warranted in a particular woman. The balance between
Risks and advantages of induction and continuation of
pregnancy must go in favor of induction.
2.Time of induction– Iatrogenic prematurity should be
avoided. In maternal indications fetal maturity is less
important e.g. Status eclampticus.If premature indication
is planned ,Corticosteroid therapy will reduce the risk of
fetal RDS.

17. 3.BISHOP SCORE
Score O 1 2 3
Cervical
Dilatation 0-<1cm 1-2cm 2-3cm >4cm
Effacement 0—30% 40-50% 60-80% >80%
Cervical >2cm 2-1 cm 1-0.5 cm <0.5 cm
length
Firm Medium Soft --
Consistency
More than3 >2cm above -1. o<2 cm 1+,2 + Below
Station cm above I.S. above I .S. I.S.
Ischial spine
Cervical Posterior Mid Anterior --
Position POsition

18. 4.PELVIC ASSESSMENT
 Pelvic assessment should be done to confirm
whether vaginal delivery is possible or not.
The success of induction depends on parity of
woman, gestational age, Bishop Score. Bishop
score of >9 is very favorable and nearly 100%
success in induction is expected. 6-9Score----70-
80% success ,Score<6 is associated with > 20%
failure rates.

19. METHODS OF INDUCTION OF LABOUR
1.Mchanical Laminaria Tent
Nipple Stimulation
Sweeping membranes
Extra Amniotic insertion of catheter/balloon
2.Surgical ARM
3.medical Oestrogen pessary, Prostglandin Relaxin
gel, Oxytocin, Mifepristone
4.Combined Surgical and Medical

20. 1. MECHANICAL METHODS
 Laminoria tent---A stem of sea weed imbibes water and swells up ,slowly dilates Cx.Local prostagandins
are also released. Lamicel,Isogel tent are also used. Disadvantages---Slow dilataion,infection,accidental
ARM,not recomonded in IUFD cases.
 Nipple Stimulation---It releases from Posterior pituitary and initiate uterine action Failure rate is very high
 Sweeping of membranes----PG released .Cervical stretching ----Ferguson reflex.
 Extra Amniotic insertion of catheter/balloon-----Mechanical stretching of Cx and separation of membranes
release PG. catheter is removed after12 hrs and Syntocinon drip is started.
Displacement of presenting part ,ARM Infection may occur
Mechanical methods are not useful in cases of PROM and IUFD
.

21. 3.MEDICAL METHODS
 Locally acting- 1. Oestradiol 150mg Vaginal pessary OD/BD –PV insertion help
in ripening the cervixin90% cases. it releases PG and proteolysis leukocyte
Induce ripening.Collegen content is reduced & Cx Is softened.
2. Relaxin 2mg gel exerts similar action.
3. Anti Progesteron (RU 486)- Mefepristone---enhances PG action.200 mg
daily for2days prior to formal induction is effective in softening and effacement of
Cx.
4.PGE2& PGF2 a -----PGE2 acts mainly on Cx and cause cervical ripening.PGF2a
Initiates uterine contractions.
PGE2----500ug viscous gel or 50ug in 0.5ml injection repeated every ½ hrly
(Maximum 3 ml ) through extra amniotic trans cervical folley’ catheter. It starts
cervical softening and uterine action.PGE2 is 5-10 times more potent. This
method bears disadvantages of mechanical methods and fetal distress.
Pge2 gel ½ ml (0.5) ml (cerviprim/cerviprost)is instilled in cervical
canal. Cervical ripening occurs in40% cases with in 4-6 hrs.15% may not
have any response.
PGE2 tabs---3mg and 1mg gel /pv gel is rapidly absorbed and more
effective than tabs. Dose may be repeated 3hrlyaccording to status of FHS
and uterine action.
Hypertonicity is reported 7.3% and 0.5% with tablets and gel repictvely.

22. MEDICAL METHODS
 Mesoprostol(PGE1) -- It is stable at room temperature. Its half
life is 3 yrs ,GI disturbances and fever are its disadvantages.
Misoprostol 25ug 3 doses at 3hr interval is effective . Higher
dose 100ug 4hrly orally /400ug 3hrly given sublingually but GI
symptoms are sometime troublesome.
Monitoring for fetal distress ,hyper tonicity is must.
Glycerol trinitrate induces painless induction.
Nitric oxide skin patch (50mg) with a surface area of 20 cm acts
fast in 24 hrs.

23. MEDICAL METHODS---
 Systemic drugs 1.oral prostaglandin-
2.Syntocinon drip
 1. Oral Prostaglandin- A 0.5 mg tablet of primiprost/Prostin is taken as 1st dose .
Dose is increased as ½ tablet every hrly until 3 conractions are there in each 10
minutes /maximum 3 tablets are administered.
Contraindications for PGS --Bronchial Asthma, Cardiac diseasePGE2
caseshypotension,PGF2a –hypertension and tachycardia
.Glauma,Epilepsy,Renal disorders,fetal distress,previous
LSCS/SCAR. sideeffects-
--
Nausea, vomittings, diarrhoea., Burning in vagina, Cervical tear, uterine
rupturein1% cases mostly multiparas. Fetal distress,hyperstimulation
syndrom,amniotic fluid embolism,
Failure----10-20 % require LSCS.

24. MEDICAL METHODS ------
 Syntocinon Synthetic version of Oxitocin a hormone
secreted by posterior pituitary gland. It is a Neuropeptide
synthetized in supraoptic and paraventricular nucleus of the
Hypothalamus and released in to post pituitary gland. Its ½ life
is 3-4 minutes and effect lasts
for 15-20 minutes.
Syntocinon –orally-desrtoyed in stomach, irregular and
slow absorption when given buccal/sublingual route .If given
IM—neutralized by Oxytocinase enzyme.

25. SYNTOCINON------
 How to start? By titration method—one unit in 500ml 5%
GDW/saline10-15 drops/minute drip started. Uterine action
and FHS monitored ,dose is Increased gradually as per
uterine action& FH rate., till 3 contractions in 10 minutes start .
Syntocinon drip is stopped if there are signs of fetal distress. It
is necessary to maintain the drip after delivery for at least 2-3
hrs to avoid delayed PPH.
 Oxytocin infusion pump----Can regulate the dose of drug and
control the uterne action effectively.

26. SYNTOCINON------
 Indication1. Induction, Augmentation, acceleration of
labur.
2. Control of atomic PPH in higher dose (20-40units in
running drip).
3 .In abortion ,MTP, Vasicuarmole---evacuation.
4. Prophylactic use in 3rd stage of labour.
5.Letting down reflex for milk secretion, breast engorgement.
6.Secodary uterine inertia in prolong labour case if there is
no fetal distress/ inco-ordinated uterine action .

27. SYNTOCINON------
Contraindication
1. Grandmultiparas—risk of rupture of uterus.
2.Contracted Pelvis, Pelvic
tumour, stenosed/scarred/cervical dystosia.
3.Malpresntations---persistent ROP, Tr. Lie., Brow
,posterior Mantum, multiple pregnancy.
4.previous hystertomy, myomectomy, LSCS scar.
5. obstructed labour.

28. SYNTOCINON------
 Complications
1. Hypertonic uetrine action---rupture uterus.
2.Fetal distress ad fetal death.
3.Delyed PPH if drip is withdrawn soon after delivery.
4.Maternal Hypotension if given in volous form.
. Waterintoxication,hypernatraemia.,convulsiovn and coma.
6.Amniotic fluid embolism.
7.Hyperbilrubinaemia in newborn.
.

29. SURGICAL METHODS-----
 ARM---to be done n morning hrs when pt is empty
stomach---risk of cord prolapse---immediate LSCS may
be taken.
 Precausions-------
Timing---- when Cx is dilated >3cm.
colour of amiotic fluid for meconium staining.
Application of scalp electrodes for fetal heart
monitoring.
Syntocinon drip started after 12 hrs/earlier .
watch for any bleeding in cases of APH ., bleeding
increases or decreases.

30. ARM------
 Risks of ARM----
1.Cord prolapse when presenting part is not engaged, Sepsis if
time interval is prolonged/ multiple PV examinations are done.
Failure of induction. when Bishops Score is <6-7.
Contraindications of ARM----
-Abnormal fetal presentation—Tr. Lie.
Breech, Brow,ROP,Face,multiple prehnancy.
-Unengaged head
-Dead fetus---- sepsis.

31. COMBINED METHODS-
 Combined method ( medical & surgical) is often required
in induction of labour ., it yields 80% of success rate ,

32. SPECIAL0NDITIONS------
1.Dead fetal---Cervical ripening by PGs, augmentation by syntocinon and ARM Under
antibiotics.
2.Previous Caesarian Section---The choice depends upon Bishops score ,integrity of scar.
3.Twin Pregnancy—only indicated when1st fetus is LOP.
4.Breech Presentation---No ARM. Cervical ripening needs careful monitoring. LSCS is
considered safer than induction.
5.PROM---Longer the interval between PROM and delivery, greater is risk of infection and fetal
distress.PGE2 vaginal Tablet or syntocinon drip is indicated if uterine contraction do not
start within 12hrs of PROM.

33. CHOICE OF METHOD-----
 It depends upon parity,station of presentng part,State of
membranes,Bishpos score,Period of gestation.
 Low parity ,low Bishops score predisposes
prolong labour and poor neonatal outcome----- higher
incidence of LSCS.
 PGS have improved the success rate, hence used more
to ripen Cx improve Bishops score and initiate uerine
action.
 Syntocinon drip is used when PGS fail or added to
augment.

34. FAILURE OF INDUCTION
 It is defined when Cx failed to dilate up to 3-4 cm in 24
hrs of induction.
 What to do now ?
- Option to wait-- if No PROM and postponement is
not harmful for fetus as well as mother.
-Review the case and if there urgency, Caesarean
delivery is performed.