At the end of this presentation, you
1-know the definition and indications of induction
2-Aware of the different methods of induction of
3-Able to select the appropriate method of labor
induction for an individual patient.
4-aware of side effect for every method
The induction is methods that used to
terminate the pregnacy for maternal
cause or fetal cause
Natural, medical,surgical and
Pharmacologic methods are used
Some inductions failed and solved by
Induction of labour
An intervention designed to
artificially initiate uterine
contractions leading to
progressive dilatation and
effacement of the cervix and
birth of the baby.
1-Severe hypertensive disorders of pregnancy
2-Postterm pregnancy and macrosomia
3-Intra-uterine growth retardation
5-Premature rupture of membranes
7-Some cases of antepartum hemorrhage
8-Diabetes mellitus with vasculopathy
7-Congenital fetal malformations
9-Maternal diseases. e.g. cardiac disease and T.B.
10-Bad obstetric history
11-Elective inductions: Induction of labor is a
medical procedure and should only be carried
out for medical reasons. Induction of labor for
social reasons is better avoided as it is hard to
justify should any legal issue arises.
Placenta previa and vasa previa
2-Abnormal fetal lie / presentation. e.g. transverse lie and
3-Umbilical cord prolapse and fetal distress
4-Previous classical Cesarean section or other transfundal
5-Active herpes infection
6-Pelvic Structural abnormality
7-Invasive cervical cancer
8-Contraindicaton specific to the inducing drug used.
I-Natural-Non Medical methods
-Relaxation techniques: advise patient to relieve
tension and try to relax then use some visual
aids to show how labor starts.
2-Visualization: The patient is advised to imagine
her uterus contracting and she is laboring.
3-Walking: The force of gravity pulls the weight
of the baby towards the birth canal leading to
dilatation and effacement of the cervix.
4-Sex: Having sex is known to induce labor. This is related to
prostaglandin content of the seminal fluid and the occurrence of
orgasm which stimulate uterine contractions
5-Nipple stimulation: The lady moves her palm and applies some
pressure in a circular fashion over her areola and massaging
nipple between thumb and forefingers for a period of 2 minutes
alternating with 3 minutes of rest. The procedure is performed
for 20 minutes. If adequate contraction pattern is not achieved,
massaging was done for 3 minutes alternating with 2 minutes
rest for additional 20 minutes. Care should be taken to avoid
massaging during a contraction and to only massage one side at
a time in order to avoid hyperstimulation.
Bath/Castor oil/Enemas: The patient is advised to take a
warm bath then to have 3 teaspoons of castor oil mixed
with some juice and an enema thereafter. This method
could stimulate the uterus to contract, which will cause
the cervix to dilate and efface.
7-Foods: Eating lots of pineapple is known to stimulate labor
and ripen the cervix. This is possibly related to its
enzyme content. Other foods with similar action include
Pizza, spicy food like Mexican, and tropical fruits
-Cumin Tea: Used by midwives in Latino cultures.
Sugar or honey may be added to lessen its bitter
9-Several herbs: Labor-enhancing herbs include
blue Cohosh, black Cohosh, Squawvine and
Dong Quai. Evening primrose oil also ripens
the cervix. It is given internally 5 gel caps up
against the cervix daily.
Few health personnel claim an association
between some acupressure points in the body
and increased uterine contractions. One point is
located deep in the webbing between thumb
and forefinger. Massaging this point in a
circular motion for 1-5 minutes stimulates labor
pain and induce labor.
2- Placement of Balloon Dilators after 42 weeks gestation:
A fluid filled balloon is inserted inside the cervix. The Balloon
provide mechanical pressure directly on the cervix which
respond by ripening and dilation. A Foley catheter (26 Fr) or
specifically designed balloon devices can be used.
Technique of balloon placement:
1- After sterilization and draping, the catheter is introduced into the
endocervix either by direct visualization or blindly by sliding it
over fingers through the endocervix into the potential space
between the amniotic membrane & the lower uterine segment.
2- The balloon is inflated with 30 to 50 mL of normal saline
and is retracted so that it rests on the internal os.
3- Constant pressure may be applied over the catheter. e.g. a
bag filled with 1 L of fluid may be attached to the
catheter end. An intermittent pressure may also be
exerted on the catheter end 2 -4 times per hour.
4-Catheter is removed at the time of rupture of membranes
or may be expelled spontaneously which indicate a
cervical dilataion of 3-4 Centimeter.
-Stripping the membranes:
- Stripping the membranes mechanically dilates the cervix which
releases prostaglandins. The membranes are stripped by inserting the
examining finger through the internal os & moving it in a circular
direction to detach the inferior pole of the membranes from the lower
- Risks include patient’s discomfort, infection, bleeding from
undiagnosed placenta previa or low lying placenta,and accidental
- The Cochrane reviewers concluded that stripping the membranes, when
used as an adjunct, decreases the mean dose of oxytocin needed and
increases the rate of normal vaginal deliveries.
2-Amniotomy - Technique:
-The FHR is recorded before the procedure.
-A pelvic examination is performed to evaluate the cervix &
station of the presenting part. The presenting part should
be well fitted to the cervix.
-The membranes are identified and a kocher is inserted
through the cervical os by sliding it along the hand &
fingers & membranes are ruptured.
-The nature of the amniotic fluid is recorded (clear, bloody,
thick or thin, meconium).
-The FHR is recorded after the procedure.
Risks of amniotomy:
1- Prolapse of the umbilical cord (0.5%)
2- Chorioamnionitis: Risk increases with
prolonged induction delivery interval
3- Postpartum hemorrhage: Risk is doubled
compared with women with spontaneous onset
4- Rupture of vasa previa
5- Neonatal hyperbilirubinemia
IV-Pharmacologic Induction of Labor
1-Prostaglandin E2: (dinoprostone): It is inserted
vaginally . It acts on the cervical connective tissue and
relaxes muscle fibres of the cervix. it should only be
administered at hospital and the patient is expected to
stay recumbent and monitored, at least, for the first 30
minutes after insertion. Contractions usually start within
60 minutes of commencing induction and peak within 4
hours. If optimal response is not achieved by 6 hours,
another dose can be administered. The maximum allowed
dose is 3 doses be administered per 24 hours.
Route of administration: Oral,
vaginal and sublingual route for
induction. Rectal route is used to
prevent and treat postpartum
(Cytotec) is a synthetic PGE1 analog that has been found to
be a safe and inexpensive agent for cervical ripening.
-Clinical trials indicate that the safe optimal dose and dosing
interval is 25 mcg intravaginally every 4-6 hours. A
maximum of 6 doses was suggested. Higher doses or
shorter dosing intervals are associated with a higher
incidence of side effects, especially hyperstimulation
-Misoprostol should not be used in women with previous CS
because of increased rates of uterine rupture
It is given by IV infusion using an
automated pump. Oxytocin has
many advantages: it is potent and
easy to titrate, has a short half-life
(one to five minutes) and is well
Side effects of oxytocin use:
1-Uterine hyperstimulation and subsequent FHR
2-Abruptio placentae and uterine rupture.
3-Water intoxication may occur with high concentrations
of oxytocin infused with large quantities of hypotonic
solutions. Therefore; prolonged administration with doses
higher than 40 mu of oxytocin per minute and infusion of
fluids in any 10 hours should not excced 1500 ml. A
rapid intravenous injection of oxytocin may cause
1-Smith CA, Crowther CA. Acupuncture for induction of labour. Cochrane
Database Syst Rev 2002;2:CD002962
2-Lin A, Kupferminc M, Dooley SL. A randomized trial of extra-amniotic
saline infusion versus laminaria for cervical ripening. Obstet Gynecol
1995; 86(4 part 1):545-9.
3-Rouben D, Arias F. A randomized trial of extra-amniotic saline infusion
plus intracervical Foley catheter balloon versus prostaglandin E2
vaginal gel for ripening the cervix and inducing labor in patients with
unfavorable cervices. Obstet Gynecol 1993;82:290-4
4-Sherman DJ, Frenkel E, Pansky M, Caspi E, Bukovsky I, Langer R.
Balloon cervical ripening with extra-amniotic infusion of saline or
prostaglandin E2: a double-blind, randomized controlled study. Obstet
Gynecol 2001;97:375-80. .
-Goldman JB, Wigton TR. A randomized comparison of extra-amniotic saline infusion
and intracervical dinoprostone gel for cervical ripening. Obstet Gynecol
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laminaria, or prostaglandin E(2) gel for labor induction with unfavorable cervix: a
randomized controlled trial. Obstet Gynecol 2000;96:106-12.
7-Foong LC, Vanaja K, Tan G, Chua S. Membrane sweeping in conjunction with labor
induction. Obstet Gynecol 2000;96:539-42.
8-Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture
during labor among women with a prior cesarean delivery. N Engl J Med
9-Hofmeyr GJ, Gulmezoglu AM. Vaginal misoprostol for cervical ripening and
induction of labour. Cochrane Database Syst Rev 2002;2:CD000941.