Induction of labour2013

Induction of Labour
SOGC Clinical Practice Guideline, 2013
Aboubakr Elnashar
Benha University Hospital, EgyptAboubakr Elnashar

DEFINITIONS
Induction of labour
initiation of contractions in a pregnant woman who
is not in labour to help her achieve a vaginal birth
within 24 to 48 hs.
Successful induction
vaginal delivery within 24 to 48 hs of induction of
labour.
Elective induction
induction of labour in the absence of acceptable
fetal or maternal indications.
Cervical ripening
use of pharmacological or other means to soften,
efface, or dilate the cervix to increase the
likelihood of a vaginal delivery.
Aboubakr Elnashar

Tachysystole
> 5 C/10-min period averaged over 30 mins. This
is further subdivided into two categories, one with
and one without FHR changes.
Hypertonus
Excessive uterine contractions lasting > 120
seconds without FHR changes.
This term should be abandoned and has been
replaced by tachystole without FHR changes.
Hyperstimulation
Excessive uterine contractions (tachysystole or
hypertonus) with abnormal FHR changes.
This term should be abandoned and has been
replaced by tachystole with FHR changes.
Aboubakr Elnashar

INDICATI ONS
1. 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 CS. (III-B)
2. If induction of labour is unsuccessful, the
indication and method of induction should be
re-evaluated. (III-B)
3. Inductions should not be performed solely for
suspected fetal macrosomia. (III-D)
4. Inductions should not be performed solely
because of patient or care provider preference.
(III-D)
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Induction is indicated when the risk of continuing
the pregnancy, for the mother or the fetus,
exceeds the risk associated with induced labour
and delivery.
Aboubakr Elnashar

I. High Priority
•• Preeclampsia ≥ 37 ws
•• Significant maternal disease not responding to
tt
•• Significant but stable APHge
•• Chorioamnionitis
•• Suspected fetal compromise
•• Term PLROM with maternal GBS colonization
Aboubakr Elnashar

II. Other Indications
•• Postdates (> 41+0 weeks) or post-term (> 42+0 weeks)
•• Uncomplicated twin pregnancy ≥ 38 weeks
•• Diabetes mellitus (glucose control may dictate urgency)
•• Alloimmune disease at or near term
•• IUGR
•• Oligohydramnios
•• Gestational hypertension ≥ 38 ws
•• IUFD
•• PROM at or near term, GBS negative
•• Logistical problems (history of rapid labour, distance to hospital)
•• IUFD in a prior pregnancy (Induction may be performed
to alleviate parental anxiety, but there is no known medical
or outcome advantage for mother or baby.)
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Unacceptable Indications
•• Care provider or patient convenience
•• Suspected fetal macrosomia
(EFWt > 4000 gm) in a non-diabetic
{no reduction in the incidence of shoulder
dystocia but twice the risk of CS}.
Maternal request
IOL should not routinely be offered. However,
under exceptional circumstances
at or after 40 w (NICE, 2008).
Aboubakr Elnashar

Breech presentation
•IOL is not generally recommended.
•IOL:
1. ECV is unsuccessful, declined or contraindicated
2. Woman refused elective CS
3. Delivery is indicated
after discussing the associated risks with the woman.
Fetal growth restriction
If severe, IOL is not recommended. (NICE, 2008)
Aboubakr Elnashar

CONTRAINDICATI ONS
•• placenta or vasa previa or cord presentation
•• abnormal fetal lie or presentation
(e.g.transverse lie or footling breech)
•• prior classical or inverted T uterine incision
•• significant prior uterine surgery
(e.g. full thickness myomectomy)
•• active genital herpes
•• pelvic structural deformities
Aboubakr Elnashar

PRE-INDUCTION ASSESSMENT
5. Bishop score to determine the likelihood of
success and to select the appropriate method of
induction. (II-2A)
6. The Bishop score should be documented. (III-
B)
7. Induction of women with an unfavourable
cervix is associated with a higher failure rate in
nulliparous patients and a higher CS rate in
nulliparous and parous patients. (II-2A)
Aboubakr Elnashar

Factors influencing success rates of
induction
1. Bishop score,
2. Parity (prior vaginal delivery),
3. BMI,
4. Maternal age,
5. Estimated fetal weight
6. Diabetes.
Elevated BMI (> 40 kg/m2)
maternal age > 35 years
estimated fetal weight > 4 kg
diabetes mellitus have been shown to increase
the CS rate when labour is induced.
Aboubakr Elnashar

Burnett modified the scoring scheme (still in use
and still known as the Bishop score) so that each
variable was assigned a maximum value of 2 points
(for a maximum score of 10).
 Bishop score of > 6 is predictive of a successful
vaginal delivery.
Initial studies were limited to parous women, but
the score was later found also to be applicable to
nulliparous women
Of the Bishop score criteria, the most important is
cervical dilatation, followed by effacement, station,
and position, with the least important being
consistency.
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Bishop scores found the highest risk of failed
induction and CS in both nulliparous and parous
women with scores of 0 to 3 versus those with a
Bishop score > 3.
Even women with a score of 4 to 6 had a
significantly higher risk of CS than those with
spontaneous labour.
Aboubakr Elnashar

US of the cervix
to predict successful labour induction: conflicting
results.
Rozenberg et al. reported that the Bishop score was
a better predictor of time interval from induction to
delivery.
Fetal fibronectin and TVS
have been shown to predict successful induction,
but neither have been shown to be superior to the
Bishop score.
Aboubakr Elnashar

PREVENTION OF INDUCTION
8. Every woman should ideally have an
ultrasound, preferably in the first trimester, to
confirm gestational age. (I-A)
9. Institutions should have quality assurance
programs and induction policies, including safety
tools such as checklists, to ensure that inductions
are performed only for acceptable indications. (II-
2B)
Routine antenatal ultrasound for confirmation of
expected date of delivery has been shown to
reduce induction rates for postdates (> 41+0
weeks) pregnancies after correction of dates
Aboubakr Elnashar

Routine sweeping (stripping) of membranes
promotes the onset of labour: decreases
induction rates.
{increase of local production of prostaglandins}.
insertion of a digit past the internal cervical os
followed by three circumferential passes of the
digit causing separation of the membranes from
the lower segment.
an adjunct to IOL rather than an actual method of
IOL.
Aboubakr Elnashar

When?
1. Prior to IOL
2. At 40& 41 w in nulliparous
3. At 41 w in parous
4. When a vag exam is carried out to assess the
cervix
5. labour does not start spontaneously.
Informed consent should therefore be obtained &
documented.
Aboubakr Elnashar

Massaging around the cervix in the vaginal
fornices
when the cervix was closed, a massage of the
cervical surface with the forefinger and middle
finger for 15 to 30 seconds .
may achieve a similar effect.
The woman should be informed of the
discomfort and pain and the possibility of bleeding
postprocedure before consent is obtained.
Aboubakr Elnashar

The effect of coitus on promoting labour is
unclear.
Reduction in the number of elective inductions
after the implementation of an induction
committee. The role of the committee was to
review each request and enforce the use of
proper indications for induction.
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POST-DATE S INDUCTION
10. Women should be offered induction of labour
between 41+0 and 42+0 weeks as this intervention
may reduce perinatal mortality and meconium
aspiration syndrome without increasing the
Caesarean section rate. (I-A)
11. Women who chose to delay induction > 41+0
weeks should undergo twice-weekly assessment for
fetal well-being. (I-A)
Aboubakr Elnashar

OPTIONS FOR CERVICAL
RIPENING/INDUCTION: UNFAVOURABLE
CERVIX
I. Mechanical Options
Balloon devices (Foley catheter with and without
extra-amniotic saline infusion) that apply pressure
on the internal os of the cervix to stretch the lower
uterine segment and increase the release of local
PG.
Advantages:
Simplicity of use, potential for reversibility,
reduction in certain side effects such as excessive
uterine activity, and low cost
Aboubakr Elnashar

12. Intracervical Foley catheters are acceptable
agents (II-2B) that are safe both in the setting of a
vaginal birth after CS (I-B) and in the outpatient
setting. (II-2B)
13. Double lumen catheters may be considered a
second-line alternative. (II-2B)
Aboubakr Elnashar

Practice Points
•• There is an increased need for oxytocin when
Foley catheters are used.
•• In comparison with prostaglandins, Foley
catheters cause much less uterine tachysystole.
•• Foley catheters are not associated with
increased rates of maternal infection
(chorioamnionitis and endometritis) or
neonatal infection.
•• Use of Foley catheters does not reduce the rate
of CS from that of PG.
Aboubakr Elnashar

Balloon Devices: Foley Catheter
For a single balloon catheter, a no. 18 Foley is
introduced under sterile technique into the
intracervical canal past the internal os. The bulb is
then inflated with 30 to 60 cc of water. The catheter
is left in place until either it falls out spontaneously
or 24 hs have elapsed.
Some practitioners apply a small degree of
traction on the catheter by taping it to the inside of
the leg.
Contraindications:
Absolute: Low-lying placenta
Relative: antepartum hemorrhage, ROM, evidence
of lower tract genital infection.
Aboubakr Elnashar

II. PHARMACOLOGICAL OPTIONS
1. Prostaglandin E2
Prostaglandins E2 (cervical and vaginal) are
effective agents of cervical ripening and induction
of labour for an unfavourable cervix. (I)
Intravaginal prostaglandins E2 are preferred to
intracervical prostaglandins E2 because they
results in more timely vaginal deliveries. (I)
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14. Prostaglandins E2 (cervical and vaginal) should
not be used in the setting of vaginal birth after
Caesarean section due to the increased risk of
uterine rupture. (II-2D)
15. Vaginal prostaglandins E2 may be considered
with ruptured membranes at term and can be used
in this setting. (I-A)
Aboubakr Elnashar

Practice Points
•• PGE2 reduce CS rates of women with an
unfavourable cervix and result in greater maternal
satisfaction.
•• Oxytocin can be started 30 mins after removal
of a dinpoprostone insert (Cervidil) and 6 hours
hours after gel (Prostin, Prepidil).
•• PGE2 in the setting of ruptured membranes had
more maternal but no more neonatal infections.
•• Care must be taken to avoid the insertion of the
higher dose of vaginal PGE2 (2 mg) into the
cervical canal.
•• Uterine tachysystole without FHR changes is
more common
Aboubakr Elnashar

2. Misoprotol:
•• Give 50 mcg orally with a drink of water (ensure
that it is swallowed quickly to avoid sublingual
absorption) or
give 25 mcg vaginally.
•• Repeat every 4 hours as long as contractions are
absent or non-painful.
•• Oxytocin can only be used 4 hours after the last
dose.
Aboubakr Elnashar

16. Misoprostol can be considered a safe and
effective agent for labour induction with intact
membranes and on an inpatient basis. (I-A)
17. Misoprostol should not be used in the setting
of vaginal birth after CS due to the increased risk
of uterine rupture. (II-3D)
18. Oxytocin should be started no earlier than 4
hours after the last dose of misoprostol. (III-B)
Aboubakr Elnashar

Practice Points
•• Misoprostol is more effective than PGE2 to
achieve vaginal delivery and results in less
epidural use but more uterine tachysystole.
•• PGE1 and PGE2 both reduce CS rates in an
unfavourable cervix.
•• The oral and vaginal routes have a similar
reduction of CS rates. The oral route needs more
oxytocin stimulation but the vaginal route will
have more tachysystole.
Aboubakr Elnashar

•• The lower vaginal dose (25 mcg) tends to need
more oxytocin stimulation and the higher vaginal
dose (≥ 50 mcg) tends to have more uterine
tachysystole.
•• All doses of misoprostol can cause uterine
tachysystole.
•• Fetal well-being is required before administration
of misoprostol. Electronic fetal monitoring should
be performed for 30 minutes after administration of
misoprostol and for 60 minutes after any
tachysystole.
Aboubakr Elnashar

OPTIONS FOR INDUCTION
WITH A FAVOURABLE CERVIX
1. Amniotomy
19. Amniotomy should be reserved for women with
a favourable cervix. Particular care should be given
in the case of unengaged presentation because
there is a risk of cord prolapse. (III-B)
20. After amniotomy, oxytocin should be
commenced early in order to establish labour. (III-
B)
Aboubakr Elnashar

Practice Point
•• Amniotomy creates a commitment to delivery
and should be performed when the indication for
induction is convincing and the reasons compelling
and documented.
Aboubakr Elnashar

2. Oxytocin
Example of low-dose protocol:
Initial dose of oxytocin..................................1 to 2 mU/min
Increase interval......................................................30 minutes
Dosage increment....................................................1 to 2 mU
Usual dose for good labour.........................8 to 12 mU/min
Maximum dose before reassessment.................30 mU/min
Example of high-dose protocol:
Initial dose of oxytocin..................................4 to 6 mU/min
Increase interval............................................15 to 30 minutes
Dosage increment...........................................4 to 6 mU/min
Usual dose for good labour.........................8 to 12 mU/min
Maximum dose before reassessment.................30 mU/min
Aboubakr Elnashar

Term PROM
21. oxytocin should be considered before expectant
management. (I-A)
22. Women positive for group B streptococcus
should be started on oxytocin as early as possible
after ruptured membranes in order to establish
labour within 24 hours. (III-B)
23. Both high- and low-dose oxytocin may be
considered within a hospital protocol. (III-B)
24. Because of the various concentrations, oxytocin
infusion rates should always be recorded in
mU/min rather than mL/hr. (III-L)
25. Oxytocin induction maybe considered in the
hospital setting of vaginal birth after CS. (II-3B)
Aboubakr Elnashar

Practice Points
•• With PROM, oxytocin stimulation is more
effective than expectant management to reduce
maternal infection and increase vaginal deliveries
within 24 hours, but it may increase CS rate.
•• In the setting of PROM, women preferred
oxytocin induction over expectant management.
Aboubakr Elnashar

Setting and timing
I. Outpatient:
If safety & support procedures are in place.
Should be audited continuously.
II. Inpatient :
In the morning {higher maternal satisfaction}.
Aboubakr Elnashar

Monitoring
1. Before:
•CTG
•Bishop score
Aboubakr Elnashar

2. During:
•CTG: When contractions begin
Once CTG is confirmed as normal: intermittent
auscultation
•Bishop score
-6 h after vag PGE2 tablet or gel, or 24 h after vag
PGE2 controlled-release pessary
-If a woman returns home after insertion of vag PGE2
tablet or gel, she should be asked to contact her
obstetrician:
when contractions begin,
if she has had no contractions after 6 h.
•Maternal & fetal monitoring
Once active labour is established
Aboubakr Elnashar

Pain relief
Inform woman:
•IOL is likely to be more painful than spontaneous
labour.
•The availability of pain relief options :
Simple analgesics
Epidural analgesia.
Support
labour in water .
Aboubakr Elnashar

Prevention & management of complications
I. Ut hyperstimulation
Tocolysis should be considered if ut hyperstimulation
occurs during induction of labour.
Tachysystole: >5 C/10 m for at least 20 m
Hypersystole/Hypertonus: C >2 m
Aboubakr Elnashar

II. Failed induction
Define:
labour not starting after one cycle of treatment
Management
Support.
CTG
Maternal condition
a. further attempt to induce labour or
b. CS
Aboubakr Elnashar

III. Cord prolapse
Prevention:
•Before induction, engagement of the presenting part
should be assessed.
•Palpate for umbilical cord presentation during the
preliminary vaginal examination
•Avoid dislodging the baby’s head.
•Amniotomy should be avoided if the baby’s head is
high.
Aboubakr Elnashar

IV. Uterine rupture
If uterine rupture is suspected during IOL: emergency
CS
Aboubakr Elnashar

Induction of labour2013

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