Induction of Labor

TITLE:

Induction of Labor

PURPOSE:

To provide and support the decision in the management of patient admitted for induction of labor.

CONDITION/APPLICABILITY:

Applied to all women admitted for induction of labor.

DEFINITIONS:
1. Induction of labor: The initiation of contractions in a pregnant woman who is not in labor to help her achieve a vaginal birth within 24 to 48 hours.
2. Cervical ripening: is the use of pharmacological or other means to soften, efface, or dilate the cervix to increase the likelihood of a vaginal delivery.
3. Tachysystole: refers to > 5 contractions per 10-minute period averaged over 30 minutes. This is further subdivided into two categories, one with and one without fetal heart rate changes.
4. The Bishop score: The cervical assessment system used in clinical practice, the score based upon the station of the presenting part and four characteristics of the cervix: dilation, effacement, consistency, and position.

POLICY:

Policy will cover all the patient admitted for induction of labor including the prerequisite for induction ,the absolute contraindication and how to approach patient with unfavorable cervix for patient with Bishop score <6 the dose and the duration permitted for induction of labor

PROCEDURE:
1. Routine admission care and prerequisite shall be completed and complied to.
2. Upon admission, the patient will be checked by the obstetrician to review the reason for induction. If there is any doubt, the case should be discussed with the consultant on call.
3. The method of induction will be chosen according to the patient condition and assessment.
4. Prerequisite for induction of labor:
  1. Explain the procedure to the patient, include the indications of induction and the method that will be used.
  2. Assessment of gestational age.
  3. perform abdominal examination for fetal presentation.
  4. cervical assessment Bishop score refer to the
  5. indication of induction should be clearly documented in the patient file.
  6. Ensure empty bladder before the starting the induction.
  7. Blood investigation for CBC, blood type and screen for rh status
  8. Perform CTG for 30 min prior to induction.
  9. vaginal examination shall be performed and Bishop score shall be assessed by the obstetrician
5. Findings of the vaginal assessment, Bishop score and the dose of Prostaglandins should be documented in the patient file.
6. Indication for induction of labor:
  1. Preeclampsia ≥ 37 weeks.
  2. Significant maternal disease not responding to treatment.
  3. Significant but stable antepartum hemorrhage.
  4. Chorioamnionitis.
  5. Suspected fetal compromise.
  6. Term pre-labor rupture of membranes with maternal GBS colonization.  
  7. Postdates (> 41+0 weeks) or post-term (> 42+0 weeks) pregnancy.
7. Other indications:
  1. Uncomplicated twin pregnancy ≥ 38 weeks  
  2. Diabetes mellitus (glucose control may dictate urgency)  
  3. Alloimmune disease at or near term  
  4. Intrauterine growth restriction  
  5. Oligohydramnios  
  6. Gestational hypertension ≥ 38 weeks  
  7. Intrauterine fetal death  
  8. PROM at or near term, GBS negative  
  9. Logistical problems (history of rapid labor, distance to hospital)  
  10. Intrauterine death 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.)  
  11. SLE at 38 wk.
8. Unacceptable indications:
  1. Care provider or patient convenience
  2. Suspected fetal macrosomia (estimated fetal weight > 4000 gm) in non-diabetic women is an unacceptable indication because there is no reduction in the incidence of shoulder dystocia but twice the risk of CS.  
9. Contraindication:
  1. placenta or vasa previa or cord presentation
  2. abnormal fetal lie or presentation (e.g. transverse lie or footling breech)
  3. prior classical or inverted T uterine incision.
  4. significant prior uterine surgery (e.g. full thickness myomectomy), more than 2ceaserian section.
  5. active genital herpes.
  6. pelvic structural deformities
10. Factors that have been shown to influence success rates of induction:
  1. the Bishop scores
  2. parity (prior vaginal delivery)
  3. BMI, maternal age
  4. estimated fetal weight
  5. diabetes.
11. Approach for ripening/ induction in unfavorable cervix for patient with Bishop score <6
  1. surgical methods
    1. Amiotomy alone or with oxytocin should not be used as primary method of induction labor unless there is specific reason for not using vaginal PGE2
    2. Amniotomy should be preserve for women with fever able cervix more caution should apply for non-engaged head due to rise incidence of cord prolapse
    3. One hrs. after amniotomy oxytocin should be initiated if uterine contraction has not started.
  2. pharmacological option:
    1. vaginal PGE2gell
      1. Complication of PGE2 gel should explain to the patient like hyper stimulation with potential consequences of fetal distress and uterine rupture and mild Side effect like fever, diarrhea and vomiting
      2. Dose and frequency of PGE2 gel in cervical ripening
      3. In primigravida the 1st cycle initial dose of 1 mg dose follow by 2nd dose 2 mg after 6 hrs according to the Bishop score and the reassessed should be done after 6 hrs. for the 3rd dose 2 mg follow by 4th dose 1 mg “maximum doses total not to exceed 6 mg “if no response rest the patient 24 to 48 hrs. then give her 2nd cycle if no response patient should be re-evaluated by her consultant for further management
      4. In multigravida

the 1st cycle initial dose of 1mg dose follow by 2nd dose 1 mg after 6 hrs. according to the Bishop score and the reassessed after 6 hrs. for the 3rd dose 1mg “maximum doses total not to exceed 3 mg “if no response rest the patient 24 to 48 hrs. then give her 2nd cycle if no response patient should be re-evaluated by her consultant for further management

6.11.2.2. PROPESS

6.11.2.2.1.the dose 10mg vaginal delivery system

6.11.2.2.2.Bishop score should be assessed, if It <6 insert the PROPESS in

the posterior vaginal fornix

6.11.2.2.3. PROPESS should be removed

1.when cervical ripening is judged to be complete.

2.Onset of labor with the presence of regular painful

uterine contractions occurring every 3 minutes

irrespective of any cervical change.

Once regular, painful contractions have been
established with PROPESS they will not reduce in frequency or intensity as long as PROPESS remains in situ because dinoprostone is still being administered.

Patients, particularly multigravida, may develop

regular painful contractions without any apparent cervical change. PROPESS in situ, the vaginal delivery system should be removed irrespective of cervical state to avoid the risk of uterine hyper stimulation.

6.11.2.2. Misoprostol

6.11.2.2.1.Recommended only in cases of non viable pregnancy

6.11.2.2.2. Start by misoprostol 25 microgram per vagina every 6 hrs.

For 24 hr, 25 microgram per oral every 2 hrs. x 24 hrs

If no response rest the patient for 24-48 hrs and repeat for 24 hrs

and if no responses case should be discussed with the

consultant.

6.11.2.2.Fore patient Bishop score >6 do amniotomy then wait for one

hrs. if no contraction starts the patient on oxytocin according to

the protocols

RESPONSIBILITY:

All physicians under labor and delivery department.

FORMS/ EQIPMENTS:

Induction of Labor pathway.

REFERENCE:

Induction of Labor NICE 2016
National Collaboration Center for Women and Child Health, June 2008
WHO recommendation for induction of labor 2011

REVISION:

APPROVALS:

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