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Induction of Labour

Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

Induction of labour is an intervention to stimulate uterine contractions before the onset of spontaneous labour.

Induction is indicated when the benefits to the mother or the fetus outweigh those of continuing the pregnancy. These include:

Maternal

  • Prolonged or post-term pregnancy
  • Hypertension, including pre-eclampsia
  • Diabetes
  • Medical problems, e.g. renal, respiratory or cardiac disease
  • Placental abruption
  • Obstetric history, such as previous stillbirth or previous caesarean section
  • Maternal request

Fetal

  • Suspected fetal compromise
  • Multiple pregnancy
  • Intrauterine death
  • Some breech presentations

Contraindications

  • Placenta praevia
  • Transverse or compound fetal presentation
  • Cephalopelvic disproportion
  • Severe fetal compromise
  • Active genital herpes

If delivery is imperative, it should be effected by caesarean section.

Methods of inducing labour

Prostaglandins

Before prescribing prostaglandin, assess cervix using the Bishop's score (See Bishop's score). Prostaglandin preparations are available as gels, tablets or controlled-release pessaries. They are inserted close to the cervix, within the posterior fornix of the vagina. Fetal heart and uterine contractions should be monitored for 30-60 minutes thereafter.

Sweeping or stripping of membrane

Sweeping the membranes can be an effective method of inducing labour in an uncomplicated pregnancy. During a vaginal examination, the clinician inserts a finger through the cervical os, and using a sweeping or circular movement, releases the fetal membranes from the lower uterine segment. The woman should be made aware that this procedure may cause some discomfort and bleeding.

Amniotomy

Anmionotomy is the artificial rupture of the fetal membranes (ARM) resulting in drainage of liquor. It is performed to induce labour when the cervix is favourable, or during labour to augment contractions. Amniotomy is also carried out to visualise the colour of the liquor or to attach a fetal scalp electrode for continuous electronic monitoring of the fetal heart rate.

Hazards include:

  • Intrauterine infection
  • Early deceleration of the fetal heart
  • Cord prolapse
  • Bleeding from the fetal vessels in the membranes (vasa praevia), friable vessels in the cervix or placenta praevia

Oxytocin

Oxytocin is used in conjunction with ARM and may be commenced at the same time or after a delay of several hours. It is administered intravenously via a pump. The aim should be to use the lowest dose required to maintain effective, well-spaced contractions (maximum 3 - 4 contractions every 10 minutes). Oxytocins should not be started within 6 hours of administration of prostaglandins. Side effects include hyperstimulation of the uterus, which could cause fetal hypoxia and uterine rupture; water retention; prolonged use may contribute to uterine atony postpartum.

The Practising Midwife featured articles

Midwives, labour induction and the Wooden Spoon award Part 1 2012; 15 (3): 22 - 27 Marie Hastings-Tolma, Steffie Goodman

Midwives, labour induction and the Wooden Spoon award Part 2 2012; 15(4): 26 - 29 Marie Hastings-Tolma, Steffie Goodman

Further reading

National Institute for Health and Care Excellence. (2008) Inducing labour. Clinical guideline 70. Available at: https://www.nice.org.uk/guidance/CG70

World Health Organization (2011). WHO recommendations for induction of labour: RHL review. The WHO Reproductive Health Library; Geneva: World Health Organization. Available at: http://apps.who.int/rhl/pregnancy_childbirth/induction/guidelines_goonewardeneme_com/en/

 

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