INDICATION

When delivery is safer to

mother & fetus than
continuation of pregnancy.
1. Postdate
2. Pre-eclampsia
3. PROM
4. Chorioamnionitis
5. IUGR
6. IUFD
7. Fetal anomalies
8. DM
9. Abruptio placenta
10. Rh isoimmunication

INDUCTION OF LABOR
Indicated in 10-20%
CONTRAINDICATION
ABSOLUTE
RELATIVE
1. Placenta previa
1. Severe pre2. Previous 2C/S, previous 1 due to eclampsia
recurrent cause, previous classical
2. Breech
C/S
presentation.
3. Abnormal antenatal CTG
3. Multiple pregnancy
4. Transverse/oblique lie
4. Grand multipara
5. Absolute contracted pelvis
5. Polydroamnios
6. Active genital herpes infection.
6. Presenting part
7. Tumor occupies pelvis
above pelvic inlet.
8. Cervical carcinoma
9. Successful pelvic floor repair &
successful surgical rx of stress
incontinence.

Bishop Score: Assess cervical condition & station of the head, in

13.
BISHOP SCORE
0
Cervical dilatation
Closed
Cervical length
>2cm
Cervical consistency
Firm
Cervical position
Station of the head

Posterio
r
-3

Bishop score <7 unfavorable cervix.

Bishop score 7 or more favorable cervix

COMPLICATION
1. Hyperstimulation fetal
distress & uterine rupture.
2. Failed induction
increased incidence of C/S.
3. Prolonged labour
instrumental delivery & PPH.
4. More painful more
analgesia
5. Prematurity
6. Infection

order to choose the best method for induction. Total score

1
1-2cm
2-1cm
Mediu
m
Centra
l
-2

2
3-4cm
1-0.5cm
Soft

3
>5cm
<0.5cm

Anterior
-1-0

Below ischial
spine

METHOD OF INDUCTION
Not reach effective contractions
Bish
op
<7

Vaginal
Prostaglandin

Bish
op
>=7

Artificial Rupture
of Membrane

Oxytocin

Indicated if effective uterine

contractions not obtained after 1-2 h
PG release from fetal
of AROM.
memb & decidua, & by
Complications:
mechanical descent of
1. Uterine hyperstimulation Uterine
fetal head
rupture & Fetal Distress
oxytocin from
2. Hypotension if given IV bolus dose.
3. Neonatal jaundice if total oxytocin
posterior pituitary
>20 units.
(Ferguson reflex)
4. Water intoxication if total amt of
Complications: Cord
fluids >1.5L confusion, convulsion,
prolapsed, placental
coma, death.
abruption, infection.
How given:
Start 2mU/min, double the dose every
30min.
Never exceed 32mU/min (multipara) &
64mU/min (primipara).
*Effective uterine contractions: 3-4 contractions, each lasting 50-60seconds in When
10minutes.
effective contractions reach,
keep lowest effective dose.

PGE2 (Prostin) most commonly

used.
PGE1 (Misoprostol)
Vaginal PGE2 pessory 3mg or
Intracervical PGE1 gel 0.5mg
Dose can be repeated every 4-6h
for a max dose of 3doses in 24h.
Main complication: Uterine
hyperstimulation Uterine rupture
& Fetal Distress.
If cervix remains unfavorable
despite max dose of PG
(3doses/24h), re-evaluate pt & if
theres no urgent indication for

Induces labor by

MANAGEMENT OF PATIENTS FOR INDUCTION OF LABOR

BEFORE INDUCTION
DURING INDUCTION
1. Counseling & explanation.
1. Good selection of method of induction (Bishop score)
2. Hx Assess GA & R/O contraindications of induction. 2. Proper dose of PG or Oxytocin.
3. Obstetrics exam Assess lie, presentation,
3. Monitoring of labor Fetal wellbeing, uterine activity, progress
engagement.
of labor & maternal wellbeing.
4. Vaginal exam: Assess Bishop score & pelvic
4. Adequate pain relief Best epidural
adequacy.
5. Ultrasound: Assess fetal age, wellbeing, amt of liquor
& placental site.
6. CTG: Assess fetal wellbeing.
TREATMENT OF HYPERSTIMULATION & FETAL DISTRESS
>7.25 Continue vaginal delivery
Fetal distress
7.2-7.25 Repeat pH after 30min
Stop oxytocin.
<7.2 Emergency c-section
Give oxygen by mask.
Lateral decubitus.
Rapid infusion normal
saline.
Uterine
Persist
hyperstimulation

Fetal scalp
Fetal
distress persist
blood
sampling

Terbutaline
Hyperstimulation
persist
0.25mg bolus
IV

Emergenc
y Csection

PROLONGED PREGNANCY
Post-date pregnancy: Continuation of pregnancy beyond 40 completed weeks
Post-term pregnancy: Continuation of pregnancy beyond 42 completed weeks
Incidence 5-10% pregnancies.
ETIOLOGY
Majority of cause no underlying cause i.e. physiological continuation of the pregnancy.
Extremely rare cases may be due to anencephaly, fetal adrenal hypoplasia or to placental sulphatase enzyme deficiency.
RISKS
A] Placental insufficiency & hypoxia which leads to:
1. Increased perinatal mortality (PNM)
2. Meconium aspiration syndrome
3. Oligohydroamnios & cord compression
B] Increased fetal weight & ossification of skull with decreased moulding, which leads to:
1. Prolonged labour and failure to progress which leads to incidence of C/S.
2. Shoulder dystocia with its neonatal & maternal risks.
a) Maternal risks vaginal & cervical lacerations & rupture uterus
b) Neonatal risks: neonatal asphyxia & death, cervical cord injury, brachial plexus injury (erbs palsy in C5&C6,
klumpks palsy in C8&T1, phrenic nerve injury in C4), clavicular & humeral fractures.
MANAGEMENT
BEFORE DELIVERY
DELIVERY
1. Counseling & explanation: explain risks on the fetus.
1. In uncomplicated postdate pregnancy, pt should be
2. Hx for accurate assessment of GA and to exclude C/I for delivered at 41wks + 3-7days.
induction.
2. Method of delivery either induction of labour (method of
3. Obstetric exam: Assess lie, presentation & engagement.
induction depends on Bishop score) or by C/S if there is C/I
4. Vaginal exam: Assess Bishop score & pelvic adequacy.
for induction.
5. Ultrasound: at 40.41 & 42 wks, to assess amt of liquor,
3. If delivery by induction of labour, a senior obstetrician
fetal wellbeing & w8.
should attend delivery due to risk of shoulder dystocia and a
6. CTG: every 3days after 40wks, to assess fetal wellbeing.
pediatrician should attend due to risk of meconium
aspiration.
ASSESSMENT OF GA

ANTENATAL METHODS
1. First day of LMP reliable in 50% of pregnancies.
2. Ultrasound best is CRL between 7-13wks, then BPD & FL between 1326wks & then BPD & FL after 26wks.
3. Clinical onset of early pregnancy sx, early bimanual exam, quickening
& serial fundal height.

POSTNATAL METHODS
1. Dubowitz score include an assessment of
the physical & neurological features of the
newborn.
2. Farr score which include an assessment of
the physical features of the newborn.