Induction of

labour and
Prolonged
pregnancy
Dr. Fayez Jallad
2010-2011

Induction of labour
Incidence :
Is indicated in about 10 20% of pregnancies
Indications :
Is indicated when delivery, due to obsterics or medical
reasons , is safer to the mother and/or the fetus than
continuation of the pregnancy .
The common indications are :
1. Postdate
2. Pre- eclampsia
3. PROM
4. Chorioamionitis
5. IUGR
6. IUFD
7. Fetal anomalies
8. Diabetes millitus
9. Abruptio placenta
10.Rh-isoimmunization

: Contraindication

Is contraindicated when the risk of vaginal delivery is unacceptable

i.e. when delivery by C/S is safer to the mother and/or fetus than
the vaginal delivery.

A. Absolute :

1. Placenta praevia
2. Previous 2C/S, previous one due to recurrent
cause, previous classical C/S
3. Abnormal antenatal CTG
4. Transverse or oblique lie.
5. Absolute contracted pelvis.
6. Active genital herpes infection.
7. Tumor occupies the pelvis
8. Cervical carcinoma
9. Successful pelvic floor repair and successful
surgical treatment of stress incontinence.

 Relative:1.Severe pre-eclampsia
2.Breech presentation
3.Multiple pregnancy
4.Grand multipara
5.Polyhydramnios.
6.Presenting part above the
pelvic inlet.

:Complications
1. Hyperstimulation which can lead to
fetal distress and uterine rupture.
2. Failed induction leading to increase
incidence of C/S
3. Prolonged labour leading to high
incidence of instrumental delivery, C/S
and postpartum haemorrhage .
4. More painful which require more
analgesia
5. Prematurity
6. Infection.

:Bishop Score

Is used to assess the cervical condition and the

station of the head , in order to choose the best
method for induction.

It consists of 5 parameters i.e. cervical

dilatation , length , consistency and
position, and the station
of the
head 2, with
0
1
total score of 13.

Cervical dilatation

Closed

1-2 cm

3-4 cm

5cm

Cervical length

>2cm

2-1 cm

1- 0.5 cm

< 0.5 cm

Cervical
consistency
Cervical position

Firm

Medium

Soft

Posterior

Central

Anterior

Station of the head

-3

-2

-1 0

Below
ischial spine

: Methods of induction
3 methods :
I. Vaginal prostaglandins
II.AROM
III.Oxytocin infusion
The selection of the method depends on the
Bishop score :
1.If the Bishop score is < 7 means unfavorable
cervix, to start with PG , followed by AROM
Oxytocin infusion .
2.If the Bishop score is 7 i.e. means favorable
cervix, to start with AROM oxytocin infusion .

:-Vaginal prostaglandins
Most commonly used is PGE2 (Prostin). Recently PGE1
(Misoprestol- Cytotec) can be used in very small doses.
PGE2 ( Prostin ) is applied in the form of vaginal pessory 3 mg or
intracervical gel 0.5mg. PGE1 ( Misoprestol- Cytotec) is applied in
the form of vaginal tablet 25g . The dose of each can be
repeated every 4- 6 hours for a maximum of 3 doses in 24 hours .
The main complication of vaginal PG is uterine
hyperstimulation which can lead to uterine rupture and fetal
distress. Other complications , which are less in vaginal PG
compared to systemic PG , are diarrhea and hyperthermia.
If the Bishop score become 7 , do AROM, and if the effective
uterine contractions are not obtained 1- 2 hours from AROM ,
start oxytocin infusion .

If the cervix remains unfavorable despite the maximum

dose of PG ( 3 doses/24hours ), re-evaluate patients and if
there is no urgent indication for delivery is present, to
repeat the PG next morning .

AROM
Is indicated if the Bishop score is 7 .
It induces labour: by increasing the
release of PG from the fetal membrane
and the decidua, by the mechanical
descent of the head , and by increasing
the release of oxytocin from posterior
pituitary ( Ferguson reflex )
The complications are: cord prolapse,
cord compression, placental abruption
and infection.

: Oxytocin
Is indicated if the effective uterine
contractions ( 3 4 contractions,
each lasting 50-60 seconds in 10
minutes) are not obtained after 12 hours of AROM .

Oxytocin Complications
The complications are :
1. The main complication is uterine hyperstimulation
which can lead to
fetal distress and uterine rupture
2.
Hypotension if oxytocin given in bolus dose I.V.
3.
Neonatal jaundice which may occur if the total
dose of oxytocin exceeds 20 units .
4. Water intoxication- which may occur if the total
amount of fluids , particularly the electrolyte free
fluids , exceeds 1.5 Liters- which may be manifested
by confusion , convulsions , coma and even death.

 How oxytocin to be given in induction of

labour
1. Start by 2mU/min and double the dose every
30 minutes until the effective uterine
contractions are obtained , but never to
exceed 32 mU/min in mutipara and 64
mU/min in primigravida.
2. After the effective contractions are
established for 30 min , reduce the dose of
oxytocin to the minimum required to maintain
the effective contractions . The infusion to be
maintained after delivery and until the 3 rd
stage of labour passed safely to prevent the
atonic postpartum haemorrhage .

How to manage a patient for

:induction of labour
A. Steps which should be taken before start
the induction:
1. Counseling and explanation why induction is
indicated, method of induction to be used and the
possible risks to the mother and the fetus.
2. History to assess gestational age and to
exclude contraindications for induction
3. Obstetric examination to assess lie,
presentation & engagement
4. Vaginal examination to assess Bishop score &
pelvic adequacy.
5. Ultrasound to assess fetal age, wellbeing and
weight, amount of liquor and placental site.

6.

CTG to assess fetal wellbeing.

B- Treatment during the induction :

1.
2.
3.
4.
5.

Good selection of the method of induction guided by Bishop

score.
Proper dose of PG or Oxytocin
Monitoring of labour Fetal wellbeing, uterine activity,
progress of labour and maternal wellbeing.
Adequate pain relief the best is epidural.
Treatment of uterine hyperstimulation and fetal distress if any
occurs during labour:

i. Immediately: stop oxytocin infusion, give oxygen by mask,

position patient on her side & rapid infusion of 250-500 cc of
normal saline.
ii. If uterine hyperstimulation persisted in spite of the above
immediate measures give Terbutaline 0.25 mg bolus I.V. If
hyperstimulation controlled, continue induction & oxytocin
infusion can be re-started at low dose. If hyperstimulation
persisted, in spite of all above measure, do emergency C/S.
iii.If fetal distress persisted in spite of above immediate measures
do Fetal scalp blood sampling (FSBS) for pH . If the pH
is > 7.25, this exclude hypoxia and to continue vaginal delivery.
If pH < 7.2, this confirm hypoxia & emergency C/S should be
performed. If the pH is between 7.2- 7.25, this is a borderline &
to repeat pH after 30 minutes. If pH became > 7.25, continue
vaginal delivery. If remains borderline, deliver by C/S.

Prolonged pregnancy
Definitions:
Post-date pregnancy: means continuation of
pregnancy beyond 40 completed weeks.
Post-term pregnancy: means continuation of
pregnancy beyond 42 completed weeks.
Incidence:
It occurs in about 5-10 % of pregnancies.
Aetiology:
In the majority of cases there is no underlying
cause ie. is a physiological continuation of the
pregnancy. Extremely rare it may be due to
anencephaly , fetal adrenal hypoplasia or to
placental sulphatase enzyme deficiency.

 Risks:
A.Placental insufficiency and hypoxia which leads
to:
1.
2.
3.

Increased perinatal mortality (PNM): the PNM is doubled for each week
after 42 weeks.
Meconium aspiration syndrome.
Oligohydramnios and cord compression

B. Increased fetal weight and 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: Erb's palsy (injury to C5&6), Klumpk's
palsy (injury to C8&T1) and Phrenic nerve injury (injury to C4)
clavicular & humeral fractures.

How to manage patient in

Post-date & Post-term
:pregnancy

A. Steps which should be taken before

delivery:

1. Counseling and explanation: explain the risks of postdate and post-term on the fetus.
2. History for accurate assessment of gestational age,
which should be the first step in patient evaluation,
and to exclude contraindications for induction.
3. Obstetric examination to assess lie, presentation &
engagement.
4. Vaginal examination to assess Bishop score &
pelvic adequacy.
5. Ultrasound at 40, 41, 42 weeks to assess the
amount of liquor, fetal wellbeing & weight.
6. CTG every 3 days after 40 weeks to assess fetal
wellbeing.

B. Delivery:
1. In uncomplicated post-date pregnancy, the
patient should deliver at 41 weeks + 3-7
days.
2. The method of delivery is either by induction
of labour ( the method of induction depends
on Bishop score ) or by C/S if there is
contraindication for induction.
3. If delivery is by induction of labour, a senior
obstetrician should attend delivery due to
risk of shoulder dystocia, and a
peadiatrician should attend delivery due to
risk of meconium aspiration.

Assessment of
:gestational age
A. Antenatal methods :
First day of LMP is reliable in 50% of pregnancies.
Ultrasound the best is Crown-Rump length (CRL)
between 7-13 weeks, then Bipariatal Diameter (BPD)
& Femur Length (FL) between 13-26 weeks & then
BPD&FL after 26 weeks.

Clinical onset of early pregnancy symptoms,

early bimanual examination, quickening &
serial fundal height.
B. Postnatal methods:
1. Dubowitz score which 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.