Labor Induction Practices and Considerations

Induction of labor (IOL) timing decision made based on various factors, including the patient's preferences, circumstances and possible risk factors.

IOL (induction of labor) is considered for complicated pregnancies at 39+0 weeks with certain high-risk factors, such as BMI over 30, age over 35, ethnicity, or assisted conception.

Regular fetal monitoring provides a current 'snapshot' but can't predict future deterioration and doesn't prevent risks like stillbirth.

Supporting the patient's choice on birth place and inducing labour while also giving options of continued monitoring or care.

Risks like stillbirth cannot be reliably predicted or prevented with monitoring alone even in prolonged pregnancies.

A fetal heart rate that deviates from the normal range, potentially indicating a problem with the fetus's well-being.

Uterine contractions that are stronger or more frequent than normal, potentially posing a risk to the mother and/or fetus.

A scoring system used to evaluate cervical ripening and readiness for vaginal delivery.

A procedure to stimulate labor by manually separating the membranes surrounding the fetus from the uterine wall.

Medical interventions used to initiate labor when it hasn't started naturally.

Locally acting chemicals that soften and ripen the cervix, increasing the likelihood of uterine contractions.

A slow-release prostaglandin pessary used to induce labor, softening the cervix.

Remove the pessary if there's an abnormal fetal heart rate or excessive contractions.

When the amniotic sac breaks before labour starts, at or after 37 weeks of pregnancy.

Women with PROM at term have two options: immediate induction of labour or expectant management for up to 24 hours, followed by induction.

If a woman with PROM at term has a positive group B streptococcus test, immediate induction of labour or Caesarean birth is recommended.

Induction of labour after a previous Caesarean section carries a higher risk of uterine rupture.

If a woman with a previous Caesarean section has had an intrauterine fetal death, induction of labour is riskier and needs careful monitoring.

Prostaglandins (like dinoprostone and misoprostol) are contraindicated in women with a uterine scar.

Women should be advised to report any changes in their general wellbeing, including flu-like symptoms, abdominal pain/tenderness, or changes in fetal movements.

A speculum examination is not necessary with PROM if liquor is visible.

Dinoprostone (PGE2) is a drug that ripens the cervix and should NOT be used when:

• Contractions are already established and painful
• Membranes are ruptured or about to rupture
• Uterine hyperstimulation or hypertonic contractions occur
• Fetal distress is detected
• Maternal complications (nausea, vomiting, hypotension or tachycardia) arise
• Less than 30 minutes before starting oxytocin infusion
• After 24 hours, regardless of cervical ripening success

Dinoprostone (PGE2) can cause:

• Nausea, vomiting, diarrhea
• Uterine hyperstimulation, placental abruption, fetal hypoxia
• Uterine rupture (rare, between 0.3% and 7%)

After Dinoprostone is administered, the woman must be monitored closely. If there are NO contractions, assessments include:

• Abdominal examination
• Fetal heart rate (FHR) with Pinard or Sonicaid
• Assessment of fetal movements
• Assessment of vaginal fluid discharge Documentation of findings. If regular, painful contractions begin, more frequent and detailed monitoring is needed, including:
• Abdominal examination
• Continuous fetal monitoring with a cardiotocograph (CTG)
• Assessment of uterine activity and fetal movements
• Vaginal examination
• Documentation of findings.

Amniotomy, also known as Artificial Rupture Of Membranes (ARM), is a surgical procedure where the amniotic sac is punctured to induce labor. It's done when the cervix is favorable in order to accelerate or augment labor.

Amniotomy (ARM) carries risks:

• Infection (chorioamnionitis)
• Early decelerations in fetal heart rate
• Cord prolapse
• Bleeding

Before performing Amniotomy (ARM), take these steps:

• Perform abdominal palpation to assess fetal position
• Conduct a vaginal examination (VE) to:
• Assess cervical dilation and effacement
• Confirm fetal presentation and position (if it's head down, in the right position)
• Rule out cord prolapse or vasa previa
• Ensure the presenting part of the baby is engaged in the pelvis.

After Amniotomy (ARM):

• Rule out cord prolapse
• Immediately assess fetal heart rate for one full minute, then again in 15 minutes
• Document the color and consistency of amniotic fluid
• Encourage the woman to move around to promote contractions
• If no contractions start after 2 hours in a woman who has had multiple previous pregnancies, consider giving oxytocin.

Pregnant women should contact their midwife when they experience contractions, ruptured membranes, bleeding, reduced fetal movements, excessive pain or uterine contractions, or any other concerns.

Midwives play a vital role in planning the birth by providing information, ensuring informed consent, and offering support to mothers.

During labor, midwives monitor maternal and fetal well-being, assess pain, track progress, and maintain detailed records.

The NICE guideline recommends offering induction of labor at 41 weeks for uncomplicated singleton pregnancies.

If women choose not to have induced labor, their decision should be respected, and alternative options should be discussed with them.

Research suggests that the risk of stillbirth increases with gestation beyond 42 weeks, making IOL a recommended option.

By 41 weeks, around 74% of women will give birth naturally, and by 42 weeks, the rate increases to 82%. However, 18% remain pregnant after 42 weeks without IOL.

The incidence of stillbirth increases with gestational age, highlighting the importance of IOL for post-term pregnancies.

Synthetic oxytocin (Syntocinon) is used as a uterotonic agent to stimulate contractions during induction of labor (IOL). However, using oxytocin alone for IOL is not recommended. It's often used in combination with amniotomy (ARM) as a 'primary method' for IOL, unless prostaglandins (PGE2) are contraindicated.

Oxytocin is usually given intravenously (IV) diluted with normal saline. It's typically administered after cervical ripening and ruptured membranes. The dosage is carefully adjusted using a volumetric pump to ensure appropriate uterine contractions.

Oxytocin can have risks, including uterine hyperstimulation, fetal hypoxia, fluid retention, and potentially uterine rupture. Prolonged use can also lead to postpartum hemorrhage (PPH) due to uterine atony.

Augmentation of labor refers to methods used to speed up the progress of labor when it's slow or stalled. Common methods include amniotomy (artificial rupture of membranes) and the use of oxytocin.

PROM occurs when the amniotic sac breaks before labor starts, at or after 37 weeks of pregnancy. Accurate history, vital signs monitoring, and frequent assessments are crucial for managing PROM.

Women with PROM at term have two primary options: immediate induction of labor or expectant management for up to 24 hours, followed by induction. Induction is typically recommended if there's a positive group B strep test or other complications.

Amniotomy is a surgical procedure where the amniotic sac is deliberately punctured to induce or augment labor. It's generally performed when the cervix is favorable to accelerate labor.