History

Fact Explanation
Presence of contraindications to vaginal delivery In the presence of any of the contraindications, induction of labor should not be done. Presence of placenta previa, scarred uterus (classic uterine incision or extensive transfundal uterine surgery), active genital Herpes and untreated maternal HIV infection are contraindications for vaginal delivery. [1]
Post-term pregnancy Pregnancy prolonging more than 42 weeks of gestation is known as post-term pregnancy. Post-term pregnancy is associated with increased risk of fetal distress, oligohydramnios, fetal macrosomia, fetal dysmaturity, and perinatal mortality. Since induction of labor is indicated in post-term pregnancy. [2,3,4]
Maternal hypertension Chronic maternal hypertension and pregnancy induced hypertension can lead to adverse fetal outcome with fetal growth retardation. [4,6]
Maternal diabetes Maternal diabetes is associated with high risk of spontaneous fetal death. The risk increases with prolongation of pregnancy. Due to this reason, induction of labor is indicated at 38 weeks of period of gestation. [7]
Premature rupture of membranes Premature rupture of membranes is the rupture of membranes before the established labor. If it occurs before 32 weeks of period of gestation it is called preterm-prelabor-rupture of membranes (PPROM). Patients will complain of gush of fluid coming out of vagina. [4]
Severe fetal growth restriction Severe fetal growth retardation is an indication for induction of labor. [8]
Intrauterine death (IUD) Dead fetus should be delivered vaginally, where induction of labor is indicated, provided there is no contraindication (eg: major degree placenta prevea, placenta accreta). [9]
Maternal request Some times mother may require early labor. In those instances induction can be done.
References
  1. PATTERSON DA, WINSLOW M, MATUS CD. Spontaneous vaginal delivery. Am Fam Physician [online] 2008 Aug 1, 78(3):336-41 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18711948
  2. IWANICKI S, AKIERMAN A. The Management of Post-Term Pregnancy Can Fam Physician [online] 1988 Sep:2027-2029 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219142
  3. MANDRUZZATO G, ALFIREVIC Z, CHERVENAK F, GRUENEBAUM A, HEIMSTAD R, HEINONEN S, LEVENE M, SALVESEN K, SAUGSTAD O, SKUPSKI D, THILAGANATHAN B, WORLD ASSOCIATION OF PERINATAL MEDICINE. Guidelines for the management of postterm pregnancy. J Perinat Med [online] 2010 Mar, 38(2):111-9 [viewed 30 August 2014] Available from: doi:10.1515/JPM.2010.057
  4. VERHOEVEN CORINE J., VAN UYTRECHT CEDRIC T., PORATH MARTINA M., MOL BEN WILLEM J.. Risk Factors for Cesarean Delivery following Labor Induction in Multiparous Women. Journal of Pregnancy [online] 2013 December, 2013:1-6 [viewed 30 August 2014] Available from: doi:10.1155/2013/820892
  5. SIMHAN HYAGRIV N., CANAVAN TIMOTHY P.. Preterm premature rupture of membranes: diagnosis, evaluation and management strategies. [online] December, 112:32-37 [viewed 30 August 2014] Available from: doi:10.1111/j.1471-0528.2005.00582.x
  6. CHAMBERLAIN G, ZANDER L. Induction BMJ [online] 1999 Apr 10, 318(7189):995-998 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115422
  7. SETJI T. L., BROWN A. J., FEINGLOS M. N.. Gestational Diabetes Mellitus. Clinical Diabetes [online] 2005 January, 23(1):17-24 [viewed 30 August 2014] Available from: doi:10.2337/diaclin.23.1.17
  8. BOERS K. E., VAN DER POST J. A. M., MOL BEN W. J., VAN LITH J. M. M., SCHERJON S. A.. Labour and Neonatal Outcome in Small for Gestational Age Babies Delivered Beyond 36+0 Weeks: A Retrospective Cohort Study. Journal of Pregnancy [online] 2011 December, 2011:1-5 [viewed 30 August 2014] Available from: doi:10.1155/2011/293516
  9. SOUTHERN E. M., GUTKNECHT G. D., MOHBERG N. R., EDELMAN D. A.. VAGINAL PROSTAGLANDIN E2 IN THE MANAGEMENT OF FETAL INTRAUTERINE DEATH. BJOG:An international journal of O&G [online] 1978 June, 85(6):437-441 [viewed 30 August 2014] Available from: doi:10.1111/j.1471-0528.1978.tb14910.x

Examination

Fact Explanation
Symphysis-fundal height (SFH) Measurement of the SFH is a crude guide to the period of gestation. SFH is lower than expected in the presence of intra-uterine growth retardation, oligohydroamnios and with abnormal lie (oblique and transverse lie). Larger SFH can be found in fetal macrosomia. [1]
Fetal lie Fetal lie should be known prior to the induction as transverse lie is a contraindication to vaginal delivery.
Speculum examination Speculum examination allows the confirmation of the rupture of membranes as liquor can be seen coming out of the external os. [2]
Vaginal examination Vaginal examination is important in assessing the cervical favorability for vaginal delivery. Bishop score is used in this which gives a score for the consistency of the cervix, position of the cervix (anterior, posterior or middle), cervical effacement, cervical length and the engagement of the presenting part of the fetus. Score of 8 or more indicates that the cervix is favourable for the induction of labor. Clinical pelvimetry is also indicated to identify severe cephalopelvic disproportion which is a contraindication to vaginal delivery. [3,4,5]
Blood pressure Maternal hypertension (either chronic hypertension or gestational hypertension) is an indication for induction of labor. [5]
References
  1. JEHAN I, ZAIDI S, RIZVI S, MOBEEN N, MCCLURE EM, MUNOZ B, PASHA O, WRIGHT LL, GOLDENBERG RL. Dating gestational age by last menstrual period, symphysis-fundal height, and ultrasound in urban Pakistan Int J Gynaecol Obstet [online] 2010 Sep, 110(3):231-234 [viewed 30 August 2014] Available from: doi:10.1016/j.ijgo.2010.03.030
  2. SIMHAN HYAGRIV N., CANAVAN TIMOTHY P.. Preterm premature rupture of membranes: diagnosis, evaluation and management strategies. [online] December, 112:32-37 [viewed 30 August 2014] Available from: doi:10.1111/j.1471-0528.2005.00582.x
  3. TAN P. C., VALLIKKANNU N., SUGUNA S., QUEK K. F., HASSAN J.. Transvaginal sonographic measurement of cervical length vs. Bishop score in labor induction at term: tolerability and prediction of Cesarean delivery. Ultrasound Obstet Gynecol [online] December, 29(5):568-573 [viewed 30 August 2014] Available from: doi:10.1002/uog.4018
  4. LAUGHON SK, ZHANG J, TROENDLE J, SUN L, REDDY UM. Using a Simplified Bishop Score to Predict Vaginal Delivery Obstet Gynecol [online] 2011 Apr, 117(4):805-811 [viewed 30 August 2014] Available from: doi:10.1097/AOG.0b013e3182114ad2
  5. CHAMBERLAIN G, ZANDER L. Induction BMJ [online] 1999 Apr 10, 318(7189):995-998 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115422

Investigations - for Diagnosis

Fact Explanation
Fetal ultrasound scan Dating scan should be preferably done before 20 weeks of amenorrhea to determine the gestational age of the fetus which is useful in diagnosing post-term pregnancy. Amniotic fluid index is low in oligohydroamnios. [1,2]
Oral glucose tolerance test (OGTT) OGTT is helpful in diagnosing gestational diabetes. [3]
References
  1. JEHAN I, ZAIDI S, RIZVI S, MOBEEN N, MCCLURE EM, MUNOZ B, PASHA O, WRIGHT LL, GOLDENBERG RL. Dating gestational age by last menstrual period, symphysis-fundal height, and ultrasound in urban Pakistan Int J Gynaecol Obstet [online] 2010 Sep, 110(3):231-234 [viewed 30 August 2014] Available from: doi:10.1016/j.ijgo.2010.03.030
  2. O'REILLY-GREEN CHRISTOPHER P., DIVON MICHAEL Y.. Predictive value of amniotic fluid index for oligohydramnios in patients with prolonged pregnancies. J. Matern. Fetal Med. [online] 1996 July, 5(4):218-226 [viewed 30 August 2014] Available from: doi:10.1002/(SICI)1520-6661(199607/08)5:4<218::AID-MFM10>3.0.CO;2-B
  3. SETJI T. L., BROWN A. J., FEINGLOS M. N.. Gestational Diabetes Mellitus. Clinical Diabetes [online] 2005 January, 23(1):17-24 [viewed 30 August 2014] Available from: doi:10.2337/diaclin.23.1.17

Investigations - Fitness for Management

Fact Explanation
Fetal cardiotocogram (CTG) Non-reassuring fetal CTG is an induction of early delivery. Fetal tachycardia (heart rate more than 160 beats per minute), bradycardia (heart rate less than 110 beats per minute) and late decelerations with good short-term variability in the CTG are indicative of nonreassuring fetal conditions. [2,3]
Transvaginal ultrasound scan Estimation of the length of the cervix can be done with the use of transvaginal ultrasound scan. Cervical length is an important determinant of cervical favorability for vaginal delivery. [1]
Ultrasound scan If the induction is being carried out due to adverse maternal medical conditions, estimation of adequate fetal maturity is mandatory before the induction. [4]
Amniocentesis Although invasive amniocentesis is indicated in the assessment of fetal lung maturity. [5]
References
  1. PANDIS G. K., PAPAGEORGHIOU A. T., RAMANATHAN V. G., THOMPSON M. O., NICOLAIDES K. H.. Preinduction sonographic measurement of cervical length in the prediction of successful induction of labor. Ultrasound Obstet Gynecol [online] 2001 December, 18(6):623-628 [viewed 30 August 2014] Available from: doi:10.1046/j.0960-7692.2001.00580.x
  2. LAWANI OSAHENI LUCKY, ONYEBUCHI AZUBUIKE KANARIO, IYOKE CHUKWUEMEKA ANTHONY, OKAFO CHIKEZIE NWACHUKWU, AJAH LEONARD OGBONNA. Obstetric Outcome and Significance of Labour Induction in a Health Resource Poor Setting. Obstetrics and Gynecology International [online] 2014 December, 2014:1-5 [viewed 30 August 2014] Available from: doi:10.1155/2014/419621
  3. SWEHA A, HACKER TW, NUOVO J. Interpretation of the electronic fetal heart rate during labor. Am Fam Physician [online] 1999 May 1, 59(9):2487-500 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10323356
  4. CHAMBERLAIN G, ZANDER L. Induction BMJ [online] 1999 Apr 10, 318(7189):995-998 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115422
  5. SETJI T. L., BROWN A. J., FEINGLOS M. N.. Gestational Diabetes Mellitus. Clinical Diabetes [online] 2005 January, 23(1):17-24 [viewed 30 August 2014] Available from: doi:10.2337/diaclin.23.1.17

Management - General Measures

Fact Explanation
Health education Females who are awaiting induction because of adverse maternal medical conditions, should be well educated about the indication, benefits and relative risks of induction.
Management of diabetes Patients with gestational diabetes, should be stressed about the importance of blood sugar control and regular monitoring. Dietary modifications include, low refined sugar, low fat and low carbohydrates. Pharmacological treatment with insulin is preferred over oral hypoglycemic drugs. Since these women are at risk of diabetes later in their life, regular exercise and dietary modifications should be continued and assessment of fasting blood sugar is necessary after the delivery. [1]
Management of maternal hypertension Treatment of high blood pressure is important in the presence of maternal lypertension. Since most of the commonly used antihypertensives are contraindicated during pregnancy, methyldopa, nifedipine and labetalol should be used in the treatment. [2]
References
  1. Gestational Diabetes Mellitus. Diabetes Care [online] 2004 January, 27(90001):88S-90 [viewed 30 August 2014] Available from: doi:10.2337/diacare.27.2007.S88
  2. MATHIESEN ER, RINGHOLM L, FELDT-RASMUSSEN B, CLAUSEN P, DAMM P. Obstetric nephrology: pregnancy in women with diabetic nephropathy--the role of antihypertensive treatment. Clin J Am Soc Nephrol [online] 2012 Dec, 7(12):2081-8 [viewed 30 August 2014] Available from: doi:10.2215/CJN.00920112

Management - Specific Treatments

Fact Explanation
Artificial separation of membranes (ASOM) ASOM is a non-invasive method of induction of labor. A gloved and lubricated finger is inserted in to the cervical canal under aseptic conditions. This procedure should be done by an experienced person. [1,5,6]
Artificial rupture of membranes (ARM) (Amniotomy) ARM should be done under aseptic conditions, using an amnihook or Kocher’s forceps. Vaginal examination should be done after the procedure to exclude cord or hand prolapse if the presenting part is not engaged. [1,2,5,6]
Prostaglandin Prostaglandin E2 pessaries are preferred over intravenous, intramuscular or oral administration, for the induction of labor because of lesser side effects. CTG is necessary after the insertion of Prostaglandin pessary. It can be repeated in 4 to 6 hours if there is no cervical dilatation or onset of uterine contractions. This method has a success rate of about 90%. [1,3]
Insertion of a Foley catheter This is a non-pharmacological method which stimulates the endogenous release of prostaglandings and cervical ripening. A Foley catheter is inserted in to the cervical canal and inflated. This should be kept until fallen spontaneously. Insertion of a Foley catheter and use of prostaglandin pessaries are equally effective. [1,4]
Syntocinon Syntocinon is a synthetic oxytocin used in the induction of labor. It is administered intravenously and the dose should be adjusted according to the uterine contractions to avoid uterine hyper-stimulation. Syntocinon is contraindicated in the presence of scarred uterus as the risk of uterine rupture is high. [1]
Isosorbide mononitrate (ISMN) ISMN is a nitric oxide donor, which is proven to cause cervical softening without causing uterine contractions. [7]
Laminaria tent Laminaria tent can be inserted in to the cervical canal where it slowly dilates the cervix. Advantages of Laminaria tent are minimal local side effects with absent systemic side effects. [8,9]
References
  1. CHAMBERLAIN G, ZANDER L. Induction BMJ [online] 1999 Apr 10, 318(7189):995-998 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115422
  2. NASSIEF SA, MCFAUL P, RANE A. Clinical trial comparing artificial rupture of membranes plus oral PGE2 tablets versus artificial rupture of membranes plus intravenous oxytocin for induction of labour in primigravid patients at term. Ulster Med J [online] 1996 Nov, 65(2):145-148 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2448590
  3. LAWANI OSAHENI LUCKY, ONYEBUCHI AZUBUIKE KANARIO, IYOKE CHUKWUEMEKA ANTHONY, OKAFO CHIKEZIE NWACHUKWU, AJAH LEONARD OGBONNA. Obstetric Outcome and Significance of Labour Induction in a Health Resource Poor Setting. Obstetrics and Gynecology International [online] 2014 December, 2014:1-5 [viewed 30 August 2014] Available from: doi:10.1155/2014/419621
  4. JOZWIAK MARTA, RENGERINK KATRIEN OUDE, BENTHEM MARJAN, VAN BEEK ERIK, DIJKSTERHUIS MARJA GK, at al. Foley catheter versus vaginal prostaglandin E2 gel for induction of labour at term (PROBAAT trial): an open-label, randomised controlled trial. The Lancet [online] 2011 December, 378(9809):2095-2103 [viewed 30 August 2014] Available from: doi:10.1016/S0140-6736(11)61484-0
  5. BRADFORD WILLIAM P., GORDON GEORGE. INDUCTION OF LABOUR BY AMNIOTOMY AND SIMULTANEOUS SYNTOCINON INFUSION. BJOG:An international journal of O&G [online] 1968 July, 75(7):698-701 [viewed 30 August 2014] Available from: doi:10.1111/j.1471-0528.1968.tb01545.x
  6. PAWSON ME, SIMMONS SC. Routine Induction of Labour by Amniotomy and Simultaneous Syntocinon (Synthetic Oxytocin) Infusion Br Med J [online] 1970 Jul 25, 3(5716):191-193 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1701156
  7. YAZDIZADEH H, ABEDI P, NAJAR S, ANGALI KA. The impact of isosorbide mononitrate on cervical ripening and labor induction in primiparous women with term pregnancy: A double-blind, randomized, controlled trial Iran J Nurs Midwifery Res [online] 2013, 18(3):246-250 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748546
  8. KURASAWA KENTARO, YAMAMOTO MEGUMI, USAMI YUKI, MOCHIMARU AYA, MOCHIZUKI AKIHIKO, AOKI SHIGERU, OKUDA MIKA, TAKAHASHI TSUNEO, HIRAHARA FUMIKI. Significance of cervical ripening in pre-induction treatment for premature rupture of membranes at term. J Obstet Gynaecol Res [online] December, 40(1):32-39 [viewed 30 August 2014] Available from: doi:10.1111/jog.12116
  9. DARWISH A.M.. Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol. Human Reproduction [online] 2004 August, 19(10):2391-2394 [viewed 30 August 2014] Available from: doi:10.1093/humrep/deh397