1. Induction of Labour (IOL)
Maternal Newborn Orientation Learning Module
Reproductive Care Program of Nova Scotia
Reviewed, May 2016
Welcome to Induction of Labour (IOL), a Maternal Newborn Orientation Learning Module by the Reproductive Care Program of Nova Scotia. This module was updated in May of 2016.
In order to provide safe and effective care for women during induction, you will need to review additional learning modules:
Supportive Care in Labour
Fetal Health Surveillance (1 and 2)

2. Reproductive Care Program of Nova Scotia, March 2012
In March 2012, the RCP released a provincial report from the Quality Assessment Review of Induction of Labour that was carried out in 3 District Health Authorities and the IWK over 2 years from 2007 to This report with the extensive bibliography is a primary reference for this module. In addition to provincial data and an overview of the indications and methods, the report includes perspectives of women who participated in focus groups to talk about their experiences and their understanding of induction. A copy has been sent to all labour and birth units in the province. It can also be downloaded from the RCP website using the link posted on this slide.
Reproductive Care Program of Nova Scotia, March 2012

3. Objectives Review the following topics related to induction of labour:
Definition, indications, and implications of induction for women and the health care system
Methods, with emphasis on prostaglandins and oxytocin
Practices to promote patient safety
In this module we will review the following topics related to induction of labour:
Definition, indications, and implications for women and the health care system;
Methods, with emphasis on prostaglandins and oxytocin; and
Practices to promote patient safety.

4. Definitions
Induction - ‘artificial initiation of labour before its spontaneous onset’. (SOGC, 2013)
Augmentation - process of stimulating contractions when progress in active labour has slowed or stopped.
Active labour: cervix effaced and dilated at least 3-4 cm. (ALARM, 2012)
Induction is defined as the ‘artificial initiation of labour before its spontaneous onset’. It includes those methods introduced to stimulate contractions and progress in early labour. Early labour, sometimes referred to as the latent phase of labour, can last many hours, up to 20 or more. It is often a time of discomfort for women, many of whom will come to the hospital seeking relief or because they believe that labour is well underway. Once there, one or more interventions may be offered with the hope of speeding up the process. This constitutes an induction not augmentation as it is often called. Augmentation refers to the process of stimulating contractions when progress in active labour has slowed or stopped. Active labour has begun when contractions that are frequent and/or regular have led to effacement and dilatation of the cervix, at least 3-4cm.

5. Indications for Induction
Post-dates pregnancy*, diabetes, HDP, PROM, IUGR, chorioamnionitis, suspected fetal compromise, hx of precipitous birth…
*Post-term pregnancy > 42+0 weeks gestation; Post-dates > 41+0
SOGC Induction of Labour Guideline
The goal of induction is to achieve vaginal birth when delivery is indicated before the onset of spontaneous labour.
Some of the medical indications include: post term pregnancy, diabetes, Hypertensive Disorders of Pregnancy(HDP), Pre-labour Rupture Of Membranes (PROM), Intra Uterine Growth Restriction (IUGR), chorioamnionitis, suspected fetal compromise, history of precipitous birth.
A full list of indications can be found in the SOGC Clinical Practice Guideline on Induction of Labour by following the link on this slide.
Note that post-term pregnancy is by definition > 42+0 week’s gestation. It is associated with an increased risk of perinatal mortality and morbidity. The SOGC has defined post-dates pregnancy as > and recommends that induction be initiated after 41+0 weeks in order to ensure that delivery occurs by 42+0 weeks.

6. Risks of Induction Inadvertent delivery before term Prolonged labour
Postpartum hemorrhage
Cesarean Section
Operative vaginal birth
Tachysystole
Hypertonus
A number of risks of induction have been identified:
Inadvertent delivery before term
Prolonged labour
Postpartum hemorrhage
Cesarean section
Operative vaginal birth
Tachysystole
Hypertonus

7. Tachysystole & Hypertonus
Tachysystole – more than 5 contractions in 10 minutes, averaged over 30 minutes
Tachysystole and hypertonus refer to the abnormal contraction patterns that are of concern during induction. During tachysystole there are more than 5 contractions in 10 minutes, averaged over 30 minutes.
Hypertonus refers to incomplete uterine relaxation between contractions. Tachysystole and hypertonus do not allow optimal reperfusion of the placenta between contractions and are associated with an increased risk of fetal acidosis at birth.
Hypertonus – resting tone > 20 to 25 mmHg

8. Implications for Women
Women told us during focus groups…..
Induction allows control of timing of birth
Induced labour is more painful
Labour is less ‘natural’ during induction; increases likelihood of more interventions
CEFM
 use of epidurals
 likelihood of cesarean section
As part of the provincial QA Review of Induction of Labour, RCP held focus groups to talk to women about induction. Some based their observations on their own experiences and others from the experiences of family and friends. Some women told us that they were in favor of induction because it allowed them to have control of the timing of birth. Some described numerous discomforts they were having in late pregnancy and told how they had asked for induction in order to end those discomforts.
Others told us that induced labour was more painful. Nova Scotia data suggests this to be true. In , 67.6% of women induced received epidural analgesia compared to 38.3% of women who laboured spontaneously.
We also heard some women describe induced labour as less ‘natural’. Several who had experienced it stated they found it restrictive because of the IV and continuous electronic fetal monitoring. Many believed that induction increased the likelihood of other interventions such as cesarean section.

9. Induction in Nova Scotia
The rate of induction is closely monitored in Nova Scotia. The graph on this slide was created using data from the NS Atlee Perinatal Database. It shows the rate of induction among women delivering in Nova Scotia, by parity, from 2005 to The rate among primiparous women was highest, ranging from 34% to 36% over those years.
Nova Scotia Atlee Perinatal Database

10. What Has Contributed to the Rate of Induction?
Changing demographic
Guidelines interpretation
Maternal choice
So what has contributed to the induction rate?
One factor is a changing demographic. Many women are delaying childbearing which places them at a slightly increased risk for stillbirth because of their age. Older women are also more likely to experience health complications such as hypertension or diabetes with the pregnancy risks that those complications impose.
Also, there is an increased incidence of obesity in the population. Obesity is an independent risk factor for stillbirth and increases the risk of co-morbidities. Risks and complications associated with obesity and advanced maternal age may contribute to a decision to induce labour.
Individual interpretation of guidelines may have an effect. For example, concerns about post-term pregnancy have led some health care providers to interpret the related guidelines as ‘deliver by 41 weeks’. Allowing women to await spontaneous labour for a day or two beyond 41+0 weeks to ensure delivery before 42+0 weeks would result in a decrease, whereas inducing at or before 41+0 weeks will increase the overall number of inductions.
Finally, maternal choice has an effect, as women have become more likely to see induction as a safe practical option as it has become more common.

11. Making the Decision to Induce
When the maternal/fetal benefits outweigh the risk of induction (SOGC)…
‘induction list’; prioritized according to need for delivery:
Additional considerations include gestation and cervical ‘readiness’ for labour
The SOGC advises that induction be undertaken only when the maternal/fetal benefits of delivery outweigh the risks of prolonging the pregnancy and of the induction itself. Information about the benefits, process of induction and associated risks should be shared with women to enable them to make an informed choice. Once a decision to induce labour has been made, in most labour and birth units the woman’s name and clinical information will be added to an induction list. Requested inductions will be scheduled according to priority of the need for delivery and may be rescheduled if the clinical situation changes. A designated or on-call obstetrician most often is responsible for prioritizing inductions.
Gestation is a factor in the timing of an induction. The physician may decide to postpone an induction if possible in order for administration of steroids to promote the development of fetal lung surfactant.
Cervical readiness for labour is also important factor as an induction with a cervix that is favorable is significantly more likely to lead to labour that progresses and results in vaginal birth.

12. Cervical Readiness for Labour
Bishop score:
Points (0 to 3) are assigned for dilatation, effacement, consistency, position of the cervix, and fetal station.
A score of ≤ 6 is unfavorable; if delivery is indicated, cervical ripening is recommended as part of the induction.
The Bishop score allows for a systematic assessment of the favorability of the cervix; 0-3 points are assigned for dilatation, effacement, consistency, position of the cervix, and fetal station.
A Bishop score of greater than 8 is associated with a high likelihood of vaginal birth following induction.
A Bishop score of ≤ 6 is unfavorable. If delivery is indicated, cervical ripening is recommended as part of the induction process.

13. Cervical Ripening
Mechanical methods – Foley catheter & cervical ripening balloon
Prostaglandin E2 (PGE2)
Misoprostol (PGE1)
Risks of PGE2 and PGE1 are tachysystole or hypertonus with or without abnormal FHR and rarely, uterine rupture.
Note that any method used to promote cervical ripening may be sufficient to stimulate contractions and induce labour without further interventions.
Mechanical methods of cervical ripening stimulate the local release of endogenous prostaglandin in the cervix by the application of direct pressure. A Foley catheter is inserted into the cervix and the bulb filled with ml of water. A cervical ripening balloon works in much the same way, except with two bulbs that allow pressure to be exerted on both the internal and external os of the cervix. In either case, light traction may be applied to the catheter which is then taped to the woman’s leg and left for 24 hours or until it falls out.
An advantage of mechanical methods is that there are fewer if any side effects and it is the only option for cervical ripening for a woman with a previous cesarean section for whom delivery is indicated and who chooses induction over a repeat section. Mechanical methods also allow simultaneous administration of oxytocin for induction.
Prostaglandin E2 and Misoprostol are more commonly used. Risks associated with those products are tachysystole or hypertonus, with or without FHR changes, and rarely, uterine rupture.

14. Prostaglandin E2 (PGE2)
Prostin® (vaginal application) – initially 1 mg followed by 2 mg in ≥6 hours if needed
Cervidil® (controlled-release vaginal insert) – 10 mg; contraindicated if membranes ruptured
Prepidil® (intracervical administration) – 0.5 mg, repeat in ≥ 6 hrs if needed
Prostaglandin E2 (or PGE2) is widely used in Nova Scotia and is available in a number of formulations:
Prostin® is inserted into the posterior fornix of the vagina. An initial 1 mg dose is followed by 2mg in ≥ 6 hours, as necessary and provided that labour has not become established. Prostin® can be given if membranes have ruptured. Depending on the policy of the unit, it may be administered by an appropriately trained RN.
Cervidil® is preferred by some clinicians because a single application of the 10mg vaginal insert offers a slow release of approximately 0.3mg of PGE2 hourly for 24 hours. An added feature is a retrieval string that allows the removal of the Cervidil® if membranes rupture, labour begins, or adverse effects occur. Cervidil® is currently contraindicated if membranes are ruptured.
Prepidil® is administered intracervically, requiring a speculum for visualization of the cervix. Ease of application of other PGE2 products and no demonstrated benefits associated with intracervical administration has resulted in less overall use of Prepidil®.

15. Recommendations for Care
A minimum of one to two hours of EFM
Oxytocin can be initiated:
6 or more hours following a dose of either Prostin® or Prepidil®
30 to 60 minutes following removal of Cervidil®
The SOGC suggests that a 20 minute electronic fetal monitoring tracing be obtained prior to administration of PGE2 and that monitoring be carried out for a minimum of 1-2 hours following. If the tracing is normal, and if labour ensues and no additional inducing agents are required, the FHR can be assessed by intermittent auscultation and contractions assessed by palpation only. If adverse effects develop following administration of PGE2, monitoring should be maintained and the primary care provider notified. Efforts to promote intrauterine resuscitation should be initiated as indicated and Cervidil® , if used, should be removed.
There is no good evidence with respect to outpatient use of PGE2 . Practices vary across Canada; in some facilities use of Cervidil® requires hospital admission.
If necessary, oxytocin can be initiated 6 or more hours following administration of either Prostin® or Prepidil® and 30 to 60 minutes following removal of Cervidil®.

16. Misoprostol (PGE1)
Misoprostol (PGE1) is only recently recommended for cervical ripening and induction in Canada – SOGC, 2013
Dosage: 50 mcg orally or 25 mcg vaginally; repeat q4h as long as contractions are absent or non-painful
Misoprostol (PGE1) has been recommended for cervical ripening and induction in Canada since the SOGC Induction of Labour Clinical Practice Guideline was revised and published in Its benefits are its low cost, ease of administration and effectiveness.
Misoprostol can be given orally (50 mcg) or vaginally in a smaller dose of 25 mcg. Misoprostol can be repeated q4h, as long as contractions are absent or non-painful.

17. Recommendations for Care
EFM prior to and for at least 30 minutes after each dose; monitor for at least 60 minutes if there is ’d uterine activity
Advised for inpatient use only and if fetal membranes are intact
Oxytocin can be initiated 4 hours following administration of misoprostol
The SOGC suggests EFM prior to and for 30 minutes following each dose. Monitoring should be resumed or continued for at least 60 minutes if there is increased uterine activity.
Misoprostol is advised for inpatient use only and only if membranes are intact. It is not an option for women with a previous cesarean section because of the risk of tachysystole, hypertonus, and uterine rupture.
If indicated, oxytocin can be initiated 4 or more hours following administration of misoprostol.

18. Methods of Induction
Amniotomy/ARM (artificial rupture of the membranes)
 levels of prostaglandin
Risks include: variable decelerations, infection and prolapsed cord
Oxytocin infusion
Two methods indicated for induction that are ineffective for cervical ripening are amniotomy (artificial rupture of the membranes or ARM) and oxytocin infusion:
ARM may be the sole method of induction or more commonly, used in combination with other methods. The effect of ARM is increased levels of prostaglandin. Risks include variable decelerations, infection, and prolapsed cord.
Oxytocin has been widely used for many years, either alone or in combination with other methods in approximately 75% of all inductions in Nova Scotia.
Note that ARM and/or oxytocin are utilized to augment labour that has slowed or stopped in the active first stage or second stage of labour. The physiologic effects of these methods are the same for both an induction and augmentation. Unless noted specifically in upcoming slides, protocols and safe practices related to oxytocin for induction or augmentation are the same.

19. Oxytocin Infusion
Oxytocin binds to receptor cells distributed throughout the myometrium, stimulating contractions. Uterine response to oxytocin is widely variable. Oxytocin is one of 12 ‘high-alert’ medications identified by the Institute of Safe Medication Practices (ISMP).
Oxytocin binds to receptor cells that are distributed throughout the uterus, stimulating contractions. The number of receptor cells increases prior to and during labour, contributing to the increase in the frequency and strength of contractions throughout labour.
The uterine response to oxytocin is widely variable which means that for some women, a small dose of oxytocin will have a negligible effect while for others the same small dosage will result in tachysystole or hypertonus.
This variable effect was a probable factor in the decision of the Institute of Safe Medication Practices to add oxytocin to the list of ‘high alert’ medications; one of 12 ‘high alert’ medications identified. Medications are designated as ‘high alert’ when there is a heightened risk of causing significant patient harm when used in error.

20. 10 U Oxytocin added to 1L R/L or NS:
Safe Use of Oxytocin
IV infusion, in mU/min.
Titrate according to a prescribed protocol, and maternal and/or fetal response
Synthetic Oxytocin for induction (or augmentation) is administered by IV infusion, piggybacked to a mainline through the port closest to the IV site. It is ordered and documented by dosage in mU/min. The dosage is titrated in a step-wise fashion following a clearly prescribed protocol and according to maternal and/or fetal response.
In each unit, a single protocol that describes mixing of the infusion, titration, and management should be used consistently by all members of the team. If one 10-unit vial of Oxytocin is added to 1 liter of R/L or N/S, 1 mU/min of oxytoxin will be administered at an IV rate of 6ml/hour.
10 U Oxytocin added to 1L R/L or NS:
1mU/min=6ml/hr

21. Oxytocin Protocols Low-dose/regular dose protocol:
initiate at 2 mU/min and increase by 2 mU/min q 30 minutes
High-dose protocol:
initiate at 4 mU/min and increase by 4 mU/min q 30 minutes
*Always titrated according to maternal and/or fetal response
There are low and high dose protocols for oxytocin induction described in the literature.
The low-dose protocol is also referred to as a regular dose protocol and is used most commonly in Nova Scotia. With this protocol oxytocin is initiated at 2 mU/min and is increased by 2 mU/min every 30 minutes.
There are instances where use of a high dose oxytocin protocol is required following reassessment of the women’s progress and fetal wellbeing. With the high dose protocol oxytocin is initiated at 4 mU/min and is increased by 4 mU/min every 30 minutes.
Tachysystole is more likely to occur when the high dose protocol is used. Again a reminder that the dose is always titrated according to maternal and/or fetal response.

22. Electronic Fetal Monitoring
The SOGC (2007) recommends…
During induction:
CEFM while the infusion is being titrated
Interrupting CEFM for periods of up to 30 mins. once the infusion is stable and provided the tracing is normal
During augmentation:
CEFM
For induction the SOGC recommends continuous electronic fetal monitoring while the rate of the oxytocin infusion is being titrated. Continuous electronic fetal monitoring (CEFM) can be interrupted for periods of up to 30 minutes (for ambulation, personal care and hydrotherapy) once the infusion is stable and provided the tracing is normal.
Continuous monitoring should be maintained when oxytocin is used for augmentation of dysfunctional labour.

23. Recommendations from the RCP QA Review Re: Oxytocin
A single protocol within each Labour and Birth Unit.
Initiate and maintain at the lowest rate possible
 or D/C if adverse effects occur.
 rate as active labour is established.
In the report from the provincial Quality Assessment Review of Induction of Labour, the RCP made these recommendations about Oxytocin:
There should be a single protocol for mixing and administering oxytocin within each Labour and Birth Unit;
Oxytocin should be initiated at a low dose and maintained at the lowest level possible to induce contractions of normal frequency, strength and duration;
The infusion should be reduced or discontinued if adverse effects occur; and
Care providers should be prepared to reduce the rate as active labour becomes established.

24. Recommended Actions for Tachysystole or Hypertonus
 oxytocin quickly until a normal contraction pattern (q2-3 minutes with seconds of relaxation in between) is reestablished.
D/C oxytocin if the abnormal pattern persists for ≥ 10 minutes, or if the FHR becomes atypical or abnormal.
There is a commonly held misconception that tachysystole and hypertonus are insignificant, unless or until the fetal heart rate becomes abnormal and there is a tendency among some care providers to continue the step wise increases in infusion the rate in spite of excessive uterine activity. There is insufficient evidence to support this practice and it is discouraged, particularly by patient safety organizations.
In the event of tachysystole or hypertonus, an oxytocin infusion should be quickly adjusted downward until a normal contraction pattern (i.e. every 2-3 minutes with seconds of relaxation in between) is reestablished. The infusion should be discontinued if the abnormal pattern persists for 10 minutes or more, or if the FHR becomes atypical or abnormal.

25. Restarting the Infusion
AWHONN* suggests:
If discontinued for < 30 minutes, the oxytocin should be restarted at ½ the rate at which the adverse response occurred.
If discontinued for > 30 minutes, oxytocin should be restarted at the initial dose.
*Association of Women’s Health, Obstetrics and Neonatal Nursing
Nurses often have questions about the rate at which oxytocin should be restarted if it is stopped because of tachysystole, hypertonus, or an abnormal fetal heart rate. There is very little evidence upon which to make a recommendation. However, AWHONN suggests that if discontinued for < 30 minutes, the oxytocin should be restarted at ½ the rate at which the adverse response occurred. If discontinued for more than 30 minutes, the oxytocin should be restarted at the initial dose.

26. Nursing Care 1:1 care Supportive care: Promote progress
Positioning/ambulation
Information and encouragement
Comfort and support
And finally….
supportive 1:1 nursing care during labour induction is essential. Safe care requires assessment of labour progress and measures to promote progress as labour becomes established. Because of the IV and continuous EFM, women induced with oxytocin are generally less able to be mobile and will likely need more assistance to change position and attend to their personal care and comfort. They will benefit from effective comfort measures, support and encouragement.
Induction may change a woman’s birth plan. It is helpful to review her plan and discuss her expectations in order to help her achieve her goals and to have a safe and satisfying birth experience.

27. Thank you!
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Thank you.
We welcome your feedback and we will incorporate it into new modules as they are being developed and when existing ones are being reviewed and revised. Please take a few moments to complete a short evaluation using the link provided below.
If you have any questions, please contact the RCP office at or by