1. Induction of Labour- Complications

2. Senior Specialist & HOD, OBGYN, Ibra Hospital, Oman
Dr. Sulsa M. Jain
(MBBS,MD,DNB,MRCOG)
Senior Specialist & HOD, OBGYN, Ibra Hospital, Oman

3. Topics Covered Introduction about IOL General complications of IOL
IOL & lscs
How can we avoid complications during IOL
Oxytocin and IOL
Care of various high risk pregnancies during IOL to avoid complications
Prostaglandins and IOL
Sweeping stretching
Artificial rupture of membranes
Intracervical Foleys catheter balloon

4. Introduction
Labor induction appears to be becoming more and more popular. In fact, between 15% and 30% of pregnant women choose to have labor induced in one or more of their pregnancies.

5. An intervention designed to artificially initiate uterine contractions leading to progressive dilatation and effacement of the cervix and birth of the baby.
This includes both women with intact membranes and women with spontaneous rupture of the membranes but who are not in labour.
The term is usually restricted to pregnancies at gestations greater than the legal definition of fetal viability(26wk)

6. Complications of Induction
May fail and require caesarean section.
All the complications of a normal vaginal delivery, plus:
Uterine hyperstimulation; fetal distress and hypoxic damage to the baby
Uterine rupture, especially in multiparous women
Intrauterine infection with prolonged membrane rupture without delivery (less likely if labour occurs within 12 hours)
Prolapsed cord can occur with first rush of amniotic fluid, if presenting part not well engaged
Amniotic fluid embolism

7. Induced labour has an impact on the birth experience of women. 
It is less efficient
and more painful than spontaneous labour, often leading to the increased use of analgesics and other pain-relieving pharmaceuticals
and is also more likely to require epidural anaesthesia and assisted delivery. 
1.5x increased risk of operative vaginal delivery and 1.8x increased risk of caesarean

8. When to induce
Until recently, the most common practice has been to induce labor by the end of the 42nd week of gestation. This practice is still very common. Recent studies have shown an increasing risk of infant mortality for births in 41st and particularly 42nd week of gestation, as well as a higher risk of injury to the mother and child .
The recomended date for induction of labor has therefore been moved to the end of the 41 week of gestation in many countries including Sweden and Canada.

9. IOL & LSCS
It has been said that IOL has lead to an increased likelihood of caesarean section delivery for the baby. (Roberts 2000). However, studies into this matter indicates that induction has no effect on the rates of caesarean section. Two more recent studies have shown that induction may increase the risk of caesarean section if performed before the 40th week of gestation, but has no effect or actually lowers the risk if performed after the 40th week.

10. How to avoid complications
It should be used when it is thought that the baby will be safer delivered than it is in utero.
The process of induction of labour should only be considered when vaginal delivery is felt to be the appropriate route of delivery
Verbal advice should be supported by accurate printed information, in a format that women can understand and which they may take away with them and read before the procedure.

11. Check prior to induction
Lie
position
amniotic fluid
cervix this is best predictor of readiness for induction and can be scored using Bishop's system: If score >8, probability of successful delivery with induction as same as spontaneous onset of labour.
tone of uterus

12. When undertaking induction of labour in women, with recognized risk factors (e.g. Including suspected fetal growth compromise, previous caesarean section and high parity) the clinical discussion regarding the timing and method of induction of labour should be undertaken at consultant level.
The induction process should not occur on an antenatal ward. C

13. Wherever induction of labour occurs, facilities should be available for continuous uterine and FHR monitoring. (C)
And also the facilities for performing vaginal instrumental delivery and lscs should be there.

14. Where oxytocin is being used for
Oxytocin & IOL
Where oxytocin is being used for
induction or augmentation of labour,
continuous electronic fetal monitoring should
be used. (C)

15. A comparison of different regimens of oxytocin administration
To reduce error, a standard dilution should always be used. Suggested standardised dilutions and dose regimens include: C
30 iu in 500 ml of normal saline; hence 1ml/hr = 1milliunits oxytocin per minute
10 iu oxytocin in 500 ml of normal saline; hence 3 ml/hr = 1milliunits oxytocin per minute

16. In cases of uterine hypercontractility with a suspicious or pathological CTG secondary to oxytocin infusions, the oxytocin infusion should be decreased or discontinued. (B)
In the presence of abnormal FHR patterns and uterine hypercontractility (not secondary to oxytocin infusion), tocolysis should be considered. (A)

17. oxytocin Increased contractions Fetal distress Rupture uterus
Amniotic fluid embolism

18. Uterine hypercontractility
Tachysystole (more than five contractions per ten minutes for at least 20 minutes)
uterine hypersystole/hypertonus
(a contraction lasting at least two minutes).

19. Combination of oxytocin and other methods
Oxytocin should not be started for six hours following administration of vaginal prostaglandin.
In women with intact membranes, amniotomy should be performed where feasible prior to commencement of an infusion of oxytocin. C
When induction of labour is undertaken with oxytocin the recommended regimen is:
a starting dose of 1-2 milliunits per minute
increased at intervals of 30 minutes or more.

20. Comparison of oxytocin and prostaglandins for induction of labour
Prostaglandins should be used in preference to oxytocin when induction of labour is undertaken in either nulliparous or multiparous women with intact membranes, regardless of their cervical favourability. A
Either prostaglandins or oxytocin may be used when induction of labour is undertaken in nulliparous or multiparous women who have ruptured membranes, regardless of cervical status, as they are equally effective. A

21. Care of
higher-risk
pregnancies

22. with suspected fetal growth compromise
Fetus with compromised growth enter labour in an increased state of vulnerability and are more likely to become acidotic
No studies that considered induction of labour specifically in babies with suspected fetal growth compromise.

23. women with a previous caesarean section
Careful consideration of the risks of an induction of labour versus the risks of an elective caesarean section should be made in light of the woman's wishes and views.
Induction of women with previous caesarean section should follow the working algorithm with careful consideration of cervical status and membrane status.

24. Women with Breech
The perinatal mortality was lower for planned caesarean section compared with planned vaginal breech delivery .Hence, no conclusions can be reached from these data regarding induction of labour with a breech presentation.(1b)

25. women of high parity
Induction of labour in women of high parity with standard oxytocin regimens may be associated with an increase in uterine rupture.

26. Diabetic Mothers
Women who have pregnancies complicated by diabetes should be offered induction of labour prior to their estimated date for delivery. (c) However, the potential benefits of induction need to be balanced against the potential to increase the risk of pulmonary complications in the fetus.
The risk of macrosomia (birth weight over 4000 g) was reduced in those women who were actively induced (1a)

27. Multifetal pregnancy
The perinatal mortality rate in twin pregnancies is increased in comparison with singleton pregnancies at term.
No conclusions can be drawn from the available trial evidence relating to the merits of an active policy of induction of labour in uncomplicated multifetal pregnancies.

28. Prelabour Rupture of the Membranes
most women go into spontaneous labour within 24 hours of rupturing their membranes.
86% of women will labour within hours.
91% will labour within hours.
94% will labour within hours.
6% of women will not be in spontaneous labour within 96 hours of PROM. IIa

29. There is no difference in operative delivery rates between induction versus a conservative approach in women with prelabour rupture of the membranes.
A policy of induction of labour is associated with a reduction in infective sequelae for mother and baby.

30. Women with prelabour rupture of the membranes at term (over 37 weeks) should be offered a choice of immediate induction of labour or expectant management. A
Expectant management of women with prelabour rupture of the membranes at term should not exceed 96 hours following membrane rupture A

31. Macrosomic fetus
all methods currently used to estimate fetal size especially for large fetuses are poorly predictive.
the evidence is inconclusive that a policy of induction of labour for suspected fetal macrosomia in women who are not diabetic can reduce maternal or neonatal morbidity.

32. Maternal Request
Where resources allow, maternal request for induction of labour should be considered when there are compelling psychological or social reasons and the woman has a favourable cervix .

33. IOL with prostaglandin
For women who are healthy and have had assessment of fetal wellbeing following the administration of vaginal prostaglandins in an otherwise uncomplicated pregnancy, an initial assessment should be with continuous electronic fetal monitoring and, once normality is confirmed, intermittent monitoring can be used.

34. A comparison of intracervical and intravaginal prostaglandins (PGE2 )
When induction of labour is undertaken with prostaglandins, intravaginal PGE 2 should be used in preference to intracervical preparations, as they are equally effective and administration of vaginal PGE 2 is less invasive. A

35. Prostaglandin gels
These gels have been associated with nausea, fever, diarrhea.

36. A comparison of different preparations of vaginal prostaglandin (PGE2
Given that they are clinically equivalent, when induction of labour is undertaken with vaginal PGE 2 preparations, vaginal tablets should be considered in preference to gel formulations. A

37. Vaginal or oral misoprostol (PGE1)
The caesarean-section rate was not different between oral and vaginal preparations. Ia
Vaginal misoprostol appears to be a more effective induction agent than either intravaginal or intracervical PGE 2 or oxytocin.
Misoprostol is significantly cheaper than currently recommended PGE 2 preparations.

38. Misoprostol
The safety issues concerning the use of vaginal misoprostol are unclear.
Further clinical trials are warranted in order to evaluate further the issues of safety regarding the use of vaginal and oral misoprostol for induction of labour using commercially produced low-dose tablets

39. Membrane sweeping for induction of labour
Sweeping the membranes during a cervical examination is done to bring on labour in women at term.
Prior to formal induction of labour, women should be offered sweeping of the membranes. A
it is typically performed at your local clinic, and you can go home afterwards and wait for the results.
Sweeping the membranes is effective in bringing on labour

40. Membrane sweeping
The review of trials found that sweeping brings on labour and is generally safe where there are no other complications.
Sweeping reduces the need for other methods of labour induction such as oxytocin or prostaglandins
It is not associated with an increase in maternal or neonatal infection
but can cause discomfort, some bleeding and accidental rupture of the amniotic sac, irregular contractions.
However, these complications are quite rare.

41. Artificial Rupture of Membranes
Cochrane Review showed that amniotomy reduced labour by minutes, but did not improve outcome. There was also a perception of increased pain associated with the procedure and potentially more variable decelerations on cardiotocograph.

42. There are some risks associated with this technique, though
There are some risks associated with this technique, though. If too much time elapses between the procedure and labor, there is a possibility of infection. The technique can also increase your risk of experiencing intense contractions during labor.

43. trans-cervical Foley catheter for labor induction
The balloon had to be removed due to complications in 95 (8.8%). The main complications were:
acute transient febrile reaction in 32 (3%),
non-reassuring fetal heart rate tracing in 22 (2%),
vaginal bleeding in 20 (1.8%),
unbearable pain that necessitated removal of the catheter in 19 women (1.7%) and
altered presentation from vertex to breech in 14 (1.3%).

44. there is some evidence that the use of a foley catheter is linked with an increase in risk of having a subsequent preterm birth.

45. THANK YOU