Labour induction

Z35.9/Z51.2

• General measures
• Medicine treatment

If induction of labour is indicated, for medical reasons, for example pre-eclampsia, diabetes, or post-term pregnancy.

GENERAL MEASURES

Counsel the woman about the risks: failed induction or uterine hyperstimulation syndrome, which may require emergency Caesarean section.

Cervix favourable and confirmed HIV-uninfected mother

Artificial rupture of the membranes.

Cervix unfavourable (Bishop score <7)

Extra-amniotic Foley catheter with/without saline infusion:
Pass a Foley catheter with 30 mL bulb through cervix with sterile technique.
Inflate bulb with 50 mL water or sodium chloride 0.9%.
Tape catheter to thigh with light traction.
Alternatively, attach sodium chloride 0.9% 1 L with giving set to catheter, and infuse sodium chloride 0.9% at 50 mL/hour. Remove after 24 hours.

LoEIII

MEDICINE TREATMENT

Cervix favourable (Bishop score <7)

Extra-amniotic Foley catheter (as above) PLUS one of the options below:

LoEI [32]
Prostaglandins, e.g.:

• Dinoprostone gel, intravaginally, 1 mg.
  • Repeat after 6 hours.
  • Do not exceed 4 mg.

OR

• Dinoprostone tablets, intravaginally, 1 mg.
  • Repeat after 6 hours.
  • Do not exceed 4 mg.

LoEIII [33]

OR

• Misoprostol, oral, 20 mcg 2 hourly until in labour, or up to 24 hours.
  • Oral misoprostol may be given as freshly made-up solution of one 200 mcg tablet in 200 mL water, i.e. 1 mcg/mL solution. Give 20 mL of this solution 2 hourly.
  • Stop misoprostol administration when in established labour.
  • Maximum 24 hours.
  • Never use oxytocin and misoprostol simultaneously.
  • Misoprostol and other prostaglandins are contraindicated in women with previous Caesarean sections and in grand multiparous women.

Note:

• Misoprostol in larger doses than indicated here for labour induction at term, may cause uterine rupture.
• Only to be prescribed by a doctor experienced in Maternal Health.

Non-stress test and cardiotocography:

Note: Perform a non-stress test (NST), before starting the induction, and cardiotocography (CTG) within an hour of each dinoprostone insertion, to evaluate the fetal condition during labour induction.
When using oral misoprostol, do a baseline NST before commencing IOL, followed by CTG 4-hourly (prior to every alternate dose).
Repeat CTG once contractions have started, or more frequently only if clinically indicated.
LoEIII

Cervix favourable (Bishop score ≥7)

Amniotomy followed 2 hours later by:
LoEIII [34]

• Oxytocin, IV, 2 units in 200 mL sodium chloride 0.9%.
  • Start at an infusion rate of 12 mL/hour (i.e. 2 milliunits/minute). If absent or inadequate contractions, increase infusion rate according to the table below:

Note:

• It is safe to perform amniotomy in pregnant women with HIV on ART who have an undetectable plasma VL at delivery.

LoEII [35]

• Avoid oxytocin in women with previous Caesarean section or parity ≥ 5.
• Continuous electronic fetal heart rate monitoring is essential.
• Aim for adequate uterine contractions (3–5 contractions in 10 minutes). Once adequate contractions achieved, do not increase rate further.
• Most women will experience adequate contractions at a dose of 12 milliunits/minute.
• If tachsystole develops (> 5 contractions in 10 minutes), reduce or stop the oxytocin infusion to achieve 3-5 contractions in 10 minutes. If there are fetal heart rate abnormalities which persist despite stopping the oxytocin, administer salbutamol as above.