INDUCTION AND

AUGMENTATION
z
OF LABOR
Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE
Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Laparoscopy and Hysteroscopy
z To download lecture deck:
z

Reference

§ Cunningham FG, Leveno KJ, Bloom SL,

Spong CY, Dashe JS, Hoffman BL, Casey
BM, Sheffield JS (eds).William’s Obstetrics
24th edition; 2014; chapter 26 Induction and
Augmentation of Labor
z
OUTLINE
1. Definition
2. Labor induction indications
3. Labor induction contraindications
4. Labor Induction techniques
5. Labor induction risks
6. Preinduction cervical ripening
7. Methods of labor induction and augmentation
 z
DEFINITION

§ Induction: stimulation of contractions before the spontaneous onset of

labor, with or without ruptured membranes.
§ When the cervix is closed and uneffaced, labor induction will often
commence with cervical ripening, a process to soften and open the
cervix.
§ Augmentation refers to enhancement of spontaneous contractions
that are considered inadequate because of failed cervical dilation and
fetal descent

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Labor Induction: Indications

§ Induction is indicated when the benefits to either mother or fetus

outweigh those of pregnancy continuation.
1. membrane rupture without labor
2. gestational hypertension

3. oligohydramnios
4. nonreassuring fetal status

5. postterm pregnancy
6. various maternal medical conditions such as chronic hypertension and
diabetes
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Labor Induction: Contraindications

§ Methods to induce or augment labor are contraindicated by most

conditions that preclude spontaneous labor or delivery.
1. prior uterine incision type
2. contracted or distorted pelvic anatomy
3. abnormally implanted placentas
4. uncommon conditions such as active genital herpes infection or cervical
cancer.
5. Fetal factors include appreciable macrosomia, severe hydrocephalus,
malpresentation, or nonreassuring fetal status.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Labor Induction: Techniques

§ Oxytocin
§ Prostaglandins (misoprostol and dinoprostone)
§ Mechanical methods: stripping of membranes, artificial rupture of
membranes, extraamnionic saline infusion, transcervical
balloons, and hygroscopic cervical dilators

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Labor Induction: Risks
1. cesarean delivery (2-3 fold increased risk in nulliparas)
2. Chorioamnionitis (Women whose labor is induced with amniotomy have an
increased incidence of chorioamnionitis compared with those in spontaneous
labor)
3. uterine scar rupture
§ labor induction using oxytocin without prostaglandins: 5-fold increased risk

§ Labor induction using oxytocin + prostaglandins 15.6-fold increased risk

§ spontaneous labor: 3-fold increased risk
The American College of Obstetricians and Gynecologists (2013d) recommends
against the use of misoprostol for preinduction cervical ripening or labor
induction in women with a prior uterine scar

4. postpartum hemorrhage from uterine atony

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Labor Induction: Factors Affecting
Successful Induction
§ Favorable factors include multiparity, body mass index (BMI) < 30, favorable
cervix, and birthweight < 3500
§ a latent phase as long as 18 hours during induction allowed most of these
women to achieve a vaginal delivery without a significantly increased risk of
maternal or neonatal morbidity.
§ Rouse and associates (2000) recommend a minimum of 12 hours of uterine
stimulation with oxytocin after membrane rupture.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Preinduction Cervical Ripening

§ pharmacological and mechanical methods that can enhance

cervical favorability
§ The condition of the cervix—described as cervical
“ripeness” or “favorability”— is important for a successful
labor induction.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Cervical Favorability
§ One quantifiable method used to predict labor induction outcomes is by
using BISHOP SCORE
§ As Bishop score decreases, the success rate of labor induction declines.

§ A Bishop score of 9 conveys a high likelihood for a successful

induction.

§ Bishop score of 4 or less identifies an unfavorable cervix and may be

526 Labor
an indication for cervical ripening.
TABLE 26-2. Bishop Scoring System Used for Assessment of Inducibility
Cervical Factor
Score Dilatation (cm) Effacement (%) Station (–3 to +2) Consistency Position
SECTION 7

C u n n in g h a m F G , L e ve n o K J ,
B lo o m S L , S p o n g C Y, D a s h e 0 Closed 0–30 –3 Firm Posterior
JS , H o ffm a n B L , C a se y B M , 1 1–2 40–50 –2 Medium Midposition
S h e ffie ld JS (e d s ).W illia m ’s
O b s te trics 2 4 th e d itio n ; 2 0 1 4 ; 2 3–4 60–70 –1 Soft Anterior
ch a p te r 2 6 In d u ctio n a n d 3 ≥5 ≥ 80 +1, +2 — —
A u g m e n ta tio n o f L a b o r

From Bishop, 1964.

Cervical
z
Ripening: Pharmacologic
Techniques

1. Prostaglandin E2
§ Dinoprostone is a synthetic analogue of prostaglandin E2. It is
commercially available in three forms: a gel, a time-release vaginal
insert, and a 10-mg suppository.
§ the gel and time-release vaginal insert formulations are indicated only for
cervical ripening before labor induction.

§ Dinoprostone gel: With the woman supine, the tip of a prefilled syringe is
placed intracervically, and the gel is deposited just below the internal
cervical os. After application, the woman remains reclined for at least 30
minutes. Doses may be repeated every 6 hours, with a maximum of 3
doses recommended in 24 hours.
C u n n in g h a m F G , L e v e n o K J , B lo o m S L , S p o n g C Y , D a sh e JS , H o ffm a n B L , C a se y B M , S h e ffie ld J S (e d s ).W illia m ’s O b s te trics 2 4 th e d itio n ; 2 0 1 4 ; c h a p te r 2 6
In d u ctio n a n d A u g m e n ta tio n o f L a b o r
 also stimulate contractions and thereby aid subsequent labor
induction or augmentation. Techniques most commonly used
for preinduction cervical ripening and induction include sev-

Cervical Ripening: Pharmacologic

eral prostaglandin analogues.

Prostaglandin E2
z Dinoprostone is a synthetic analogue of prostaglandin E2. It is

Techniques commercially available in three forms: a gel, a time-release vagi-

nal insert, and a 10-mg suppository. The gel and time-release
vaginal insert formulations are indicated only for cervical ripen-
ing before labor induction. However, the 10-mg suppository is
indicated for pregnancy termination between 12 and 20 weeks
and for evacuation of the uterus after fetal demise up to 28 weeks.
Local application of dinoprostone is commonly used for cervical
ripening (American College of Obstetricians and Gynecologists,
1. Prostaglandin E2 2013b). Its gel form—Prepidil
— l—is available in a 2.5-mL syringe
for an intracervical application of 0.5 mg of dinoprostone. With
the woman supine, the tip of a prefilled syringe is placed intra-
Dinoprostone insert: thin, flat, rectangular polymeric waferstone
helddesignedwithin a
FIGURE 26-1 Cervidil vaginal insert contains 10 mg of dinopro-
§ cervically, and the gel is deposited just below the internal cervical
to release approximately 0.3 mg/hr during a
os. After application, the woman remains reclined for at least
10-hour period.

small, white, mesh polyester sac. e sac has a long attached tail to allow
easy removal from the vagina. the insert provides slower release of
medication—0.3 mg/hr—than the gel form.
§ used as a single dose placed transversely in the posterior vaginal fornix.
Following insertion, the woman should remain recumbent for at least 2
hours. The insert is removed after 12 hours or with labor onset and at
least 30 minutes before the administration of oxytocin.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
Cervical
z
Ripening: Pharmacologic
Techniques

1. Prostaglandin E2
§ Prostaglandin E2 preparations should only be administered in or near
the delivery suite to guard against uterine tachysystole

§ When contractions begin, they are usually apparent in the first hour and
show peak activity in the first 4 hours.

§ oxytocin induction that follows prostaglandin use for cervical ripening

should be delayed for 6 to 12 hours following prostaglandin E2 gel
administration or for at least 30 minutes after removal of the vaginal
insert.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
Cervical
z
Ripening: Pharmacologic
Techniques
1. Prostaglandin E2
§ Side Effects.
§ Uterine tachysystole: >5contractions in a 10-minute period (It should always
be qualified by the presence or absence of fetal heart rate abnormalities)
§ Because uterine tachysystole associated with fetal compromise may
develop when prostaglandins are used with preexisting spontaneous labor,
such use is not recommended.

§ If tachysystole follows the 10-mg insert, its removal by pulling on the tail
of the surrounding net sac will usually reverse this effect. Irrigation to
remove the gel preparation has not been shown to be helpful.
Cervical
z
Ripening: Pharmacologic
Techniques
1. Prostaglandin E 2
§ Exercise caution for women with ruptured membranes, glaucoma or asthma.

§ Other contraindications include the following:

§ a history of dinoprostone hypersensitivity
§ suspicion of fetal compromise or cephalopelvic disproportion
§ unexplained vaginal bleeding

§ women already receiving oxytocin

§ 6 or more previous term pregnancies
§ contraindication to vaginal delivery

§ women with a contraindication to oxytocin or who may be endangered by prolonged uterine

contractions, for example, those with a history of cesarean delivery or uterine surgery.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
Cervical
z
Ripening: Pharmacologic
Techniques

2. Prostaglandin E1
§ Considered illegal in the Philippines, but still used in some other countries as
the preferred cervical ripening agent.
§ Misoprostol—Cytotec—is a synthetic prostaglandin E1 that is approved as a
100- or 200-μg tablet for peptic ulcer prevention. It has been used “off label”
for preinduction cervical ripening and may be administered orally or
vaginally.

§ The American College of Obstetricians and Gynecologists (2013b)

reaffirmed its recommendation for use of the drug because of proven safety
and efficacy.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
Cervical
z
Ripening: Pharmacologic
Techniques
3. Nitric Oxide Donors
§ Rationale: nitric oxide is likely a mediator of cervical ripening; Also, cervical nitric
oxide metabolite concentrations are increased at the beginning of uterine
contractions; cervical nitric oxide production is very low in postterm pregnancy
§ isosorbide mononitrate and glyceryl trinitrate.
§ Isosorbide mononitrate induces cervical cyclooxygenase 2 (COX-2), and it also
brings about cervical ultrastructure rearrangement similar to that seen with
spontaneous cervical ripening.
§ Despite this, clinical trials have not shown nitric oxide donors to be as effective as
prosta- glandin E2 for cervical ripening
§ the addition of isosorbide mononitrate to either dinoprostone or misoprostol did not
enhance cervical ripening either in early or term pregnancy nor did it shorten time to
vaginal delivery
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 Bullarbo and colleagues (2007) reviewed rationale and use
of two nitric oxide donors, isosorbide mononitratee and glyceryl Chorion
Amnion
trinitrate. Isosorbide mononitrate induces cervical cyclooxygen-

Cervical Ripening: Mechanical

ase 2 (COX-2), and it also brings about cervical ultrastructure

SECTION 7
rearrangement similar to that seen with spontaneous cervical
ripening (Ekerhovd, 2002, 2003). Despite this, clinical trials
z
Techniques
have not shown nitric oxide donors to be as effective as prosta-
glandin E2 for cervical ripening (Chanrachakul, 2000b; Osman,
2006). Moreover, the addition of isosorbide mononitrate to
either dinoprostone or misoprostol did not enhance cervical 30 mL
ripening either in early or term pregnancy nor did it shorten Extraamnionic
time to vaginal delivery (Collingham, 2010; Ledingham, 2001; saline
Wölfler, 2006). A metaanalysis of 10 trials including 1889
women concluded that nitric oxide donors do not appear to

1. Transcervical Catheter be useful for cervical ripening during labor induction (Kelly,
2011).

§ a Foley catheter is placed through the internalTechniques

■ Mechanical cervical os, and
These include transcervical placement of a Foley catheter with
downward tension is created by taping the catheter to the thigh
or without extraamnionic saline infusion, hygroscopic cervi-
cal dilators, and membrane stripping. In a recent metaanaly-
FIGURE 26-2 Extraamnionic saline infusion (EASI) through a 26F
Foley catheter that is placed through the cervix. The 30-mL bal-
sis of 71 randomized trials including 9722 women, Jozwiak loon is inflated with saline and pulled snugly against the internal
and associates (2012) reported that mechanical techniques os, and the catheter is taped to the thigh. Room-temperature
§ A modi cation of this—extraamnionic saline infusion (EASI)—consists of reduced the risk of uterine tachysystole compared with pros- normal saline is infused through the catheter port of the Foley at
30 or 40 mL/hour by intravenous infusion pump.
taglandins, although cesarean delivery rates were unchanged.
a constant saline infusion through the catheter into the space between Trials comparing mechanical techniques with oxytocin found a
lower rate of cesarean delivery with mechanical methods. Trials
vaginal dinoprostone gel, dinoprostone vaginal inserts, and
the internal os and placental membranes comparing mechanical techniques with dinoprostone found a
vaginal misoprostol, reported similar outcomes between th
higher rate of multiparous women undelivered at 24 hours with
mechanical technique and the prostaglandin agents. Also
mechanical techniques. Another metaanalysis done to compare fewer overall cases of cardiotocographic changes were seen in
Foley catheter placement with intravaginal dinoprostone inserts
§ chorioamnionitis was significantly less frequent when infusion was done also found similar rates of cesarean delivery and less frequent
the mechanical technique group (Jozwiak, 2011, 2013a, 2014
Wang, 2014).
uterine tachysystole (Jozwiak, 2013a).
compared with no infusion—6 versus 16 percent. Hygroscopic Cervical Dilators
Transcervical Catheter
Cervical dilatation can be accomplished using hygroscopi
Generally, these techniques are only used when the cervix is osmotic cervical dilators, as described for early pregnancy ter
unfavorable because the catheter tends to come out as the cer- mination (Chap. 18, p. 365). These mechanical dilators hav
vix opens. In most cases, a Foley catheter is placed through the been successfully used for more than 40 years when inserted
internal cervical os, and downward tension is created by taping before pregnancy termination. They have also been used fo
the catheter to the thigh (Mei-Dan, 2014). A modification of cervical ripening before labor induction. Intuitive concern
this—extraamnionic saline infusion (EASI)—consists of a con- of ascending infection have not been verified. Thus, their us
stant saline infusion through the catheter into the space between appears to24 beth safe, although anaphylaxis has rarely followed
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics edition; 2014;
the internal os and placental membranes (Fig. 26-2). Karjane laminaria insertion (Lichtenberg, 2004). Dilators are attractiv
chapter 26 Induction and Augmentation of Labor and coworkers (2006) reported that chorioamnionitis was sig- because of their low cost. However, placement generally require
 z

Cervical Ripening: Mechanical Techniques

2. Hygroscopic Cervical Dilators

§ Laminaria

§ these mechanical dilators have been successfully used for more than 40
years when inserted before pregnancy termination.
§ their use appears to be safe, although anaphylaxis has rarely followed
laminaria insertion
§ Dilators are attractive because of their low cost.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics
24th edition; 2014; chapter 26 Induction and Augmentation of Labor
 z

Methods of Induction and Augmentation

§ Labor induction has primarily been done with the use of

amniotomy, prostaglandins, and oxytocin, alone or in
combination.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Methods of Induction and Augmentation

1. Prostaglandin E1
§ both vaginal and oral misoprostol are used for either
cervical ripening or labor induction.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z

Methods of Induction and Augmentation

2. Oxytocin
§ induction or augmentation may be continued with solutions of
oxytocin given by infusion pump.
§ first polypeptide hormone synthesized, an achievement for
which the 1955 Nobel Prize in chemistry was awarded
§ Oxytocin may be used for labor induction or for augmentation.
§ With oxytocin use, the American College of Obstetricians and
Gynecologists (2013b) recommends fetal heart rate and
contraction monitoring similar to that for any high-risk pregnancy.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z

Methods of Induction and Augmentation

2. Oxytocin
§ In general, oxytocin should be discontinued if the number of
contractions persists with a frequency of more than 5 in a 10-minute
period or more than seven in a 15-minute period or with a persistent
nonreassuring fetal heart rate pattern.
§ When oxytocin is stopped, its concentration in plasma rapidly falls
because the half-life is approximately 3 to 5 minutes.
§ uterus contracts within 3 to 5 minutes of beginning an oxytocin
infusion and that a plasma steady state is reached in 40 minutes.
§ uterine response to oxytocin increases from 20 to 30 weeks’
gestation and increases rapidly at term

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Methods of Induction and Augmentation

2. Oxytocin
§ Oxytocin Dosage. A 1-mL ampule containing 10 units usually is
diluted into 1000 mL of a crystalloid solution and administered by
infusion pump.
§ A typical infusate consists of 10 or 20 units, which is 10,000 or
20,000 mU or one or two 1-mL vials, mixed into 1000 mL of lactated
Ringer solution à results in an oxytocin concentration of 10 or 20
mU/mL, respectively.
§ To avoid bolus administration, the infusion should be inserted into
the main intravenous line close to the venipuncture site.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Methods of Induction and Augmentation
530 Labor

percent. As perhaps expe

TABLE 26-3. Various Low- and High-Dose Oxytocin
cantly more frequent wit
2. Oxytocin Regimens Regimens Used for Labor Induction
Other investigators re
Starting Incremental tal increases. Frigoletto (

SECTION 7
Dose Increase Interval coworkers gave oxytocin
Regimen (mU/min) (mU/min) (min) every 15 minutes. Merr
Although the regimens
0.5–1.5 1 15–40 4.5  mU/min, with incre
at first appear
2 4, 8, 12, 16, 15 and associates (1992) beg
disparate, if 20, 25, 30 15 minutes. Thus, there
there is no uterine High-dose 4 4 15 cols that at least appear d
activity, either regimen 4.5 4.5 15–30 cols from two institution
6 6a 20–40b
is delivering 12 mU/ 1. The Parkland Hospita
min by 45 minutes into a
With uterine tachysystole and after oxytocin infusion oxytocin at 6 mU/min
40 minutes, but it em
the infusion. is discontinued, it is restarted at the previous dose and
increased at 3 mU/min incremental doses. tachysystole.
b
Uterine tachysystole is more common with shorter 2. The University of Alab
intervals. col begins oxytocin at
Data from Merrill, 1999; Satin, 1992, 1994; Xenakis, 1995. every 15 minutes to 4
Thus, although the r
there is no uterine activity
Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor min by 45 minutes into t
 z
Methods of Induction and Augmentation

3) Amniotomy
§ Artificial rupture of the membranes—sometimes called surgical induction—can
be used to induce labor, and it always implies a commitment to delivery.

§ “Elective amniotomy” - Membrane rupture with the intention of accelerating

labor.

§ amniotomy at approximately 5-cm dilation accelerated spontaneous labor by 1 to

11⁄2 hours.
§ During amniotomy, to minimize cord prolapse risk, dislodgement of the fetal head
is avoided. For this, fundal or suprapubic pressure or both may be helpful.
§ Some clinicians prefer to rupture membranes during a contraction.
§ Because of the risk of cord prolapse or placenta abruptio, the fetal heart rate is
assessed before and immediately after amniotomy.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z
Methods of Induction and Augmentation

3) Amniotomy
§ With early amniotomy, however, there is an increased incidence of
chorioamnionitis.
§ main disadvantage of amniotomy used alone for labor induction is
the unpredictable and occasionally long interval until labor onset
§ “amniotomy augmentation” à performing amniotomy when labor is
abnormally slow.
§ the American College of Obstetricians and Gynecologists (2013a)
recommends the use of amniotomy to enhance progress in active
labor, but cautions that this may increase the risks of chorioamnionitis
and maternal fever.

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
 z

Methods of Induction and

Augmentation

4) Membrane Stripping
§ Fingers separate the chorionic membrane from the decidua of
the lower uterine segmentà releases prostaglandins

§ can induce labor and thereby prevent postterm pregnancy

§ Drawbacks of membrane stripping included pain, vaginal
bleeding, and irregular contractions without labor

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS (eds).William’s Obstetrics 24th edition; 2014;
chapter 26 Induction and Augmentation of Labor
z
SUMMARY

1. Definition
2. Labor induction indications
3. Labor induction contraindications
4. Labor Induction techniques
5. Labor induction risks
6. Pre-induction cervical ripening
7. Methods of labor induction and augmentation
z

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