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How to Treat Labour Induction?

Things to note:
  • Counsel the woman about the risks: failed induction or uterine hyperstimulation syndrome, which may require emergency caesarean section.
Cervix favourable and confirmed HIV negative mother
  • Artificial rupture of the membranes.
Cervix unfavourable
Extra-amniotic saline infusion: recommended if attempts at ripening the cervix with prostaglandins fail.
  • 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.
  • Attach sodium chloride 0.9% 1 L with giving set to catheter.
  • Infuse sodium chloride 0.9% at 50 mL/ hour.
  • Remove after 24 hours if catheter has not fallen out.

Medical Treatment:
Cervix favourable
Amniotomy (if HIV negative) followed 2 hours later by:
  • 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)
  • Avoid oxytocin in women with previous caesarean section or parity greater than or equal.
  • Oxytocin use requires continuous electronic fetal heart rate monitoring.
  • Aim for adequate uterine contractions (3-5 contractions in 10 minutes).
  • Most women will experience adequate contractions at a dose of 12 milliunits/minute.
  • If uterine hyperstimulation syndrome develops (greater than 5 contractions in 10 minutes with fetal heart rate abnormalities), stop the oxytocin infusion and administer salbutamol as above.
Cervix unfavourable
Prostaglandins, e.g:
  • Dinoprostone gel, intravaginally, 1 mg.
    • Repeat after 6 hours.
    • Do not exceed 3 mg.
  • Dinoprostone tablets, intravaginally, 1 mg.
    • Repeat after 6 hours.
    • Do not exceed 3 mg.
  • Perform a non-stress test (cardiotocography) within an hour of each dinoprostone insertion, to evaluate the fetal condition during labour induction.
  • 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.
  • If no response, consider extra-amniotic saline infusion.
  • Never use oxytocin and misoprostol simultaneously.
  • Misoprostol and other prostaglandins are contraindicated in women with previous Caesarean sections and in grand multiparous women.
  • Misoprostol is not registered for this indication in SA.
  • 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.
  • A non-stress test to be done 4-hourly during misoprostol administration.