Induction of Labor

G1P0 at ≥ 39 WGA with h/o GDM and new onset preeclampsia presents for induction of labor (IOL). Gravid uterus; vertex per Leopold’s and ultrasound.

  • Obtain GBS swab results prior to induction

  • ACOG Induction of Labor Safety Checklist reviewed before induction

  • Bishop score < 6: Initiate cervical ripening prior to IOL

    • Mechanical cervical dilation (select one)

      • Laminaria japonica; risk of peripartum infection discussed with pt

      • Foley balloon (14-26 French)

    • No h/o c-section: PGE analogues

      • Misoprostol (Cytotec, PGE1) 25 mcg intravaginally q4h for 6 doses

      • Dinoprostone (Cervidil, PGE2) 10 mg insert; recheck after 12 hours

    • Other

      • H/o C-section: Start low dose pitocin at 0.5 mU/min and increase 1 mU every 30 minutes

      • Consider amniotomy in addition to Pitocin to reduce induction-to-delivery interval

      • Pt advised to try nipple stimulation

  • Bishop ≥ 7: Start Pitocin 2 mU/min; increase by 2 mU/min every 30 minutes to achieve contractions q3 minutes (maximum 40 mu/min)

    • Fetal head engaged and not ballotable: Consider amniotomy

    • Stop pitocin if any of the following are observed; restart at 2 mU/min and retitrate once resolved

      • Tachysystole, i.e. > 5 contractions/10 min averaged over 30 min

      • Repeat decelerations on fetal heart tracing

  • Stop induction due to failure to progress if no appreciable cervical change observed after 24 hours


Notes

  • Elective induction

    • Do not perform before 39 WGA; research into benefit between 39 and 41 weeks is ongoing

    • Cervical ripening vs. beginning pitocin at Bishop score 6-7 is provider and patent dependent

  • IOL indications

    • Abruptio placenta

    • Chorioamnionitis

    • Fetal demise

    • Gestational HTN

    • Preeclampsia

    • Post term pregnancy

    • Maternal medical condition (DM, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)

    • Fetal compromise (severe fetal growth restriction, isoimmunization, oligo/polyhydramnios)

  • IOL contraindications

    • Vasa previa or complete placenta previa

    • Transverse fetal lie

    • Umbilical cord prolapse

    • Previous classical c-section

    • Active genital herpes infection

    • Previous myomectomy entering endometrial cavity