We know an induction can sound scary, and understanding exactly what it involves is key. Ready to deliver and welcome your little one? There are some natural ways to induce labor.
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Balloon devices provide mechanical pressure directly on the cervix as the balloon is filled. A Foley catheter 26 Fr or specifically designed balloon devices can be used. The technique is described in Table 3. The catheter is introduced into the endocervix by direct visualization or blindly by locating the cervix with the examining fingers and guiding the catheter over the hand and fingers through the endocervix and into the potential space between the amniotic membrane and the lower uterine segment.
Additional steps that may be taken: Apply pressure by adding weights to the catheter end. Constant pressure: attach 1 L of intravenous fluids to the catheter end and suspend it from the end of the bed.
Saline infusion 12 : Inflate catheter with 40 mL of sterile water or saline. Remove six hours later or at the time of spontaneous expulsion or rupture of membranes whichever occurs first.
Information from references 7 , and 12 through Currently, several RCTs are comparing use of a balloon device with administration of an extra-amniotic saline infusion, laminaria, or prostaglandin E 2 PGE 2. Results from these trials indicate that each of these methods is effective for cervical ripening and each has comparable cesarean-section delivery rates in women with an unfavorable cervix.
The membranes are stripped by inserting the examining finger through the internal cervical os and moving it in a circular direction to detach the inferior pole of the membranes from the lower uterine segment. The Cochrane reviewers concluded that stripping of the membranes alone does not seem to produce clinically important benefits, but when used as an adjunct does seem to be associated with a lower mean dose of oxytocin needed and an increased rate of normal vaginal deliveries.
It is hypothesized that amniotomy increases the production of, or causes a release of, prostaglandins locally. Risks associated with this procedure include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding from placenta previa or low-lying placenta, and possible fetal injury.
The technique for performing amniotomy is described in Table 4. A pelvic examination is performed to evaluate the cervix and station of the presenting part.
A cervical hook is inserted through the cervical os by sliding it along the hand and fingers hook side toward the hand. The nature of the amniotic fluid is recorded clear, bloody, thick or thin, meconium. Information from references 7 and Only two well-controlled trials studied the use of amniotomy alone, and the evidence did not support its use for induction of labor. Prostaglandins act on the cervix to enable ripening by a number of different mechanisms.
They alter the extracellular ground substance of the cervix, and PGE 2 increases the activity of collagenase in the cervix. They cause an increase in elastase, glycosaminoglycan, dermatan sulfate, and hyaluronic acid levels in the cervix. A relaxation of cervical smooth muscle facilitates dilation. Finally, prostaglandins allow for an increase in intracellular calcium levels, causing contraction of myometrial muscle.
Currently, two prostaglandin analogs are available for the purpose of cervical ripening, dinoprostone gel Prepidil and dinoprostone inserts Cervidil. Prepidil contains 0. The techniques for gel and pessary placement are described in Tables 5 and 6 , respectively.
Patient is afebrile. No active vaginal bleeding is present. Fetal heart rate tracing is reassuring. Patient gives informed consent. Bring gel to room temperature before application, per manufacturer's instructions. Monitor fetal heart rate and uterine activity continuously starting 15 to 30 minutes before gel introduction and continuing for 30 to minutes after gel insertion. If the cervix is uneffaced, use the mm endocervical catheter to introduce the gel into the endocervix just below the level of the internal os.
If the cervix is 50 percent effaced, use the mm endocervical catheter. After application of the gel, the patient should remain recumbent for 30 minutes before being allowed to ambulate. End points for ripening include strong uterine contractions, a Bishop score of 8, or a change in maternal or fetal status.
Do not start oxytocin for six to 12 hours after placement of the last dose, to allow for spontaneous onset of labor and protect the uterus from overstimulation. Information from Hadi H. Cervical ripening and labor induction: clinical guidelines.
Clin Obstet Gynecol ;— Patient selection see Table 5. Using a small amount of water-miscible lubricant, place the tab into the posterior fornix of the cervix. As the device absorbs moisture and swells, it releases dinoprostone at a rate of 0. Monitor fetal heart rate and uterine activity continuously, starting 15 to 30 minutes before introduction of the insert.
Because hyperstimulation may occur up to nine and one-half hours after placement of the insert, fetal heart rate and uterine activity should be monitored from placement of the insert until 15 minutes after it is removed. Remove the insert by pulling the cord after 12 hours, when active labor begins, or if uterine hyperstimulation occurs. The Cochrane reviewers examined 52 well-designed studies using prostaglandins for cervical ripening or labor induction. Compared with placebo or no treatment , use of vaginal prostaglandins increased the likelihood that a vaginal delivery would occur within 24 hours.
In addition, the cesarean section rate was comparable in all studies. The only drawback appears to be an increased rate of uterine hyperstimulation and accompanying FHR changes.
Misoprostol Cytotec is a synthetic PGE 1 analog that has been found to be a safe and inexpensive agent for cervical ripening, although it is not labeled by the U. Food and Drug Administration for that purpose. Clinical trials indicate that the optimal dose and dosing interval is 25 mcg intravaginally every four to six hours.
Risks also include tachysystole, defined as six or more uterine contractions in 10 minutes for two consecutive minute periods, and hypersystole, a single contraction of at least two minutes' duration. Finally, uterine rupture in women with previous cesarean section is also a possible complication, limiting its use to women who do not have a uterine scar.
Place one fourth of a tablet of misoprostol intravaginally, without the use of any gel gel may prevent the tablet from dissolving. Monitor fetal heart rate and uterine activity continuously for at least three hours after misoprostol application before the patient is allowed to ambulate. When oxytocin Pitocin augmentation is required, a minimum interval of three hours is recommended after the last misoprostol dose. A randomized trial of misoprostol and extra-amniotic saline infusion for cervical ripening and labor induction.
Obstet Gynecol ;91 5 pt 1 —9. The Cochrane reviewers concluded that use of misoprostol resulted in an overall lower incidence of cesarean section. In addition, there appears to be a higher incidence of vaginal delivery within 24 hours of application and a reduced need for oxytocin Pitocin augmentation. Mifepristone Mifeprex is an antiprogesterone agent. Progesterone inhibits contractions of the uterus, while mifepristone counteracts this action.
Currently, seven trials are underway involving women using mifepristone for cervical ripening. Results have shown that women treated with mifepristone are more likely to have a favorable cervix within 48 to 96 hours when compared with placebo.
In addition, these women were more likely to deliver within 48 to 96 hours and less likely to undergo cesarean section. However, little information is available about fetal outcomes and maternal side effects; thus, there is insufficient information to support the use of mifepristone for cervical ripening.
The hormone relaxin is thought to promote cervical ripening. Cochrane reviewers evaluated results of four studies involving women and concluded that there is insufficient support for the use of relaxin at this time. As with many of the other methods described in this review, further trials are needed. As pregnancy progresses, the number of oxytocin receptors in the uterus increases by fold at 32 weeks and by fold at the onset of labor.
Oxytocin activates the phospholipase C-inositol pathway and increases intracellular calcium levels, stimulating contractions in myometrial smooth muscle. Numerous randomized, placebo-controlled studies have focused on the use of oxytocin in labor induction. It has been found that low-dose physiologic and high-dose pharmacologic oxytocin regimens are equally effective in establishing adequate labor patterns.
Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. What happens with dilation? Visualize the mini-donut again. The cervical opening starts out like a dimple and gradually opens. One centimeter is the size of your fingertip, two centimeters the width of a penny and four centimeters is the size of a Ritz cracker.
Most of these things occur prior to the onset of labor. Some women are about two or three centimeters dilated when they start to go into labor, however you may not be dilated at all or sit around for weeks at four centimeters.
For some, it gives some false reassurance things will happen at any time. Others worry it never will. So many women focus on all these signs to give an indicator when the time is near.
But the truth is, no one knows when labor will begin. He or she will be worth the much anticipated wait. Maureen Boyle believes strongly in building a trusting relationship with her patients. She treats each woman as though they were her mother, sister or daughter, using that rule as a guide for finding the best treatment possible.
You can see Dr.
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