KHUH

WHO

NICE

ACOG

SOGC

FOGSI

Queensland

Non-Pharmacological Methods

Membrane Sweeping

-Before formal IOL

· Nulliparous: at 40-41 weeks

· Multiparous: at 41 weeks

-Alternative (if cerv-ix closed) cervical massage in vaginal fornices

-Can reduce formal IOL

-Before formal IOL

· Nulliparous: at 40-41 weeks

· Multiparous: at 41 weeks

-Alternative (if cerv-ix closed) cervical massage in vaginal fornices

-Increases chance of spontaneous labour within 48 hours

-Promotes onset of labour

-Alternative (if cervix closed) cervical massage in vaginal fornices

-Can be done at same time of assessing cervix prior to induction

-Can repeat if labour does not spontaneously start

-Can reduce formal IOL

-Alternative (if cerv-ix closed) cervical massage in vaginal fornices

-Can reduce formal IOL

Amniotomy

After procedure:

-Document liquor colour and consistency

-Encourage mobilization

-Not recommended alone for IOL

-Can be used in combination with oxytocin if there is a risk of uterine hyperstimulation (where PGE₂ cannot be used)

-Performed as IOL if cervix favourable

-Shorter induction to delivery interval if combined with oxytocin

NA

-Not recommended alone for IOL

During procedure:

-Control flow of amniotic fluid with fingers in vagina. Slowly drain liquor to avoid sudden decompression of uterus

-Effective when membranes accessible and cervix favourable

-Creates commitment to delivery

-Perform if cervix favourable

-Avoid ARM over face

After procedure:

-Observe color and amount of liquor and commence oxytocin immediately after amniotomy or 2 hours after based on intensity of uterine contractions

Pharmacological Methods

Prostaglandin E₂

-Preferable to use if unfavourable cervix

-Forms and Dosing:

· 2 doses of 3mg tablet 6 hours apart

OR

· 1 controlled-release vaginal pessary containing PGE₂

-Forms: gel, tablet, vaginal pessary

-Preferred method

-Forms and Dosing:

Vaginal PGE₂ gel or tablets:

· 2 doses every 6 hours

· maximum of 2 doses

OR

-Forms and Dosing:

Intracervical gel:

· 2.5g/0.5mg PGE₂ every 6-12 hours

· maximum of 3 doses in 24 hours

OR

-Use to ripen unfavourable cervix

-Forms and Dosing:

Intravaginal gel:

· 1 or 2 mg

Intracervical gel:

· 0.5 mg

OR

-Forms and Dosing:

Intracervical gel

· 3g/0.5 mg PGE₂ every 6-8 hours

· maximum of 3 doses in 24 hours

OR

-Forms and Dosing:

Intravaginal gel

· 1mg (multiparous) 2mg (nulliparous) every 6 hours

· maximum dose of < 3 mg in 6 hours

OR

· 1 controlled-release vaginal pessary containing 10mg PGE₂ once in 24 hours

NA

-Caution: do not use in VBAC

NA

Oxytocin

-Preferable to use if favourable cervix

-Perform ARM first if membranes are intact

-Dosing: start infusion with 1 mU/min and increase dose every 30 minutes

Do not give oxytocin

< 6 hours after last dose of vaginal PGE₂

-Stop if:

· Hypertonic contractions

· Increased resting uterine tone

· Signs of fetal compromise

-Use oxytocin alone when PG unavailable

Do not give oxytocin

alone

Dosing (mU/min)

Low Dose Regimen

-Perform ARM first if membranes are intact

-Dosing: start infusion with 1mU/min and increase dose at ≥ 30 minutes

-Stop oxytocin if labour established

-Restart infusion if

· <30 minutes: half previous rate

· >30 minutes: initial rate

Start with 0.5-2 and increase with increments of 1-2 mU/min 15-40 minutes apart

Start with 1-2 and increase with increments of 1-2 mU/min 30 minutes apart

High Dose Regimen

Start with 6 and increase with increments of 3-6 mU/min 15-40 minutes apart

Start with 4-6 and increase with increments of 4-6 mU/min 15-30 minutes apart

Do not give oxytocin

· < 4 hours after last misoprostol dose

-For favourable cervix

-Use:

· Alone

· With ARM

· If PG unavailable

· < 6-12 hours after maxi-mum dose of PG

· < 30-60 minutes after removing vaginal pessary

Do not administer bolus

NA

Do not give oxytocin

· < 6 hours after administering PGE₂ gel

· < 30 minutes after removing PGE₂ pessary

Misoprostol

NA

-Use only in non-scarred uterus

-Dosing: 25 mcg

· Orally every 2 hours

OR

· Vaginally every 6 hours

-Use for IUFD

To only be used in the case of IUFD

-Uses: cervical ripening and IOL

Not approved for IOL by Drug Controller General of India

Not recommended for live birth

-Dosing:

(oral, sublingual or intravaginal):

· 25 mcg every 3-6 hours

OR

· 50 mcg every 6 hours

-Dosing:

· 25 mcg vaginally every 4 hours

OR

· 50 mcg orally every 4 hours with water

Do not give misoprostol

- If previous CS or < 4 hours after last misoprostol dose

Mifepristone

NA

NA

Not recommended

NA

Mechanical Methods

Laminaria Tents

NA

-Can be used

Not recommended

-Osmotic dilator for cervical ripening

NA

Not recommended

Balloon Catheters

-Recommended for IOL

-Alternative method of IOL if PG unavailable: combine balloon catheter with oxytocin

Double balloon catheter (uterine and vaginal) with traction

-Keep in place for 12 hours

-Deflate and remove device if:

· Labour begins

· Device expels spontaneously

· Membranes ruptured

· Suspecting fetal distress

- For cervical ripening and IOL

Single balloon catheter

-Foley catheter: 14-26 Fr with inflation volume of 30-80 ml

Double balloon catheter

- Atad Ripener device

-Extra-amniotic saline infusion with rate of 30-40 ml/hr

Single balloon catheter

-Foley catheter: 18 Fr with inflation volume of 30-60 ml and traction

Double balloon catheter

-Second line alternative

-Use in scarred uterus and unfavourable cervix with no signs of infection

-Apply small amount of traction on catheter

Single balloon catheter

Inflate uterine balloon with 30-80 ml

Double balloon catheter

Inflate uterine balloon with 40 ml and vaginal balloon with 20 ml

-After removal, perform VE and plan for ARM and oxytocin

-Leave catheter in place until it spontaneously falls after 24 hours

Abbreviations: NA: not applicable; IOL: induction of labour; FHR: fetal heart rate; CTG: cardiotocograph; ARM: artificial rupture of membranes; PG: prostaglandin; CS: Cesarean section; PGE₂: prostaglandin E₂; APH: antepartum haemorrhage; GBS: group B streptococcus; VBAC: vaginal birth after Cesarean; C/I: contraindications; VE: vaginal examination