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Sometimes it’s necessary

Sanjeevani was due one week ago. Her obstetrician has determined that the baby is doing well and the water around the baby is adequate. She has advised Sanjeevani to get admitted for induction of labour. Sania, on the other hand is 37 weeks pregnant. She has high blood pressure, which developed in pregnancy. It is best to induce labour and deliver the baby before the high blood pressure can affect the mother or foetus.

What is induction of labour? Induction of labour is the use of artificial means, such as a medication, to start the process of childbirth. Contrary to popular belief, induced labour is not more painful than natural labour.

Reasons for inducing labour

* Postdated pregnancy i.e. pregnancy that has continued 7 to 10 days past the due date

* Rupture of the membranes before labour has started

* Pregnancy induced hypertension (PIH) i.e. the mother has high blood pressure caused by the pregnancy

* Diabetes in pregnancy (especially if the mother is taking insulin to control the sugar levels)

* If the baby is small due to poor growth

* Separation of the placenta (abruption) from the inner lining of the uterus

* Logistical reasons (for example, the pregnant woman lives too far from a hospital or there is a history of fast labour)

* Death of the baby before birth (intrauterine foetal demise).

Ripening of the cervix For induction to succeed, the cervix (mouth of the uterus) must be favourable or ‘ripe’. A cervix that is still thick and closed is said to be unfavourable or ‘unripe’.

To improve the chances for a successful induction, the obstetrician will proceed with ripening of the cervix.

Stripping of the membranes is a procedure where the obstetrician inserts the examining finger through the opening of the cervix and gently detaches the membrane of the amniotic sac from the wall of the uterus. This may help start the process of ripening.

Ripening of the cervix is better achieved by using prostaglandin gel placed in the cervix, or prostaglandin tablets placed in the vagina or given orally.

Methods of inducing labour

Amniotomy If the cervix is favourable (thinned out and dilated), an amniotomy is often resorted to. Amniotomy is the process of rupturing the amniotic membranes and letting out the amniotic fluid. Though it may not be an effective method for labour induction by itself, it works well in combination with medications like oxytocin and prostaglandins.

Oxytocin The commonest drug used for the induction, the world over, is oxytocin. Oxytocin is the hormone that the body produces in spontaneous labour. It makes the uterus contract. For induction, a synthetic form of the drug is given intravenously (IV). The dosage of oxytocin is always low to begin with and then gradually increased till adequate and effective contractions set in. The contractions are monitored carefully to make sure that they are not stronger than what is safe for the mother and baby.

As with any procedure, induction of labour with oxytocin must be done according to standard protocols. This will help avoid any risk to the mother and baby.

Prostaglandin tablets As an alternative to oxytocin, prostaglandin tablets may be given orally. The dose is increased gradually till contractions start. Once labour has started, the contractions may be made stronger and more effective with the use of oxytocin given intravenously (IV).Prostaglandin tablets or gel are best avoided if the woman has had a previous caesarean section. Their usage may sometimes result in the previous scar giving way.

Risks of labour induction When monitored properly, induction of labour is very safe. As with any procedure, induction of labour carries some risk for the mother and baby. In some cases, there is a small risk of complications such as

* foetal distress where the baby is not tolerating labour well

* a Caesarean section which may need to be done if the induction is not successful or if there is foetal distress

* a tear or rupture of the uterus (rare)

When should labour not be induced? Induction of labour is not attempted when the placental position is abnormal, if the foetus is in an abnormal position or if there is a deep scar on the uterus because of a prior surgery.

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