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Referral and warning signs
When to refer
IOL should occur in hospital capable of monitoring & emergency C/S. Refer women needing IOL.
Red flags
- Uterine hyperstimulation
- Signs of fetal distress
- Suspected uterine rupture
- Significant bleeding
- Cord prolapse
Signs and symptoms
- Not applicable - Procedure description.
Risk factors
- Factors indicating need for IOL (post-term, PET, PROM etc.).
- Risks of IOL: Failed induction, Hyperstimulation, Fetal distress, Increased C/S rate, Uterine rupture, PPH.
Diagnosis
Clinical assessment
Assess indication, contraindications. Assess cervical favourability (Bishop score).
Investigations
- Confirm fetal presentation (cephalic).
- Assess fetal well-being.
- Assess cervical status (Bishop score).
Diagnostic criteria
Clear medical/obstetric indication for delivery, vaginal birth not contraindicated.
Management
Non-pharmacological management
- Counseling (indication, process, risks/benefits).
- Ensure appropriate facility (monitoring, C/S capable).
- Continuous maternal/fetal monitoring.
Pharmacological treatment
- Unfavourable Cervix (Low Bishop Score <6-8): Ripening First. Misoprostol (Vaginal 25mcg Q6H / Oral 20mcg Q2H - caution, contraindicated if previous C/S). Dinoprostone gel/pessary. Foley Catheter.
- Favourable Cervix (Bishop >=6-8) OR After Ripening: Amniotomy (ARM) + Oxytocin infusion within 1-2h. OR Oxytocin Infusion alone.
- - Oxytocin Infusion: Start low dose (e.g., ~2.5 mU/min), titrate gradually Q30min until adequate contractions (3-5/10min). Continuous monitoring essential. STOP if hyperstimulation/fetal distress.
- Contraindications: Previous classical C/S, Praevia, Vasa praevia, Active herpes, Transverse lie, Cord prolapse, CPD.
Monitoring
Continuous monitoring: Contractions, FHR, Maternal vitals, Labour progress (Partograph).
Complications
- Failed induction.
- Uterine hyperstimulation -> Fetal distress / Rupture.
- Cord prolapse (ARM).
- Infection.
- Increased C/S rate.
- PPH.
Prevention
- Careful patient selection.
- Accurate assessment.
- Appropriate method choice.
- Close monitoring.
- Adherence to protocols.
Patient education
- Reason for induction.
- Methods used.
- Process/timeline.
- Monitoring need.
- Pain relief.
- Risks/benefits.
- Possibility of C/S.
Uganda-specific notes
Common indications: Post-term, PET, PROM. Misoprostol common for ripening (use carefully). Strict Oxytocin protocols needed. Monitoring/C-S capacity essential.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 16, Section 16.4.2