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Induction of Labor

By Julie S. Moldenhauer, MD, Associate Professor of Clinical Obstetrics and Gynecology in Surgery, The Garbose Family Special Delivery Unit; Attending Physician, The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia; The University of Pennsylvania Perelman School of Medicine

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Induction of labor is stimulation of uterine contractions before spontaneous labor to achieve vaginal delivery.


Induction of labor can be

  • Medically indicated (eg, for preeclampsia or fetal compromise)

  • Elective (to control when delivery occurs)

Before elective induction, gestational age must be determined. Elective induction is not recommended before 39 wk.

Contraindications to induction include having or having had the following:

  • Fundal uterine surgery

  • Open fetal surgery (eg, myelomeningocele repair)

  • Myomectomy involving entry into the uterine cavity

  • Prior classic or vertical cesarean incision in the thickened, muscular portion of the uterus

  • Active genital herpes

  • Placenta or vasa previa

  • Abnormal fetal presentation (eg, transverse lie, umbilical cord presentation, certain types of fetopelvic disproportion)

Multiple prior uterine scars and breech presentation are relative contraindications.


If the cervix is closed, long, and firm (unfavorable), the goal is to cause the cervix to open and become effaced (favorable). Various pharmacologic or mechanical methods can be used. They include

  • Misoprostol 25 mcg vaginally q 3 to 6 h

  • Prostaglandin E2 given intracervically (0.5 mg) or as an intravaginal pessary (10 mg) (Prostaglandins are contraindicated in women with prior cesarean delivery or uterine surgery because these drugs increase the risk of uterine rupture.)

  • Oxytocin in low or high doses

  • Use of laminaria and transcervical balloon catheters, which may be useful when other methods are ineffective or contraindications exist

Once the cervix is favorable, labor is induced.

Constant IV infusion of oxytocin is the most commonly used method; it is safe and cost-effective. Low-dose oxytocin is given at 0.5 to 2 milliunits/min, increased by 1 to 2 milliunits/min, usually q 15 to 60 min. High-dose oxytocin is given at 6 milliunits/min, increased by 1 to 6 milliunits/min q 15 to 40 min to a maximum of 40 milliunits/min. With doses >40 milliunits/min, excessive water retention may lead to water intoxication. Use of oxytocin must be supervised to prevent uterine tachysystole (> 5 contractions in 10 min averaged over 30 min), which may compromise the fetus.

External fetal monitoring is routine; after amniotomy (deliberate rupture of the membranes), internal monitoring may be indicated if fetal status cannot be assessed externally. Amniotomy can be done to augment labor when the fetal head is applied to a favorable cervix and not ballotable (not floating).

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