Induction or Augmentation?

When a woman’s labor is started artificially, it’s considered an induction — whether elective or medically indicated. When a woman’s labor starts on its own, but for one reason or another is put on Pitocin to strengthen the contractions, it’s considered an augmentation of labor. But what is it called when a woman’s water breaks but contractions don’t start immediately, and she goes to the hospital and is put on Pitocin? Is it an induction or augmentation?

My first pregnancy, my water broke about half an hour before contractions set in; one of my sisters had rupture of membranes followed by no labor for 18 hours, at which point she went to the hospital for… an induction, or augmentation?

Usually, when a woman’s water breaks before labor begins, contractions are not far behind; but sometimes, some time passes before it happens. I think of stories I’ve read of women who have had “high leaks” or even a full “water breaking”, but either the tear resealed itself, or the baby was so premature that even with ROM, it was better for him to stay in utero than to be born (as long as the mom didn’t have an infection or any other medical reason for the baby to be born then). Most of the time, however, either the baby needs to be born early, or the woman is at term or close enough to term that the doctors want to start or speed up labor, out of fear of infection.


7 Responses

  1. The real answer: it’s an augmentation of labor. Although active labor has not started, her membranes are ruptured. That’s considered early labor, even if she’s not contracting.

  2. The real answer: it’s an induction of labour. When the membranes rupture before labour we call it “PROM” (pre-labour rupture of membranes), which tells you something! (PPROM is preterm prelabour rupture of membranes).

    NICE (National Institute of Clinical Excellence) in the UK say that women with PROM should be offered induction (not augmentation). Dublin approach (O’Driscoll’s active management of labour) says that administration of oxytocics before active labour is induction, not augmentation (and point to incorrect diagnosis of labour onset as the cause of inappropriate use of oxytocics). My copy of Mayes Midwifery gives PROM as an indication for induction, not augmentation. Ditto my copy of Myles.

    Having said that, PROM at term is an indication for induction of labour, to reduce the risk of infection.

  3. Heh-heh — that sounds about right — two opposing viewpoints from two knowledgeable sources — and at the time of this comment, the votes are evenly split on the doctor/midwife/nurse side. 🙂

  4. And more to the point. If you are going to induce labour (augment labour, doesn’t much matter what you call it) in a woman who has ruptured membranes and not contracting, why would you use pitocin, rather than prostaglandins??

    • Hmm, I never thought of this – my reaction to this question is that prostaglandins would be used vaginally via Cervidil or Prepidil, or even in pill form (Cytotec, misoprostol), and anything placed into the vagina increases the risk of infection. Perhaps I’m wrong in this, but I’ve never heard of anyone (in America – maybe it’s different elsewhere) using prostaglandins with the intention of starting labor, but rather with the intention of softening the cervix. Of course, prostaglandins can start labor, but the intention is for cervical effacement, with Cytotec being a possible exception, since it frequently starts contractions as well as softens the cervix.

      • Prostaglandins are an effective method of labour induction, and there’s plenty of evidence that prostaglandins after PROM are also safe and effective. Moreover, just because the membranes are ruptured doesn’t mean the cervix is favourable (it may be, but it ain’t necessarily so). A ton of oxytocin on an unripe cervix – horrible, it’s just not a good recipe.

        Where it’s not specifically contraindicated, I much prefer prostaglandin as an induction agent (in UK context) because it can allow labour to progress in a way that is much more similar to spontaneous onset, and because we don’t have to use continuous monitoring (after an initial normal trace), don’t need an IV, can use the pool etc…..regardless of membranes intact or ruptured and regardless of parity.

        Obviously, in contexts where continuous monitoring, IV etc… are standard, the benefits of prostaglandins are reduced.

        Avoiding VEs with ruptured membranes over a long period is important for reducing infection, but if you are inducing, then you are already committing to delivery within a certain timeframe, so the avoidance of VEs is correspondingly less important. Certainly, I wouldn’t place avoidance of VEs as more important than ensuring the cervix is favourable before beginning oxytocin.

        • Avoiding VEs with ruptured membranes over a long period is important for reducing infection, but if you are inducing, then you are already committing to delivery within a certain timeframe, so the avoidance of VEs is correspondingly less important.

          True – in America, it is not uncommon for a woman to have multiple vaginal exams (one every hour in many hospitals), and also to have an IUPC and/or internal fetal monitoring, which are all pathways of infection, so why *not* do internal prostaglandins. It’s just not something I’ve heard of – maybe more common in the UK than in America. Maybe it’s done, and I just haven’t heard of it, which is of course always a possibility. 🙂 However, there are other practices which are quite different – like “gas and air” which is unknown in American hospitals – so it doesn’t necessarily make it right or wrong that it’s done here and not there, or there and not here.

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