Induction starts labor artificially; augmentation strengthens labor that has already begun. Operative vaginal birth uses vacuum or forceps, and cesarean birth delivers the fetus through abdominal and uterine incisions.

Common indications for induction

• Post-term pregnancy (commonly offered at 41 0/7–41 6/7 weeks)
• Prelabor rupture of membranes at term
• Hypertensive disorders (gestational hypertension, preeclampsia), diabetes, fetal growth restriction, oligohydramnios, intraamniotic infection, fetal demise
• Elective induction at 39 0/7 weeks in low-risk nulliparous clients is reasonable (ARRIVE trial: fewer cesareans and less hypertensive disease)

Contraindications to induction (same as for vaginal birth)

• Placenta previa, vasa previa, transverse lie, cord prolapse
• Previous classical (vertical) uterine incision, previous uterine rupture, or extensive transfundal uterine surgery
• Active genital herpes
• HIV with high or unknown viral load (planned cesarean); invasive cervical cancer

Cervical readiness — Bishop score (dilation, effacement, station, consistency, position; 0–13)

• Score of 8 or more = favorable; induction likely to succeed
• 6 or less = unfavorable → cervical ripening first

• Gestational age confirmation (early ultrasound) before elective induction
• Bishop score, fetal presentation, baseline FHR (Category I preferred), contraction pattern, maternal vital signs
• For operative birth: full dilation, ruptured membranes, engaged head with known position, adequate analgesia, empty bladder, consent
• For TOLAC: number and type of previous uterine incisions (operative report)
• During oxytocin: contraction frequency, duration, resting tone, FHR, intake and output, signs of water intoxication

• Ultrasound: presentation, estimated fetal weight, placental location
• Laboratory before cesarean: CBC, type and screen (crossmatch for high hemorrhage risk)
• Continuous EFM throughout oxytocin infusion and after prostaglandin placement

Cervical ripening

• Oxytocin may start about 4 hours after the last misoprostol dose and about 30 minutes after removing a dinoprostone insert (6–12 hours after dinoprostone gel)
• Membrane sweeping at term can reduce post-term pregnancy
• Amniotomy: confirm engaged presenting part; check FHR immediately (cord prolapse), note fluid characteristics; infection risk rises with time

Oxytocin — a high-alert medication

• Diluted in an isotonic solution, given by infusion pump as a secondary line piggybacked into the mainline at the port closest to the client, so it can be stopped at once while IV access remains
• Dosed in milliunits per minute; low-dose regimens commonly start at 0.5–2 mU/min and increase by 1–2 mU/min every 15–40 minutes; high-dose regimens start and increase faster. The maximum dose is set by facility protocol (often 20–40 mU/min)
• Goal: adequate labor (e.g., contractions every 2–3 minutes), not maximal contractions
• Adverse effects: tachysystole and FHR decelerations, uterine rupture, water intoxication (antidiuretic effect → hyponatremia: headache, confusion, seizures) with high doses and hypotonic fluids, hypotension with rapid IV bolus, postpartum hemorrhage from uterine fatigue

Operative vaginal birth

• Vacuum: generally not used before 34 weeks; newborn cephalohematoma, scalp lacerations, and subgaleal hemorrhage (a boggy scalp swelling that crosses suture lines and can cause hypovolemic shock)
• Forceps: maternal third- and fourth-degree lacerations; newborn facial bruising and facial nerve palsy
• Episiotomy is used selectively, not routinely. A midline episiotomy heals easily but extends more often into the anal sphincter; a mediolateral cut lowers that risk but causes more pain

Perineal laceration degrees

• Third- and fourth-degree tears (obstetric anal sphincter injuries) need repair in good lighting with adequate analgesia, a single prophylactic antibiotic dose, stool softeners, and no rectal medications, enemas, or rectal temperatures; watch for fecal incontinence and rectovaginal fistula

Cesarean birth

• Indications: labor arrest, nonreassuring fetal status, malpresentation, previa, PAS, cord prolapse, previous classical incision, active herpes, some multiple births
• Uterine incisions: low transverse (most common; less bleeding; allows TOLAC) vs. classical vertical (higher rupture risk; no future labor)
• Preoperative: consent; clear liquids up to about 2 hours before planned surgery; aspiration prophylaxis (nonparticulate antacid, H2 blocker); cefazolin 2 g IV (3 g if weight ≥ 120 kg (265 lb)) within 60 minutes before incision (adding azithromycin for clients in labor or with ruptured membranes); indwelling urinary catheter; hair clipping (not shaving); chlorhexidine–alcohol skin prep; mechanical VTE prophylaxis; left uterine displacement on the table
• Enhanced recovery after cesarean (ERAC): early oral intake, early catheter removal and ambulation, scheduled acetaminophen and NSAIDs with opioids only for breakthrough pain

Trial of labor after cesarean (TOLAC) / VBAC

• Candidates: one (or two) previous low transverse incisions, no other contraindications
• Most clients who attempt TOLAC give birth vaginally; the main risk is uterine rupture (under 1% with one low transverse scar)
• Requires a facility able to perform an emergency cesarean; continuous EFM; oxytocin or mechanical ripening allowed with counseling, misoprostol not used

Listed in priority order.

1. Oxytocin safety
   • Baseline 20–30 minutes of FHR and contractions before starting
   • Continuous FHR and uterine monitoring; assess and document before each dose increase
   • Tachysystole with abnormal FHR: stop or reduce oxytocin, reposition to lateral, IV fluid bolus, notify the provider; tocolytic (terbutaline) if ordered
   • Tachysystole with Category I FHR: reduce oxytocin per protocol
   • Monitor intake and output and sodium with prolonged high-dose infusion
2. After amniotomy or cervical ripening: FHR immediately, fluid color and odor, temperature
3. Cesarean preparation
   • Verify consent, allergies, labs, antibiotics timing; insert catheter; remove jewelry; continuous FHR until skin prep
   • Surgical safety checklist and newborn resuscitation team ready
4. After cesarean
   • Airway, vital signs, SpO2 and respiratory rate/sedation (neuraxial morphine can cause delayed respiratory depression for up to about 24 hours)
   • Fundus (palpate gently, supporting the incision) and lochia — hemorrhage risk remains
   • Incision, urine output, bowel sounds, pain; early ambulation, incentive spirometry, sequential compression devices
   • Breastfeeding support (football hold keeps the baby off the incision)
5. After operative vaginal birth: check newborn head circumference and scalp for subgaleal hemorrhage; assess mother for lacerations, hematoma, and urinary retention

• Explain induction methods, expected duration (it can take more than a day with ripening), and the right to ask questions
• After cesarean: splint the incision with a pillow when coughing; walk early; avoid lifting anything heavier than the baby; report fever, incision redness or drainage, heavy bleeding, calf pain, or shortness of breath
• Interpregnancy interval of at least 18 months lowers uterine rupture risk in a future TOLAC
• Know the type of uterine incision for future pregnancy planning
• After a third- or fourth-degree tear: take stool softeners, avoid straining, use sitz baths, and report leakage of stool or gas, or stool from the vagina
• After vacuum or forceps birth: newborn bruising or swelling usually resolves; report poor feeding, pallor, or increasing head swelling
• Driving is usually avoided while taking opioids or until able to brake suddenly without pain

• Bishop score ≥ 8 favorable; ≤ 6 → ripening
• Misoprostol is contraindicated after cesarean (rupture risk)
• Oxytocin: infusion pump, piggyback at proximal port, continuous monitoring
• Tachysystole + abnormal FHR → stop oxytocin, lateral position, fluids, notify
• Oxytocin can cause water intoxication
• Amniotomy → FHR immediately (cord prolapse)
• Low transverse incision → TOLAC possible; classical → no labor
• Cefazolin within 60 minutes before incision
• Vacuum → cephalohematoma, subgaleal hemorrhage
• After cesarean: fundus and lochia still assessed; early ambulation