Induksi persalinan ialah suatu tindakan terhadap ibu hamil yang belum

inpartu, baik secara operatif maupun medisinal untuk merangsang timbulya

kontraksi Rahim sehingga terjadi persalinan. Induksi persalinan berbeda dengan
akselerasi persalinan, di mana pada akselerasi persalinan, tindakan-tindakan
tersebut dilakukan pada wanita hamil yang sudah inpartu. (Wiknjosastro H, 2000).
In the United States, the incidence of labor induction more than doubled from 9.5
percent in 1991 to 23.2 percent in 2011 (Martin, 2013). The incidence is variable
between practices. At Parkland Hospital approximately 35 percent of labors are
induced or augmented. By comparison, at the University of Alabama at
Birmingham Hospital, labor is induced in approximately 20 percent of women,
and another 35 percent are given oxytocin for augmentation—a total of 55
percent. (William obstetric)
Secara medis dilakukan dengan infus oksitosin, prostaglandin seperti misoprostol
dan dinoprostone. Sedangkan secara manipulatif atau dengan tindakan, dilakukan
dengan amniotomi, melepaskan selaput ketuban dari bagian bawah rahim
(stripping of the membrane), pemakaian rangsangan listrik dan rangsangan pada
puting susu, extraamnionic saline infusion, transcervical balloons, and
hygroscopic cervical dilators. (Wiknjosastro H, 2000)

Indikasi janin (Wiknjosastro H, 2000)

1. Kehamilan lewat waktu.
2. Ketuban pecah dini.
3. Janin mati.
Indications
Induction is indicated when the benefits to either mother or fetus
outweigh those of pregnancy
continuation. The more common indications include membrane rupture
without labor, gestational
hypertension, oligohydramnios, nonreassuring fetal status, postterm
pregnancy, and various maternal
medical conditions such as chronic hypertension and diabetes (American
College of Obstetricians
and Gynecologists, 2013b).
Indikasi ibu
1. Kehamilan dengan hipertensi.
2. Kehamilan dengan diabetes mellitus.
Contraindications
1, Malposisi dan maipresentasi janin.
2. Insufisiensi plasenta.
3. Disproporsi sefalopelvik.
4. Cacat rahim, misalnya pernah mengalami seksio sesarea, enukleasi
miom.
5. Grande multipara.
5. Gemelli.
7. Distensi rahim yang berlebihan misalnya pada hidramnion.
8. Plasenta previa.

Contraindications
Methods to induce or augment labor are contraindicated by most
conditions that preclude spontaneous
labor or delivery. The few maternal contraindications are related to prior
uterine incision type,
contracted or distorted pelvic anatomy, abnormally implanted placentas,
and uncommon conditions
such as active genital herpes infection or cervical cancer. Fetal factors
include appreciable
macrosomia, severe hydrocephalus, malpresentation, or nonreassuring

fetal status.

Amniotomi artifisialis dilakukan dengan cara memecahkan ketuban baik di

bagian bawah depan (fore water) maupun di bagian belakang (hind water) dengan
suatu alat khusus (Drewsmith catbeter - Macdonald klem). Sampai sekarang
belum diketahui dengan pasti bagaimana pengaruh amniotomi dalam merangsang
timbulnya kontraksi rahim. (Wiknjosastro H, 2000)
Beberapa teori mengemukakan bahwa: (Wiknjosastro H, 2000)
a. Amniotomi dapat mengurangi beban rahim sebesar 40% sehingga tenaga
kontraksi rahim dapat lebih kuat untuk membuka serviks.
b. Amniotomi menyebabkan berkurangnya aliran darah di dalam rahim kira-kira
40 menit setelah amniotomi dikerjakan, sehingga berkurangnya oksigenasi otot-
otot rahim dan keadaan ini meningkatkan kepekaan orot rahim.
c. Amniotomi menyebabkan kepala dapat langsung menekan dinding serviks di
mana di dalamnya terdapat banyak syaraf-syarat yang merangsang kontraksi
rahim.
Bila setelah amniotomi dikerjakan 6 jam kemudian, belum ada tanda-tanda
permulaan persalinan, maka harus diikuti dengan cara-cara lain untuk merangsang
persalinan, misalnya dengan infus oksitosin. (Wiknjosastro H, 2000)
Pada amniotomi perlu diingat akan terjadinya penyulit-penyuiit sebagai
berikut. (Wiknjosastro H, 2000)
a. Infeksi.
b. Prolapsus funikuli.
c. Gawat janin.
d. Tanda-tanda solusio plasenta (bila ketuban sangat banyak dan dikeluarkan
secara cepat).
Teknik amiotomi
Jari telunjuk daniari tengah tangan kanan dimasukkan ke dalam jalan lahir sampai
sedalam kanalis servikalis. Setelah kedua jari berada dalam kanalis servikalis,
maka posisi jari diubah sedemikian rupa, sehingga telapak tangan menghadap ke
arah atas. Tangan kiri kemudian memasukkan pengait khusus ke dalam jalan lahir
dengan tuntunan kedua jari yang telah ada di dalam. Ujung pengait diletakkan di
antara jari telunjuk dan jari tengah rangan yang di dalam. Tangan yang di luar
kemudian memanipulasi pengait khusus tersebut untuk dapat menusuk dan
merobek selaput ketuban. Selain itu menusukkan pengait ini dapat juga dilakukan
dengan satu tangan, yaitu pengait dijepit di antara jari tengah dan jari telunjuk
tangan kanan, kemudian dimasukkan ke dalam jalan lahir sedalam kanalis
servikalis. Pada waktu tindakan ini dikerjakan, seorang asisten menahan kepala
janin ke dalam pintu atas panggul. Setelah air ketuban mengalir keluar, pengait
dikeluarkan oleh tangan kiri, sedang jari tangan yang di dalam memperlebar
robekan selaput ketuban. Air ketuban dialirkan sedikit demi sedikit untuk menjaga
kemungkinan terjadinya prolaps tali pusat, bagian-bagian kecil janin, gawat janin
dan solusio plasenta. Setelah ielesai tangan penolong ditarik keluar dari jalan
lahir. (Wiknjosastro H, 2000)

Risks
Maternal complications associated with labor induction consist of cesarean
delivery,
chorioamnionitis, uterine scar rupture, and postpartum hemorrhage from

uterine atony.

Cesarean Delivery Rate

This is especially increased in nulliparas undergoing induction (Luthy, 2004;
Yeast, 1999). Indeed,
several investigators have reported a two- to threefold increased risk
(Hoffman, 2003; Maslow,
2000; Smith, 2003). Moreover, these rates are inversely related with cervical
favorability at
induction, that is, the Bishop score (Vahratian, 2005; Vrouenraets, 2005).
The increased risk for
cesarean delivery with labor induction does not appear to be lowered with
preinduction cervical
ripening in the nullipara with an unfavorable cervix (Mercer, 2005). In fact,
the cesarean delivery
rate following elective induction was significantly increased even in women
with a Bishop score of 7
or greater compared with that in those with spontaneous labor (Hamar,
2001). Station and position of
the fetal vertex may also affect success rates. For example, in nulliparas at
> 41 weeks’ gestation and
with an unengaged vertex, the cesarean delivery rate was increased 12-
fold compared with that in
women with an engaged fetal vertex (Shin, 2004).
The premise that elective labor induction increases the risk of cesarean
delivery has been
questioned (Macones, 2009). Many studies have compared women
undergoing labor induction to
those laboring spontaneously. However, using women undergoing
expectant management, Osmundson
and colleagues (2010, 2011) reported similar cesarean delivery rates in
more than 4000 women
undergoing elective induction between 39 and nearly 41 weeks with or
without a favorable cervix.
Currently, this subject remains unresolved.

Chorioamnionitis
Amniotomy is often selected to augment labor (p. 531). Women whose
labor is managed with
amniotomy have an increased incidence of chorioamnionitis compared
with those in spontaneous
labor (American College of Obstetricians and Gynecologists, 2013a).
Rupture of a Prior Uterine Incision
Uterine rupture during labor in women with a history of prior uterine
surgery can be catastrophic
(Chap. 31, p. 613). Some of these risks were quantified by Lydon-Rochelle
and associates (2001),
who reported that the uterine rupture risk is increased threefold for
women in spontaneous labor with
a uterine scar. With oxytocin labor induction without prostaglandins, the
risk was fivefold increased,
and with prostaglandins, it was strikingly increased 15.6-fold. The
Maternal-Fetal Medicine Units
Network also reported a threefold increased risk of uterine scar rupture
with oxytocin, and this was
even higher when prostaglandins were also used (Landon, 2004). The
American College of
Obstetricians and Gynecologists (2013d) recommends against the use of
misoprostol for preinduction
cervical ripening or labor induction in women with a prior uterine scar
(Chap. 31, p. 615).
Uterine Atony
Postpartum hemorrhage from uterine atony is more common in women
undergoing induction or
augmentation. And, atony with intractable hemorrhage, especially during
cesarean delivery, is a
frequent indication for peripartum hysterectomy (Shellhaas, 2009). In a
study from Parkland Hospital,
labor induction was associated with 17 percent of 553 emergency
peripartum hysterectomies
(Hernandez, 2013). In the United States, Bateman and coworkers (2012)
reported that the postpartum
hysterectomy rate increased 15 percent between 1994 and 2007. This was
largely attributable to
increased rates of atony associated with more medical labor inductions
and more primary and repeat
cesarean deliveries. Finally, elective induction was associated with

Factors Affecting Successful Induction

Several factors increase or decrease the ability of labor
induction to achieve vaginal delivery.
Favorable factors include multiparity, body mass index
(BMI) < 30, favorable cervix, and
birthweight < 3500 g (Peregrine, 2006; Pevzner, 2009). For
both nulliparas and multiparas,
Kominiarek and colleagues (2011) found that labor duration
to reach the active phase and to complete
dilatation was adversely affected by a higher BMI.
In many cases, the uterus is simply poorly prepared for
labor. One example is an “unripe cervix.”
Indeed, investigators with the Consortium on Safe Labor
reported that elective induction resulted in
vaginal delivery in 97 percent of multiparas and 76 percent
of nulliparas, but that induction was more
often successful with a ripe cervix (Laughon, 2012a). The
increased cesarean delivery risk
associated with induction is likely also strongly influenced
by the induction attempt duration,
especially with an unfavorable cervix (Spong, 2012). Simon
and Grobman (2005) concluded that a
latent phase as long as 18 hours during induction allowed
most of these women to achieve a vaginal
delivery without a significantly increased risk of maternal or
neonatal morbidity. Rouse and
associates (2000) recommend a minimum of 12 hours of
uterine stimulation with oxytocin after
membrane rupture.

Cervical “Favorability”
One quantifiable method used to predict labor induction
outcomes is the score described by Bishop
(1964) and presented in Table 26-2. As favorability or
Bishop score decreases, the rate of induction
to effect vaginal delivery also declines. A Bishop score of 9
conveys a high likelihood for a
successful induction. Put another way, most practitioners
would consider that a woman whose cervix
is 2-cm dilated, 80-percent effaced, soft, and midposition
and with the fetal occiput at –1 station
would have a successful labor induction. For research
purposes, a Bishop score of 4 or less
identifies an unfavorable cervix and may be an indication

for cervical ripening.

TABLE 26-2. Bishop Scoring System Used for Assessment of Inducibility

DAFTAR PUSTAKA
Wiknjosastro H., dkk. 2000. Ilmu Bedah Kebidanan. Jakarta: Yayasan Bina
Pustaka-Sarwono Prawirohadjo.