What are the contraindications for labor induction?

Contraindications for Labor Induction

Labor induction should not be performed when the risks outweigh the benefits, with absolute contraindications including placenta previa, vasa previa, prior classical cesarean delivery, active genital herpes infection, and umbilical cord prolapse.

Absolute Contraindications

• Placenta previa or vasa previa - These conditions present significant risk of catastrophic hemorrhage if labor is induced 1
• Transverse fetal lie or presentation - Abnormal presentations contraindicate induction due to risk of cord prolapse and dystocia 2
• Prior classical (vertical) uterine incision or T-shaped incision - These prior incision types significantly increase risk of uterine rupture 3
• Active genital herpes infection - Risk of neonatal herpes transmission during vaginal delivery 2
• Umbilical cord prolapse - Requires immediate cesarean delivery 2
• Previous uterine rupture - High risk of recurrence with labor induction 4

Relative Contraindications

• Previous cesarean delivery with unknown scar type - Increased risk of uterine rupture, though not an absolute contraindication 3, 4
• Suspected fetal macrosomia - ACOG guidelines state that suspected fetal macrosomia is not an indication for induction and may increase cesarean delivery rates without improving outcomes 3
• Grand multiparity (≥5 previous deliveries) - Increased risk of uterine rupture and postpartum hemorrhage 5
• Certain medical conditions requiring specialized care during labor:
  • Severe cardiovascular disease 3
  • Uncontrolled hypertension 3
  • Unstable maternal medical conditions 6

Special Considerations for Labor Induction

Anticoagulation Therapy

• Women receiving prophylactic anticoagulation should have planned delivery to allow appropriate timing of anticoagulant discontinuation 3
• For women on LMWH, spontaneous labor is preferred over induction when possible to minimize bleeding complications 3

Previous Cesarean Delivery

• Prior low transverse cesarean is not an absolute contraindication to labor induction, but requires careful consideration 3
• Misoprostol (Cytotec) should not be used for cervical ripening or induction in women with prior cesarean delivery due to increased risk of uterine rupture (13% in one study) 3
• Mechanical methods of cervical ripening (e.g., Foley catheter) appear to have lower risk of uterine rupture in women with previous cesarean 3

Timing Considerations

• Elective induction (defined as induction without medical indication) should be avoided before 39 weeks due to risk of neonatal respiratory complications 3, 1
• Induction prior to post-term (41+0-6 weeks) compared to awaiting 42 weeks is associated with increased risk of cesarean section (RR=1.11), labor dystocia (RR=1.29), and other complications 7

Important Clinical Pitfalls

• Misuse of oxytocin: FDA labeling specifically states oxytocin is indicated for medical rather than elective induction of labor 1
• Inadequate assessment before induction: Cervical assessment is essential to determine optimal approach and likelihood of successful induction 8
• Inappropriate use of misoprostol: Should never be used in women with prior uterine scars due to significantly increased risk of uterine rupture 3
• Failure to recognize contraindications: Thorough evaluation for contraindications should precede any decision to induce labor 2, 5

Remember that the decision to induce labor should always be based on clear medical indications where the benefits of expeditious delivery outweigh the risks of continuing the pregnancy and the potential risks associated with the induction procedure itself 2.