7_Induction of Labour 2.pptxscsdrdavidbc

Detail explanation about induction of labour.

1. INDUCTION OF LABOUR Refresher Obstetrics - Masanga 2023 DR. DAVID BREWEN CONTEH

2. What ist induction of labour? Triggering labour artificially before it begins naturally Two steps: cervical ripening (effacement, mid- position, early dilation) induction of contractions that dilate the cervix

3. WHO guidance: Indications (1/2) Postterm ≥41 weeks (only confirmed) PROM at term, within 24 hours Chorioamnionitis at any GA APH at term (or earlier if instable) Growth restriction at term (only confirmed) IUFD or severely abnormal fetus

4. WHO guidance: Indications (2/2) Hypertensive disease and PET Preeclampsia at term Poorly controlled hypertensive disease at term Unstable severe preeclampsia at any gestation Preeclampsia with dead fetus Eclampsia (after stabilization)

5. WHO guidance – NO indication Low risk pregnancy < 41 weeks Gestational diabetes <41 weeks (without polyhydramnios or fetal macrosomia) Suspected macrosomia at term Twins (no studies available!)

6. Other Indications for IOL? PPROM? Only if signs of infection Reduced growth preterm? Only if oligohydramnios / growth arrest Oligohydramnios at term? Early sign of placental insufficiency! Reduced movements at term? Placental insufficiency

7. WHO recommended methods Misoprostol 25 mcg 4 hourly 200mcg in 200ml H2O = 25 ml Or 25mcg PV 6 hourly (if 25mcg tabs available) Amniotomy and Oxytocin (not ARM alone) Mechanical: Balloon catheter Membrane sweep?

8. How do you chose the method of induction? Parity Indication Previous uterine surgery Staffing Resources available Experience of staff Favourability of cervix – Bishop’s score Preference of mother?

9. Cervical ripening

10. (Simplified) Bishop Score Bishop score > 5 - favourable ’ for Oxytocin and Amniotomy Bishop score ≤ 5 = unfavourable Score 1 2 Dilatation closed 1 – 2 cm > 3 cm Length (Effacement) > 2cm (0 – 30%) 1 – 2 cm (40 – 50%) < 1cm (> 60%) Station < 3/5 2/5 > 1/5 Consistency firm medium soft Position posterior mid anterior

11. Examples

12. Afternoon handing over You are on call! From maternity they report about a woman with following vitals: BP >180/90 4+ protein in dipstick

13. Assessment What do we need to know to undertake a safe and effective IOL?

14. Case Details 18 yr old G1/P0 32/40 by SFH, FH 142 bpm BP controlled following treatment 4+ proteinuria, severe fascial oedema Cephalic 3/5 BS 2, membrane intact

15. Induction? How? Risks? Precautions?

16. Induction with Misoprostol Once given, there`s no way back Take caution in: Multipara, especially grand- multipara ROM BS >4 (especially if multipara or ROM) Unsure / unstable fetal condition Avoid Previous C/S or myomectomy Latent phase

17. Second case Details 25 year old G4 P3 A2 - all SVD 35 weeks by SFH ROM > 24 hours - pink Vitals and FH stable Cephalic 3/5 palpable BS 5, 1 contraction mild in 10 minutes

18. Induction? How? Risks? Precautions?

19. Induction in PROM and pPROM At term – Within 24 hours or immediately if evidence of infection At any gestation if evidence of infection In Pre- viable PPROM

20. WHO guidance for Oxytocin titration – IOL (and augmentation of labour) 2.5 IU Oxytocin in 500ml N/S or D5 Start infusion at 10 dpm (0.5ml or 2.5 mIU/min) Increase by 10 dpm every 30 minutes until 3-4 moderate to strong contractions/10 minutes then maintain rate If good contraction pattern not established by 60 dpm set up a new drip (double dose: 5 IU in 500ml), half the infusion rate (30 dpm) and then increase by 10 dpm every 30 min Maximum rate 60 dpm (at double dose)

21. Important considerations High level of monitoring required with properly trained and supervised staff Membranes must be ruptured for oxytocin infusion to be effective - includes fore- waters Dose needs to be titrated correctly in order to be safe and effective - potentially very dangerous drug even when used for IOL Multiparas will often respond very rapidly and infusion often needs to be stopped entirely The purpose of the infusion is to achieve contractions. If there are inadequate contractions there will likely be inadequate progress - there is no point using an Oxytocin infusion unless you are willing to try to make it work

22. Example The above described G4 P3 with PROM has a 2.5 IU in 500ml infusion commenced. After 2 hours the drops are on 40 dpm and she is noted to have 6/10 strong contractions What do you do?

23. Hyperstimulation Stop the Oxytocin drip if running (note the rate) May be appropriate to check dilatation Rotate women to left lateral and stay with her Check FH and vitals – FH abnormal manage as fetal distress If contractions not reduced by 20 minutes consider tocolysis Once contractions <5/10 review 30 minutes and consider re- starting Oxytocin infusion (If received misoprostol consider tocolysis)

24. Tocolysis Terbutaline 250mcg s/c Salbutamol 10mg in 1 liter at 10dpm quick acting Betamimetics are contraindicated in cardiac disease Nifedipine 20mg po as alternative (chew it!) Note: Perform VE before administering! If delivery imminent (full dilation) tocolysis can cause PPH!

25. Third Case Example You are inducing a multipara with severe PET at 36 weeks. Her starting BS is 7 and you perform an ARM and start an oxytocin infusion of 2.5 IU in 500ml After 2 hours she is has strong contractions 4/10 and the FH is heard to fall to 70 bpm. You perform VE: 7cm What do you do?

26. Fetal Distress Very Difficult to diagnose accurately If suspected: Stop Oxytocin drip if ongoing Left lateral/upright position, O2 if available VE – meconium/cord/presentation/progress/blood Check for cause and treat if possible e.g. iv fluids, tocolysis, antibiotics Is delivery required – How?

27. Fourth case Example You are inducing a P0 at term for PROM. Her starting BS was 5 After 8 hours of an oxytocin infusion she is 3cm with a <1cm long which is soft and anterior and head at 2/5 What is her Bishop score? How will you proceed? What other information do you need?

28. Induction? How? Risks? Precautions?

29. Case Details: SFH 37/40 G3 P2 Admitted with heavy PV bleed of > 1 liter, Abdo pain Hypotension on admission but responded to 1l iv fluid Observations now stable Minimal active bleeding PV FH stable USS – placenta not low, Cephalic 35/40 by BPD, FH + VE – 3cm dilated, 1 cm long, soft, mid, head 4/5, membranes intact, bulging

30. What to do?

31. Antepartal bleeding Absolute indication for expediated delivery unless small, self limiting and preterm Possible DDx Abruptio placentae Placenta praevia Uterine rupture