Induction of labor

NURSING

1. INDUCTION OF LABOUR

2. DEFINITION : Induction of labor means initiation of uterine contractions (after the period of viability) by any method (medical, surgical, or combine) for the purpose of vaginal delivery .

3. - When the risks of continuation of pregnancy either to the mother or to fetus is more, induction is indicated.(rarely preterm indication may have to done). - Elective induction of labor. - The major risks are iatrogenic prematurity ,increases cesarean delivery for failed induction. PURPOSE :

4. - Pre-eclampsia, eclampsia. - Postmaturity. - Abruptio placenta - Premature rupture of membrane. -Intrauterine death of fetus. - oligohydramnios, polyhydnios. INDICTION FOR IOL

5. -Malpresentation (breech,transvere or oblique lie). - High risk pregnancy with fetal compromise. - Heart disease. -Umblical cord prolapse. -Cervical carcinoma. CONTRAINDICTIONS OF IOL

6. Postmaturity Intrauterine fetal death Pre-eclampsia/eclampsia Premature rupture of membrane Chronic hydraminous COMMON INDUCTION FOR IOL:

7. MATERNAL : . To confirm the indication for IOL . Exclude the contraindication of IOL . Adequate counselling about the risks,benefits of IOL. . Assess Bishopscore (score >6 favorable) PARAMETERS TO ASSESS PRIOR TO IOL :

8. FETAL: To ensure fetal gestational age To estimate fetal weight Ensure fetal presentation and lie Confirm fetal well-being CNTD

9. Period of gestation - pregnancy nearer the term or post term. Preinduction score - Bishop score >6 is favorable. Sensitivity of the uterus - Positive oxytocin sensitivity test. Case profile - A low bishop < 5 is unripe and unfavorable cervix. Cervical ripening - FACTORS FOR SUCCESSFUL IOL:

10. Induction of labor have three method 1.Medical Method. 2.Surgical Method 3.Combinef Method. METHODS OF INDUCTION OF LABOR

11. DRUGS USED : Prostaglandins PGE2, PGE3 . : Oxytocin : Mifepristone MEDICAL INDUCTION :

12. Act locally (autocrine and paracrine harmones) on the contagious cells. PGE2 and PGF2 both cause myometrial contraction But PGE2 is primarily important for cervical ripening whereas PGF2 for myometrial contraction. Misoprostol (PGE1) is being used either transvaginally or orally for IOl.total 6-8 dose are used. 1.Prostaglandins :

13. It is an endogenous uterotonic that stimulate uterine contraction. Oxytocin receptor contraction increas during pregnancy and labor. Oxytocin acts by a) receptor medication b) voltage mediated calcium channel c)prostaglandian presentation. OXYTOCIN

14. Mifepristone (progesterone receptor antagonists) block both progestrone and glucocorticoid receptors. 200 mg vaginally daily for 2 days to induce labor. Onapristone is a more selective progestrone receptors antagonists. MIFEPRISTONE :

15. METHODS : It has three methods- 1.Aritificial rupture of membranes (ARM) 2 . Stripping the membrens 3. Low rupture of membrane (LRM) SURGICAL INDUCTION

16. Mechanism of onset of labor : may be related with (a) stretching of thee cervix (b) sepration of membranes and ( c) reduction of amniotic fluid volume. Effective depends on : (a) state of the cervix (b) station of the presenting part. Advantages of amnioromy : (a) High success rate Artificial rupture of membrane :

17. b) chance to observe the amniotic fluid for blood or meconium. (c) access to use fetal scalp. Limitation : it can not be employ in an unfavorable cervix.(the cervix should be at least one finger dilated) cntd

18. Lowering of the blood pressure in pre-eclampsia,eclampsia. Relief of maternal distress in hydramnios. Control of bleeding in APH. Relief of tension in abruptio placentae and initiation of labor. Immediate beneficial effects of ARM

19. O n ce the procedure is adopted ,there is no scope of retreating from the decision of delivery. Chance of umblical cord prolapse. Accidental injury to the placenta cervix or uterus . Liquor amnii embolism. HAZARDS OF ARM :

20. It is widely practised with high degree of success..The branes below the presenting part overlying internal are rupture to drain some amount of amniotic fluid. Contraindiction ; it iis preferably avoided in chronic hydramnios, as there risk of sudden massive liquor drainage. LOW R UP TURE OF MEMBRANES :

21. Preliminaries - it is an indoor procedure.The procedure may be conducted in the labor ward or in operation theatre. ACTUAL STEPS = The patient is asked to empty her bladder. Full surgical asepsis is to be taken. Two fingers are introduced into the vagina smeared with antiseptic ointment. PROCEDURES :

22. The index finger is passed through the cervical canal beyond the internal. With one or two fingers still in the cervical canal with the palmar surface upward, a long Kochrr's forcep with the blades . The blades are open to size the membranes and are torn twisting movements. Amnihook is used to scratch over the membranes.This is followed by viskible escape of amniotic fluid. CNTD

23. (a) color of the amniotic fluid. (b) statis of the cervix. (c) Station of the head. (d) Detection of cord prolapse. HAZARDS : a) cord prolapse (b) uncontrolled escape of amniotic fluid c) Injury to the cervix. After the membranes rupture,the follwing are to be assessd :

24. Stripping of the membranes means digital sepration of the chrioamniotic membranes from the wall of the cervix and lowrr uterine segment. It is the simple safe and beneficial for induction of labor. STRIPPING THE MEMBRANES

25. Act by release of endogenous prostaglandians from the mmbranes and maternal decidua to induce lablor and cervical ripening. Hygroscppic dilatpr e.g. Laminaria ,lamicel act by absorption of water.they swell and forcibly dilate the cervix. Mechnical dilators are as safe and effective as PGE2 in cervical ripening. Mechanical : Dilators

26. The combined medical and surgical methods are commonly used to increase the efficacy of induction by reducing the induction -delivery interval. The oxytocin infusion is started either prior to or following rupture of the membranes depending mainly upon the state of the cervix. COMBINE METHOD :

27. 1) more effective than any single procedure. (2 shortnes the induction delivery interval. 3) minimise the risk of infection. (4 lessens the period of observation . The Advantages of combine method

28. Prostaglandin (PGE2) - Used either in the form of the gel 500 ug intracervical or 1 to 2 mg in posterior fornix. The application may have to be repeated after 6 to 8 hours. Labor will start in 30 to 50 percent of caese. METHODS OF CERVICAL RIPENING

29. 2 - Stripping of the membranes : It is possible if one finger can be introduced through the cervix. 3 - Oxytocin infusion may be used with some success. However on occasion ,labor starts following the use of any of method. CNTD

30. Is a series of complex biochemical changes in the cervix which is mediated by the harmone. The cervix is normally two centimeters long,firm and closed throughout pregnancy. Umtimately the cervix becomes soft and palpable. Cervical Ripening

31. THANQ