Induction of labour

Induction of labour

1. Induction of labour Mrs. U SREEVIDYA Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2. INDUCTION OF LABOUR IOL means init i ation of uterine contraction period of v iabi l ity method(medical combined)for the ,surgical purpose (after the )by any or of vaginal delivery. ----D.C DUTTA DEFINITION OF IOL

3. DEFINITIONOF AUGMENTATION OF LABOUR a process of It is stimulation contrac t ion o f ut e rine ( both in frequency and intensity) that are already present but found to be inadequate. D.C.DUTTA

4. PURPOSES OF INDUCTION OF L ABOUR Risk of continuation of pregnancy either to the mother or fetus is more.

5. G O ALS The goal of induction of labour to eliminate the potential risks to the fetus with prolonged intrauterine existence while minimizing the likelihood of operative delivery.

6. Indications for induction of labor : Maternal indications Post-term (main indication] P.I.H (Timing depend )on the[ severity] Diabetes Mellitus (increase risk of baby loss and mortality rate) Medical conditions (as renal, respiratory and cardiac diseases) Placenta insufficiency (as moderate or sever e placenta abruption but commonly C.S) Prolonged pre-labor rupture of membranes. Rheuses isoimmunization. Maternal request.

7. Indications for Induction of Labor cond.. Fetal Indications : Suspected fetal compromise (I.U.G.R ) Intrauterine death (I .U.F.D).

8. INDICATIONS OF INDUCTION LABOUR 1. HYPER T ENSIVE DISORDER OF PREGNANCY 2. DIABETES, RENAL DISEASE CHRONIC PU L MONARY DISEASE PREM A TURE RUPTURE OF MEMBRANE RH ISO IMMUNI Z A TION POSTDATED PREGNANCY

9. CONTRAINDICATIONS OF IOL Contracted pelvis and CPD Malpresentation (breech , transverse or oblique lie) Previous classical caesarean section or hysterotomy Uteroplacental factors : unexplained , vaginal bleeding , vasa praevia, placenta praevia. High risk pregnancy with fetal compromise Active genital herpes infection Heart disease Pelvic tumour Elderly primigravidae with obstetric or medical complications Umbilical cord prolapsed Cervical carcinoma.

10. PARAMETERS TO ASSESS PRIOR TO IOL MATERNAL To confirm the indication for IOL Exclude the contraindication of IOL Assess Bishop score (>6, favourable) Perform clinical Pelvimetry to assess pelvic adequacy Adequate counselling about the risks, benefits and alternatives of IOL with the women and the family members

11. CONT.. FETAL To ensure fetal gestational age To estimate fetal weight(clinical and USG ) Ensure fetal lung maturation status Ensure fetal presentation and lie Confirm fetal well- being

12. FACTORS FOR SUCCESSFUL IOL Period of gestation- term or post term Pre- induction score- Bishop score >6 is favourable . Cervical ripening – favourable in parous women and in case with PROM Sensitivity to uterus- positive oxytocin sensitivity test is favourable to IOL. Presence of fibronectin in vaginal swab (> 50ng/ml) - favourable for successful IOL Other positive factors –maternal height >5’inches,normal BMI,EFW<3 kgs.

13. CERVICAL RIPENING Series of complex biochemical changes in the cervix which is mediated by the hormones. Ultimately the cervix become soft and pliable.

14. METHODS OF CERVICAL RIPENING PHARMACOLOGICAL METHODS Prostaglandins-Dinoprostone , Misoprostol Oxytocin Progesterone receptor antagonist- Mifepristone Relaxin Hyaluronic acid Estrogen

15. Cont.. NON PHAMOCOLOGICAL METHODS Stripping of membrane Amniotomy(ARM) Mechanical dilators, osmotic dilators Transcervical balloon catheter Extr a - a m in o tic sal i ne infusion

16. The Bishop score Bishop score is producing a scoring system to quantify the state of readiness of the cervix and fetus. High scores (a favourable cervix) are associated with an easier shorter induction.

17. BISHOP’S PREINDUCTION CERVICAL SCORING SYTEM(MODIFIED) PARAMETERS SCORE 1 2 3 CERVIX DIL A T A T I ON CLOSED 1-2 3-4 5+ EFFACEMENT % 0-30 40-50 60-70 ≥80 CONSISTENCY FIRM MEDIUM SOFT - POSITION POSTERIOR MIDLINE ANTERIOR - HE A D -S T A T I ON -3 -2 -1,0 +1,+2 CE R VIC A L LENGTH >4 2-4 1-2 <1

18. CONT.. TOTAL SCORE=13 Favorable score=6-13 Unfavorable score=0-5

19. METHODS OF IOL Natural non-medical methods Mechanical Medical Surgical Combined

20. Natural-Non Medical methods Relaxation techniques : advise patient to relieve tension and try to relax then use some visual aids to show how labor starts. Visualization: The patient is advised to imagine her uterus contracting and she is laboring. Hypnosis/self- hypnosis helps. Walking: The force of gravity pulls the weight of the baby towards the birth canal leading to dilatation and effacement of the cervix.

21. Natural-Non Medical methods (Cont.) 4. Cumin Tea: Used by midwives in Latino cultures. Sugar or honey may be added to lessen its bitter taste 5. Several herbs : Labor-enhancing herbs include blue Cohosh, black Cohosh, Squawvine and Dong Quai. Evening primrose oil also ripens the cervix. It is given internally 5 gel caps up against the cervix daily.

22. MECHANICAL INDUCTION Effective Low cost Low risk of tachysystole Disadvantage-infection

23. II-Mechanical methods 1- Hygroscopic dilators They absorb endocervical and local tissue fluids, causing the device to expand within the endocervix and provide mechanical pressure. These dilators are either natural osmotic dilators (e.g., Laminaria japonicum) or synthetic osmotic dilators (e.g., Lamicel). A dvan t a g e s : 1 - O u tp a t i en t p l ac e m en t fetal monitoring 2 - N o ne ed f o r Risks: fetal and/or maternal infection

24. Hygroscopic dilators

25. II- Mechanical methods (Cont .) 1- Hygroscopic dilators : Technique of insertion : -The perineum and vagina are sterilized with antiseptic sol & the patient is drapped. -Using a sterile speculum, the dilator is introduced into the endocervix. -Dilators are progressively placed until the endocervix is full. -A sterile gauze pad is placed in the vagina to maintain the position of the dilators.

26. II- Mechanical methods (Cont .) 2- Placement of Balloon Dilators after 42 weeks gestation: A fluid filled balloon is inserted inside the cervix. The Balloon provide mechanical pressure directly on the cervix which respond by ripening and dilation. A Foley catheter (26 Fr) or specifically designed balloon devices can be used. Technique of balloon placement: 1- After sterilization and draping, the catheter is introduced into the endocervix either by direct visualization or blindly by sliding it over fingers through the endocervix into the potential space between the amniotic membrane & the lower uterine segment.

27. II- Mechanical methods (Cont.) The balloon is inflated with 30 to 50 mL of normal saline and is retracted so that it rests on the internal os. Constant pressure may be applied over the catheter. e.g. a bag filled with 1 L of fluid may be attached to the catheter end. An intermittent pressure may also be exerted on the catheter end 2 -4 times per hour. Catheter is removed at the time of rupture of membranes or may be expelled spontaneously which indicate a cervical dilataion of 3-4 Centimeter. (References 2-6 - Evidence level B, systematic review of non-RCTs)

28. DRUGS USED FOR MEDICAL INDUCTION Prostaglandins(PGE2,PG E1) Oxytocin Mifepristone

29. PROSTOGLANDLINS(PGE2) It act locally on the contiguous cells and both causes the myometrial contraction . Intracervical application of Dinoprostone ( PGE2- 0.5mg) gel is the gold standard for cervical ripening. It may be repeated after 6 hours for 3 – 4 doses if required. The women should be in bed 30 min following application and is monitored for uterine activity and fetal heart rate .

30. MISOPROSTOL ( PGE1) ROUTE- Transvaginally or orally DOSE- 25μg vaginally every 4 hours is found either superior or similarly effective to that of PGE2 for cervical ripening and labour induction. Maximum doses is 6-8 SIDE EFFECTS -tachysystole ,meconium passage ,fetal heart rate irregularities and uterine rupture Contraindicated – previous LSCS

31. OXYTOCIN ACTION : Uterine activity (CONTRACTION), Produce cervical dilation and effect delivery (WHEN RIPEN) Oxytocin is effective for IOL when cervix is ripe.

32. Cont.. DOSE- 0.5 -2.5 mu/min Initiated at the dosage of 1 mu/min, with increases of 1 or 2 mU/minute every 20–30 minutes until a maximum administration rate of 16–32 mU/minute is reached or adequate uterine activity is present

33. MEFEPRISTONE It blocks both progesterone and glucocorticoid receptor . RU 486,200mg vaginally daily for 2 days has been found to ripen the cervix and to induce labour. Onapristone is a more selective progesterone receptor antagonist.

34. SURGICAL INDUCTION OF LABOUR

35. SURGICAL INDUCTION METHODS Artificial rupture of membrane Low rupture of membrane High rupture of m e mbr a n e (rar e ) Stripping of membrane

36. LOW RUPTURE OF MEMBRANES (LRM) It is widely practiced nowadays with high degree of success. The membranes below the presenting part over lying the internal os are ruptured to drain some amount of amniotic fluid.

37. ARTIFICIAL RUPTURE OF MEMEBRANE S INDICATION : Abruption placenta Chronic hydramnios Severe pre-eclampsia/eclampsia To place scalp electrode for electronic fetal monitoring.

38. ARM CO N T R AIN D ICA T I O NS: IUFD Maternal AIDS Genital active Herpes Infection

39. PROCEDURE OF ARM Preliminaries : empty the bladder . The procedure can be done in labour room or in OT if the risk of cord prolapse is high Actual steps Position the patient in lithotomy position Full surgical asepsis to be maintained Two fingers are introduced into the vagina smeared with antiseptic ointment The index finger is passed through the cervical canal beyond the internal os

40. AMNIOHOOK

41. KOCHER”S FORCEPS

42. Cont.. The membranes are swept free from the lower segment as far as reached by the fingers With one or two fingers still in the cervical canal with the palm a r surface upwards , a long kocher’s forceps with the blades closed or an amnion hook is introduced along the palmer aspect of the fingers up to the membranes The blades are opened to seize the membranes and are torn by twisting movements Amnihook is used to scratch over the membranes . This is followed by visible escape of amniotic fluid .

43. ARTIFICIAL RUPTURE OF MEMBRANE USING AMNI- HOOK

44. TIMINGS

45. ARM

46. HAZARDS OF ARM

47. Stripping of the membranes means digital sepration of the chrioamniotic membranes from the wall of the cervix and low e r uterine segment. It is the simple safe and beneficial for induction of labor.

48. COMBINED METHOD

49. 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.

50. ADVANTAGES OF COMBINED METHOD More effective than any single procedure Shortens the induction- delivery interval thereby minimizes the risk of infections and lessens the period of observation

51. MECHANISM OF ONSET OF LABOUR May be related with a)Stretching of the cervix Separation of the membranes (liberation of prostaglandins) Reduction of amniotic fluid volume

52. SCHEME OF IOL

53. NURSING RESPONSIBILITY

54. NURSING RESPONSIBILITY OF MEDICAL INDUCTION Nurse should know about the administration of drugs Nurse should administer PGE2 gel 0.5mg before the cervical ripening Nurse should observe about the cervical ripening Nurse should monitor for 30min after she should given drugs 3 or 4 doses after 6hrs. Nurse should know about the dose and route of misoprostol drugs Nurse should administer 25g vaginally every 4hours Nurse should know about the preparation of Oxytocin solution Oxytocin should be started in low dose with interval of 20- 30minutes Oxytocin should be administer 2units in 500ml ringer solution with drop rate of 60/minutes

55. NURSING RESPONSIBILITY OF SURGICAL INDUCTION OF LABOUR Nurse should maintain aseptic techniques She should provide proper position to the patient She should do vaginal examination with the use of proper aspetic techniques She should known about how to assess in procedure of low rupture of membrane She should know about the instruments which is used in the surgical induction of labour She should know how to use Amni hook She should observe by visible escape of amniotic fluid

56. GENERAL NURSING RESPONSIBILITY 1. AFETR THE MEMBRANE RUPTURED Check FHR Check rate of infusion Check uterine contractions and FHR 15min 2. GENERAL CARE Nurses provide care to women and their newborn during the ante partum, post partum and neonatal stages of this important life event. They assess each mother and baby and develop an individualized plan of care They implement the plan of care by monitoring the mother and baby and by teaching patients about their care and topics related to women’s health and newborn care.

57. 5. Nurses evaluate the effectiveness of the care plan and modify it is needed to meet the changing needs of the mother, newborn and family 6. They also provide psychological and emotional support to patients and families.

58. When an induction fails, the options include attempting induction again at some point in the future,or performing a Caesarean section. Delaying delivery further is only acceptable if there is no major threat to fetal or maternal condition.This may be the case with a failed social induction,for example. Failed induction in the setting of preeclampsia or fetal growth restriction will usually necessitate Caesarean delivery.