Induction of labour

Hope it helps.. This presentation describes about labour induction, its types, methods, management and responsibilities. also the procedure of performing the methods. pictures as per need attached for the reference. like and comment if any suggestion.

1. INDUCTION OF LABOUR Deepa Mishra Assistant Professor (OBG)

2.   Induction of labour An intervention designed to artificially initiate uterine contractions leading to progressive dilatation and effacement of the cervix. Is the planned initiation of labor prior to the onset of spontaneous labor. It is an obstetric intervention that should be used when elective birth beneficial to mother and baby.

3. Objectives At the end of this presentation you should be: Aware of the indications and contraindications for induction of labor Aware of the different methods of induction of labor Able to select the appropriate method of labor induction for an individual patient.

4. Indications for induction of labor

5.   Contraindications 

6. Augmentation of labor  Is refers to intervention to correct slow progress in labor . Correction of ineffective uterine contraction includes Amniotomy and/or Oxytocin infusion.

7. Criteria Before Induction Sure estimation of weeks of gestation. Evidence of fetal maturity. Absence of cephalopelvic disproportion. An engaged head in longitudinal lie. Cervix is ready for delivery. High score Bishop's score. Induction with Caution Multiple pregnancy. • Hydramnios . • Grand parity. • Maternal age of >35years. • Previous cesarean section

8. Bishop’s Score Cervical feature Modified  Bishop score 1 2 3 Dilation (cm) < 1 1–2 2–4 > 4 Length of  cervix  (cm) > 4 2–4 1–2 < 1 Station (relative to ischial spines) −3 −2 −1/0 +1/+2 Consistency Firm Average Soft – Position Posterior Mid/anterior – – High scores (a favourable cervix) are associated with an easier shorter induction

9. Methods of Induction of Labor

10. Natural-Non Medical methods

11. Nipple stimulation: The lady moves her palm and applies some pressure in a circular fashion over her areola and massaging nipple between thumb and forefingers for a period of 2 minutes alternating with 3 minutes of rest. The procedure is performed for 20 minutes Tea : Used by midwives in Latino cultures. 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. Acupressure: One point is located deep in the webbing between thumb and forefinger. Massaging this point in a circular motion for 1-5 minutes stimulates labor pain and induce labor .

12. Mechanical methods 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

13. 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.

14. Mechanical methods Placement of Balloon Dilators after 42 weeks- 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.

15. Technique of B alloon 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.

16. Technique of B alloon Insertion (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 dilatation of 3-4 Centimeter.

17. Surgical Methods Stripping the membranes Amniotomy

18. Before ARM

19. After ARM

20. Pharmacological Induction of Labour Prostaglandin E2 (Dinoprostone)-  It is inserted vaginally as a gel (Prepidil), as a removable tampon (Cervidil) or as a vaginal pessary. It acts on the cervical connective tissue and relaxes muscle fibres of the cervix. Dinoprostone should only be administered at hospital and the patient is expected to stay recumbent and monitored, at least, for the first 30 minutes after insertion.

21. Pharmacological Induction of Labour Prostaglandin E2 (Dinoprostone)-   Contractions usually start within 60 minutes of commencing induction and peak within 4 hours. If optimal response is not achieved by 6 hours, another dose can be administered. The maximum allowed dose is 3 doses be administered per 24 hours. Cervidil contains 10 mg of dinoprostone and provides a lower constant release of medication (0.3 mg per hour) than Prepidil does. Cervidil have the advantage of being removed more easily if uterine hyperstimulation occurs. In addition, it does not require refrigeration. PGE2 can cause uterine hyperstimulation , fetal distress and Cesarean section.

22. Before Interventions Review patient history before administration (to ensure there are no contraindications or any caution). Fetal heart rate and uterine contractions should be monitored continuously for 30-60 minutes after administration. (there is a risk of uterine hyper stimulation and rupture of uterus with or without fetal distress )  Instruct woman to pass urine before administering prostaglandin (because she will stay for long time in bed)

23. The mother should remain in lateral or supine position with hip tilt for 30 to 60minutes after administration of gel, for 2 hours after insertion of vaginal tablets. (to minimize leakage and improve effectiveness ). Assess cervical dilatation 6 hours after insertion. (If no cervical response and no adverse effects, the dose may be repeated). Monitor side effects of prostaglandins: Pyrexia, warm feeling in vagina, vomiting, diarrhea, and back pain . It is necessary to allow at least 2 hours to elapse between the last prostaglandin dose and starting Syntocinon infusion, (because Prostaglandin increase the sensitivity of the uterus to Syntocinon). If any adverse reactions occur notify doctor to remove gel or suppository if possible.

24. Misoprostol Pharmacokinetics: Route of administration : Oral, vaginal and sublingual route for induction. Rectal route is used to prevent and treat postpartum hemorrhage . Bioavailability : Extensively absorbed from the GIT Metabolism : De-esterified to prostaglandin F analogs Half life: 20–40 minutes Excretion : Mainly renal 80%, remainder is fecal : 15%

25. Misoprostol ( Cytotec ) is a synthetic PGE1 analog that has been found to be a safe and inexpensive agent for cervical ripening. Clinical trials indicate that the safe optimal dose and dosing interval is 25 mcg intravaginally every 4-6 hours. A maximum of 6 doses was suggested. Higher doses or shorter dosing intervals are associated with a higher incidence of side effects, especially hyperstimulation syndrome. Misoprostol should not be used in women with previous CS because of increased rates of uterine rupture there appears to be a higher incidence of vaginal delivery within 24 hours of application and a reduced need for oxytocin augmentation

26. Mifepristone Mifepristone ( Mifeprex ) is an antiprogesterone agent which counteracts the inhibitory effect of Progesterone on the uterus. Few studies with small number of women enrolled, have shown that women treated with mifepristone in a dose of 600 mg are more likely to have a favorable cervix and deliver within 48 to 96 hrs when compared with placebo and also they these were less likely to undergo C.S. Information about fetal outcomes & maternal side effects is scarce and cannot be used to recommend the use of mifepristone for cervical ripening.

27. High Dose Protocol- Mifepristone Prepare15 IU of oxytocin/500 mL 5% dextrose. Start IV solution infusion at a rate of 4.5-6 mU /minute (9-12 mL/hour) and increased by 4.5 mU /minute every 30 minutes for a maximum of 40 milliunits per minute. This protocol have the advantage of shorter induction delivery interval but with more hyper-stimulation

28. Oxytocin Infusion   Oxytocin infusion in an isotonic solution is used to stimulate uterine contractions after rupture of the membranes. The dose and increasing rate depend on each agency protocols. Oxytocin Protocol If infusion volumes were found to be excessive, prepare double strength solution. If no progress occurred after 8–12 hours of starting induction, either discontinue the oxytocin and reapply a cervical ripening agent or reinitiate oxytocin the next day. Continuous electronic FHR monitoring during induction is essential to monitor fetal response to labor and uterine response to the inducing agent. If severe FHR abnormalities or hyper-stimulation occurred, decrease/discontinue the oxytocin infusion.

29. Side Effects of Oxytocin use Uterine hyperstimulation and subsequent FHR abnormalities. Abruptio placentae and uterine rupture. Water intoxication may occur with high concentrations of oxytocin infused with large quantities of hypotonic solutions. Therefore ; prolonged administration with doses higher than 40 mu of oxytocin per minute and infusion of fluids in any 10 hours should not exceed 1500 ml. A rapid intravenous injection of oxytocin may cause hypotension.

30. Other Complications may Occur during Oxytocin Infusion In addition to hyper-stimulation of uterus and fetal distress those complications may occur: Ruptured uterus as a result of overstimulation if any cephalopelvic disproportion present. Amniotic fluid embolism is rare which may caused by strong, tumultuous contractions. (usually occur in 3rd stage after placenta separation and with tetanic condition of uterus)

31. Signs of Hyperstimulation of the uterus Contraction occur more frequently than every 2 minutes. Duration of contraction is longer than 90 seconds. Elevation of resting tone of uterus is greater than 15 to 20 mmHg over her baseline of intrauterine pressure. Blood pressure increases when contractions increase in frequency, duration, and intensity because of decrease in utero-placental circulation. Client experience increasing pain because of increased frequency, duration, and intensity of contractions. Sustained tetanic contractions occur.

32.   Signs of Fetal Distress: Tachycardia or bradycardia . Late decelerations, variable decelerations, or prolonged deceleration. Loss of variability. Increased fetal activity. Excessive moulding or caput-succedaneum formation . Meconium stained amniotic fluid in cephalic presentation.