L12- Induction of Labor.ppt. .

Science research

1. INDUCTION OF INDUCTION OF
LABOURLABOUR
King Khalid University HospitalKing Khalid University Hospital
Department of Obstetrics & GynecologyDepartment of Obstetrics & Gynecology
Course 482Course 482

2. INTRODUCTIONINTRODUCTION
DEFINITION DEFINITION Induction of labour is Induction of labour is
defined as an intervention designed to defined as an intervention designed to
artificially initiate uterine contractions artificially initiate uterine contractions
leading to progressive dilatation and leading to progressive dilatation and
effacement of the cervix and birth of effacement of the cervix and birth of
the baby. This includes both women the baby. This includes both women
with intact membranes and women with intact membranes and women
with spontaneous rupture of the with spontaneous rupture of the
membranes but who are not in labour. membranes but who are not in labour.

3. INDICATIONSINDICATIONS

Post-term pregnancy Post-term pregnancy  most common most common

PROMPROM

IUGRIUGR

Non-reassuring fetal suvillenceNon-reassuring fetal suvillence

Maternal medical conditions Maternal medical conditions  DM, renal disease, DM, renal disease,
HPT, gestational HPT, significant pulmonary HPT, gestational HPT, significant pulmonary
disease, antiphospholipid syndromedisease, antiphospholipid syndrome

ChrioamnionitisChrioamnionitis

AbruptionAbruption

Fetal deathFetal death

4. RISKS of IOLRISKS of IOL

 rate of operative vaginal deliveriesrate of operative vaginal deliveries

 rate of CS rate of CS

Excessive uterine activityExcessive uterine activity

Abnormal fetal heart rate patternsAbnormal fetal heart rate patterns

Uterine ruptureUterine rupture

Maternal water intoxicationMaternal water intoxication

Delivery of preterm infant due to Delivery of preterm infant due to
incorrect estimation of GAincorrect estimation of GA

Cord prolapse with ARMCord prolapse with ARM

5. CONTRAINDICATIONSCONTRAINDICATIONS
(Contraindications to labor or vaginal delivery)(Contraindications to labor or vaginal delivery)

Previous myomectomy entering the cavityPrevious myomectomy entering the cavity

Previous uterine rupturePrevious uterine rupture

Fetal transverse lieFetal transverse lie

Placenta previaPlacenta previa

Vasa previaVasa previa

Invasive Cx CaInvasive Cx Ca

Active genital herpesActive genital herpes

Previous classical or inverted T uterine Previous classical or inverted T uterine
incisionincision

2 or more CS2 or more CS

6. PREREQUISITESPREREQUISITES
To assess the followingTo assess the following

Indication / any contraindicationsIndication / any contraindications

GAGA

Cx favourability (Bishop score)Cx favourability (Bishop score)

Pelvis, fetal size & presentationPelvis, fetal size & presentation

Membranes statusMembranes status

Fetal heart rate monitoring prior to IOLFetal heart rate monitoring prior to IOL

Elective induction should be avoided Elective induction should be avoided
due the potential complicationsdue the potential complications

7. Cx ripening prior to IOLCx ripening prior to IOL
Indication Indication  if the Bishop score is if the Bishop score is ≤ 6≤ 6

The state of the Cx is an important predictor of The state of the Cx is an important predictor of
successful IOLsuccessful IOL
Methods :Methods :

Intracervical PGE2 gelIntracervical PGE2 gel 0.5 mg/6hrs----3 doses0.5 mg/6hrs----3 doses

Intravaginal PGE2 gelIntravaginal PGE2 gel 1-2 mg/6hrs----3doses1-2 mg/6hrs----3doses
PGE2 gel PGE2 gel  the rate of not being delivered in 24 hrs the rate of not being delivered in 24 hrs
 the use of oxytocin for augmentation of laborthe use of oxytocin for augmentation of labor
PGE2 gel PGE2 gel  the rate of uterine hyperstimulation the rate of uterine hyperstimulation

MisoprostolMisoprostol  Should not be used for term fetuses Should not be used for term fetuses

Mechanical methodsMechanical methods

8. Cx ripening prior to IOLCx ripening prior to IOL
Mechanical methodsMechanical methods
Foley CatheterFoley Catheter

It is introduced into the cervical canal past the It is introduced into the cervical canal past the
internal os, the bulb is inflated with 30-60 cc of waterinternal os, the bulb is inflated with 30-60 cc of water

It is left for up to 24 hrs or until it falls out It is left for up to 24 hrs or until it falls out

Contraindications Contraindications Low laying placenta, antepartum Low laying placenta, antepartum
Hg, ROM, or cervicitisHg, ROM, or cervicitis

No difference in operative delivery rate, or maternal No difference in operative delivery rate, or maternal
or neonatal morbidity compared to PG gel or neonatal morbidity compared to PG gel
Hydroscopic dilatorsHydroscopic dilators (Eg.Laminaria tents) (Eg.Laminaria tents)

Higher rate of infections Higher rate of infections

9. IOLIOL
1-Oxytocin with Amniotomy1-Oxytocin with Amniotomy

IVIV

Half life 5-12 minHalf life 5-12 min

A steady state uterine response occurs in 30 min or >A steady state uterine response occurs in 30 min or >

Fetal heart rate & uterine contractions must be monitored Fetal heart rate & uterine contractions must be monitored

If there is hyperstimulation or nonreassuring fetal heart If there is hyperstimulation or nonreassuring fetal heart
rate pattern rate pattern  D/C infusion D/C infusion

Women who receive oxytocin were more likely to be Women who receive oxytocin were more likely to be
delivered in 12-24 hrs than those who had amniotomy delivered in 12-24 hrs than those who had amniotomy
alonealone
& less likely to have operative delivery& less likely to have operative delivery

10. IOLIOL
2-PGE22-PGE2

For women with favorable Cx For women with favorable Cx  PGE2 PGE2  the rate of the rate of
operative delivery & failed IOL when compared to operative delivery & failed IOL when compared to
OxytocinOxytocin

PGE2 PGE2   GIT side-effects, pyrexia & uterine GIT side-effects, pyrexia & uterine
hyperactivity hyperactivity
3-Sweeping of the membranes3-Sweeping of the membranes

Vaginally the examining finger is placed through the Vaginally the examining finger is placed through the
os of the Cx & swept around to separate the os of the Cx & swept around to separate the
membranes from the lower uterine segment membranes from the lower uterine segment
  local PGF2 local PGF2 αα production & release from decidua production & release from decidua
& membranes & membranes  onset of laboronset of labor

 the rate of delivery in 2-7 days the rate of delivery in 2-7 days

 the rate of post-term the rate of post-term

 the use of formal induction methodsthe use of formal induction methods

If there is urgent indication for IOL sweeping is not If there is urgent indication for IOL sweeping is not
the method of choicethe method of choice

11. Specific circumstances or indicationsSpecific circumstances or indications
Prelabor SROM at termPrelabor SROM at term

6-19%6-19%

IOL with oxytocin IOL with oxytocin  risk of maternal risk of maternal
infections (chorioamnionitis& endometritis) & infections (chorioamnionitis& endometritis) &
neonatal infectionsneonatal infections

PG also PG also maternal infections & neonatal maternal infections & neonatal
NICU admissionsNICU admissions
IOL after CSIOL after CS

PG should not be used as it can result in PG should not be used as it can result in
rupture uterusrupture uterus

Oxytocin or foley catheter may be usedOxytocin or foley catheter may be used