obstetrics II class handout.pptx

Obstetrics of delivery

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2. Objectives By the end of this session the students will be able to: Define Analgesia and anesthesia Distinguish commonly used types of Analgesia and anesthesia

3. 5/8/2024 What is the difference between analgesia and anesthesia

4. Introduction Relief of pain during labor and delivery is an essential part in g ood ob st e tric ca r e. Choice of anesthesia depends upon the patient ’ s conditions and the associate disorders. Anesthesia following full meal m a y cause maternal death due to vomiting and aspi r ation of g astric co nt ents . 5/8/2024 Rebuma M. 5

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11. NERVE SUPP L Y OF THE GENI T AL TRAC T :- Uterus is under both nervous and hormonal control. Hypothalamus controls the uterine ac t ivity through the reti c ular formation which balances the effects of the two autonomic divisi o n s . M O T OR NE R VE SUPP L Y :- The uterus receives both sympathetic and parasympathetic nerve fibers. 5/8/2024 Rebuma M. 12

12. The sympathetic ne r ve f i bers arise from lower thoracic and upper lumbar segments of the spinal cord. The parasympathetic fibers arise from sacral 2, 3 and 4 segments of the spinal cord . Sens o r y stimuli from the uterine body : are transmitted through the pelvic, superior hypogastric and aorticorenal plexus to the10 t h , 1 1 th and 1 2 th dorsal and the first lumbar segments o f the spinal cord. Senso r y stimuli from ce r vix pass through the pelvic plexus along the pelvic parasympathetic ne r ves to sacral se g ments 2, 3 and 4 of the spinal cord. 5/8/2024 Rebuma M. 13

13. Sens o r y stimuli from upper vagina pass to 2, 3 and 4 sacral parasympathetic segments and from lower vagina pass through the pudendal nerve. The perineum receives both motor and senso r y inne r vation from sacral roots 2, 3 and 4 through the pudendal nerve. The b r anches of ilioinguinal and genital b r anch of genito f emo r al ne r ves supply the labia majora and also car r y the impulses from the perineum. 5/8/2024 Rebuma M. 14

14. HORMONAL CONTROL:- It is generally agreed that intact ne r ve supply is not essential for the initiation and progress of labo r . Ox y tocin , a hormone derived from posterior pituitary maintains the uterine activity during labo r . Progeste r one is the p r egnancy–s t abilizing hormone. Labor commences when it is withdrawn. Adrenal in with its beta activity inhibits the contraction of uterus, while its alpha activity excites it . 5/8/2024 Rebuma M. 15

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16. Pain during labor results from a combination of uterine cont r actions and cervical dilatation. The intensity of labor pain depends on the i ntensity and duration of uterine contractions, degree of dilatation of ce r vix, distension of per i neal tissue, parity and the pain threshold of the woman. 5/8/2024 Rebuma M. 17

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19. PSYCHOPROPHYLAXIS It is psychological method of antenatal preparation designed to prevent or at least to minimi z e pain and difficulty during labo r . Patient is taught about the physiology of pregnancy and labor in antenatal (mother craft) classes. Relaxation exercises are practiced. Husband or the partner is also involved in the management. 5/8/2024 Rebuma M. 20

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21. Eve r y case of labor does not require analgesia and only sympathetic e xplanation m a y be all that is required . 5/8/2024 Rebuma M. 22

22. COMMON L Y USED L OCAL ANESTH E SIA IN OBSTETRICS 5/8/2024 Rebuma M. 23

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24. When complete relief of pain is needed throughout labor, epidural analgesia is the safest and simplest method for procuring it . It provides senso r y and motor blocked of the regions. A lumbar puncture is made between L2 and L3 with the epidur al needle ( T uo h y needle). I . R E GIONAL (NEURAXIAL) ANE S TH E SIA 5/8/2024 Rebuma M. 25

25. With the patient on her left side, the ba c k of the patient is cleansed with antiseptics before injection. When the epidural space is ensured, a plastic catheter is passed through the epidu r al needle for continuous epidu r al analgesia. A local anesthetic agent (0.5% bupivacaine) is injected into the epidu r al space. Full dose is given after a test dose when there is no toxicit y . For cesarean delivery a block from T4 to S1 is needed. 5/8/2024 Rebuma M. 26

26. Advantages of regional Anesthesia The patient is awake and can enjoy the birth time Newborn APGAR score generally good Lower risk of maternal aspiration Postoperative pain control is better 5/8/2024 Rebuma M. 27

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30. P AR A CE R VICAL NE R VE B L OCK is useful for pain relief during the first s t age of labo r antiseptic safe guards, a long needle ( 1 5 cm or more) is passed into the lateral forni x , at the 3 a nd 9 o ’ clock Five to ten mil l iliter of 1 % lignocaine are injected at the site of the cervix and the procedure is repeated on the other side. Although used from 5 cm dilatation of the ce r vix, it is most useful toward the end of the first stage of labor to remove the desire to bear down earlier. 5/8/2024 Rebuma M. 31

31. PUDENDAL NERVE BLOCK It is a safe and simple method of analgesia during delive r y. Pudendal ne r ve block does not r e lieve the pain of labor but affords perineal analgesia and relaxation. Pudendal ne r ve block is mostly us e d for forceps and vag i nal br e e c h deliver y . The pu d endal ne r ve may be blocked by ei t her the transva g inal o r the transperineal rout e . T ransvaginal route : is commonly preferred. The index and middle fingers of one hand are introduced into the vagina, the finger tips are placed on the tip of the ischial spine of one side. 5/8/2024 Rebuma M. 32

32. The needle is passed along the groove of the fingers and guided to pierce the vaginal wall on the apex of ischial spine and thereafter to push a little to pierce the sacrospinous ligament just above the ischial spine tip. After aspirating to exclude blood, about 10 mL of the solution is injected. The similar procedure is adopted to block the nerve of the other side by changing the hands. 5/8/2024 Rebuma M. 33

33. SPINAL AN E S TH E SIA obtained by injection of local anesthetic agent into the suba r achnoid space of the L3 or L4 lumbar interspace It has less procedure time and high success r ate. For normal delive r y or for outlet forceps with episiotomy, ventouse delivery, block should extend from T10 (umbilicus) to S1 . Hyperbaric bupivacaine (5 – 1 mg) or lignocaine (25 – 50 m g) is use d . 5/8/2024 Rebuma M. 34

34. The blood pressure and respiratory rate should be recorded every 3 minutes for the first 10 minutes and every 5 minutes thereafter. Oxygen should be given for respiratory depression and hypotension. Sometimes vasopressor drugs may be required if a marked fall in blood pressure occurs. 5/8/2024 Rebuma M. 35

35. INFI L TR A TION ANA L G E SIA P erineal infilt r a tion: For episioto m y: P erineal infilt r ation anesthesia is e xtensively used prior to episioto m y . A 10 mL syringe, with a fine needle and about 8 – 10 m L 1% lignocaine h y d r ochloride ( X ylocaine) a r e r equi r ed. The perineum on the proposed episiotomy site is infiltrated in a fanwise manner starting from the middle of the f ou r chette. 5/8/2024 Rebuma M. 36

36. Each time prior to infiltration, aspiration to exclude blood is mand at or y . Episiotomy is to be done about 2 – 5 minutes f ollowing infilt r ation. 5/8/2024 Rebuma M. 37

37. GENERAL ANESTH E SIA FOR C E S AREAN S E CTION Cesarean sec t ion may have to be done either as an elective or eme rg ency p r ocedu r e. Ryel ’ s tube aspirati o n o f gastric contents is to be done, especially when the stomach contains f ood. Induction of anesthesia is done with the injection of thiopentone sodium 200–250 mg (4 mg/kg) as a 2.5% solution intravenously . 5/8/2024 Rebuma M. 38

38. Uterine contractility may be diminished by volatile anesthetic agents like ether, halothane . Halothane, isoflurane cause cardiac depression, hepatic necrosis and hypotension. Uterine incision-Delive r y (U - D) inte r val is more predictive o f neon a tal status (Ap g ar sco r e ). Prolonged U - D inte r val of more than 3 minutes results in lower Apgar scores and neonatal acidosis . 5/8/2024 Rebuma M. 39

39. Muscle relaxants: Succinylcholine is commonly used immediately after the induction drug to f acilitate intubation. It is a short acting muscle relaxant with r apid onset of action. I n tub a tion: An assistant is asked to apply cricoid pressure as s o on as the consciousness is lost. 5/8/2024 Rebuma M. 40

40. Intubation is done with a cuffed endotracheal tube and the cuff is i n fl a t e d . Presence of obe s ity, severe edema, neck abnormalities, short stature or airw a y abnormalities ma k e intubation difficult . Anesthesia is maintained with 50% nitrous oxide, 50% oxygen and a trace (0.5%) of halothane. 5/8/2024 Rebuma M. 41

41. Complications of general anesthesia: Aspiration of gastric contents ( Mendelson’s syndrome) is a serious and life threatening one. Delayed gastric emptying due to high level of serum progesterone , decreased motility and maternal apprehension during labor is the predisposing factor. is due to aspiration of gastric acid contents ( pH < 2.5) with the development of chemical pneumonitis, lung damage , atelectasis and bronchopneumonia. 5/8/2024 Rebuma M. 42

42. Mana g eme n t: Immediate suct i oning of oropha r ynx and nas o pha r ynx is done to remove the inhaled fluid. Bronchoscopy may be needed if there is any large particulate m a tt e r . Continuous positive pressure ventilation to maintain arterial oxygen satu r ation of 95% is done. 5/8/2024 Rebuma M. 43

43. Abnormal labor Objectives At the end of the session the learners will be able to: Define abnormal labor or dystocia Identify etiologies of abnormal labor Discuss on classification of abnormal labor Describe the diagnosis and management options 5/8/2024 Rebuma M. 44

44. P hysiology of normal labor Labor - is a clinical diagnosis defined as uterine contractions resulting in progressive cervical effacement and dilatation , which results in birth of the baby -often accompanied by a bloody discharge, bloody show. Stages- first stage -latent -active -second stage -third stage -fourth stage 5/8/2024 Rebuma M. 45

45. Definition: Dystocia(abnormal labor) literally means difficult labor (child birth)and is characterized by abnormally slow progress of labor. Most common cause of primary c/s. More common for primi (25-30 %) multipara (10-15 %). 46 5/8/2024 Abnormal labor( Dystocia) Rebuma M.

46. 5/8/2024 47 Induced labor. Multiple gestation. Malpresentation. Pre/Post term. Assisted delivery. Precipitous labor . Poor progress or arrest . Abnormal labor Rebuma M.

47. 5/8/2024 48 Classifications of abnormal labor patterns – Four major groups Prolongation disorders Protraction disorders Arrest Disorders Precipitate labor Rebuma M.

48. 5/8/2024 49 Prolongation Disorders Only one prolongation disorder Prolonged latent phase of labor A latent phase lasting longer than 20 hrs. for nulliparous and 14 hrs. for multiparas. Challenge in diagnosis is often due to the problem in diagnosing the exact time of onset of labor Causes: 1- Power (Inefficient uterine contraction) a) Hypertonic uterine dysfunction b) Hypotonic uterine dysfunction 2- Excessive use of sedative or analgesia. Rebuma M.

49. Hypertonic:- contractions are: -painful -ineffective and -associated with increased uterine tone. There is a high resting basal tone between contractions. Therefore, uterine circulation does not return to normal between contractions and consequently fetal distress is more common. Hypotonic :- - contractions are less painful and characterized by easily indentable uterus during the contractions and occur more frequently during the active phase. They are considered as the most common cause of poor progress in labor. 50 5/8/2024 Rebuma M.

50. Risk factors: -Extreme reproductive age (too young or too old). -Primigravida. -Unusually anxious women. -Uterine over distention, e.g. multiple gestation, polyhydraminos. -Minor degrees of cephalo-pelvic disproportion. -Malposition of the fetal head. 51 5/8/2024 Rebuma M.

51. Cont …. Management depend on the cause : * hypertonic activity respond erratically to oxytocin but usually respond to therapeutic rest with 15-20mg morphine sulphate or pethidine * hypotonic activity respond well to IV(infusion) oxytocin. * excessive sedation or analgesia resolved spontaneously after their effect have disappeared . * ARM . 52 5/8/2024 Rebuma M.

52. 5/8/2024 53 Protraction Disorders Two protraction disorders Protracted cervical dilatation A dilatation< 1.2 cms per hour in the primigravida and <1.5 cms per hour in the multigravida during active labor Protracted descent Descent < 1 cms per hour in the primigravida and <2 cms per hour in the multigravida Rebuma M.

53. Management generally these disorders don’t respond to oxytocin stimulation or therapeutic rest or ARM , they should be treated expectantly as long as the fetal HR is satisfactory and labor continues to progress. If due to hypotonic activity it will respond to oxytocin. over sedation , normal labor will resume if the effect of drug is allowed to wear off. 54 5/8/2024 Rebuma M.

54. 5/8/2024 55 Arrest Disorders Arrest of Cervical Dilatation No cervical dilatation for 2 or more hours in the active phase of labor Arrest of descent No descent for more than 1 hours Rebuma M.

55. Management of labor abnormalities Expectant management — Most women with prolonged second stage ultimately deliver vaginally Treatment of hypo contractile uterine activity Assisted vaginal delivery  Cesarean delivery  5/8/2024 Rebuma M. 56

56. Definition: Strong and frequent contractions causing abnormally rapid progress of delivery within 1 hr in multipara and 3 hrs in primipara . Over-efficient contractions in the absence of obstruction. Risk factors: Strong uterine contractions. Small sized fetus. Minimal soft tissue resistance. Previous history of precipitate labor. Precipitate labor 5/8/2024 Rebuma M. 57

57. Precipitate labor Complications: Maternal: Laceration: Cervix, vagina, and perineum. Uterine inversion – postpartum hemorrhage Uterine atony – postpartum hemorrhage Amniotic fluid embolism Fetal: Intracranial hemorrhage Fetal distress Delivery in inappropriate place 5/8/2024 Rebuma M. 58

58. Precipitate labor Management: Stop oxytocin infusion (if used). Tocolytics (Mg sulfate, terbutaline ). Episiotomy to avoid fetal and birth canal injuries. Observe for PPH. Observe fetus for injuries. 5/8/2024 Rebuma M. 59

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60. Partograph and Criteria for Active Labor Label with patient identifying information Note fetal heart rate, color of amniotic fluid, presence of moulding , contraction pattern, medications given Plot cervical dilation Alert line starts at 4 cm--from here, expect to dilate at rate of 1 cm/hour Action line: if patient does not progress as above, action is required 5/8/2024 Rebuma M. 61

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66. 5/8/2024 67 Obstructed Labor Cont … Outline Define obstructed labor Discuss the etiology of obstructed labor Describe the diagnosis of obstructed labor Outline complications of obstructed labor Outline steps in the management of obstructed labor Rebuma M.

67. 5/8/2024 68 Obstructed labor – a neglected case of labor in which there is failure of descent of fetal presenting part through the birth canal for mechanical reasons in the presence of adequate uterine contractions. Major cause of maternal and perinatal mortality and morbidity in low-resource settings with inadequate or inaccessible intrapartum care. Definitions – Obstructed labor Rebuma M.

68. 5/8/2024 69 Etiology of Obstructed Labor (I) Maternal causes: 1-Bony obstruction : e.g. - Contracted pelvis. - Tumours of pelvic bones. 2-Soft tissue obstruction: i) Uterus: - Impacted subserous pedunculated fibroid. ii) Cervix: cervical dystocia. iii) Vagina: − Septa. − Stenosis. − Tumours. iv) Ovaries : Impacted ovarian tumours . Rebuma M.

69. 5/8/2024 70 (II) Foetal causes: 1- Malpresentations and malpositions : e.g. - Persistent occipito - posterior and deep transverse arrest, -Persistent mento -posterior and transverse arrest of the Face presentation. - Brow, - Shoulder, - Impacted frank breech. 2- Large sized foetus ( macrosomia ). 3- Congenital anomalies : e.g. - Hydrocephalus. - Foetal ascitis . - Foetal tumours . 4- Locked and conjoined twins. Rebuma M.

70. 5/8/2024 71 (A) History: of - prolonged labour , - frequent and strong uterine contractions, - rupture membranes. (B) General examination : shows signs of maternal distress as: - exhaustion, - high temperature (≥ 38 o C ), - rapid pulse, - signs of dehydration : dry tongue and cracked lips. Diagnosis of Obstructed Labor Rebuma M.

71. 5/8/2024 72 (C) Abdominal examination: 1- The uterus : - is hard and tender, - frequent strong uterine contractions with no relaxation in between ( tetanic contractions). - rising retraction ring is seen and felt as an oblique groove across the abdomen. 2- The foetus : - foetal parts cannot be felt easily. - FHS are absent or show foetal distress due to interference with the utero -placental blood flow. Diagnosis cont… Rebuma M.

72. 5/8/2024 73 (D) Vaginal examination: 1- Vulva: is oedematous. 2- Vagina : is dry and hot. 3- Cervix: is fully or partially dilated, oedematous and hanging. 4- The membranes : are ruptured and o ffensive liquor 5- The presenting part: is high and not engaged or impacted in the pelvis. If it is the head it shows excessive moulding and large caput. 6-High station 7- The cause of obstruction can be detected. Diagnosis cont… Rebuma M.

73. 5/8/2024 74 (E) Differential diagnosis: 1- Full bladder. 2- Fundal myoma. Diagnosis cont… Rebuma M.

74. 5/8/2024 75 Obstructed labor versus Parity Primigravid labor Uterine inertia following obstruction Labor can continue for days Sepsis and shock are causes of death Fistula is a major complications Multiparous labor Increased uterine contractions Uterine rupture within hours Death often faster compared to the primigravida Rebuma M.

75. 5/8/2024 76 Complications of Obstructed Labor Maternal Hypovolemia/Shock Maternal distress and ketoacidosis. Infection/Sepsis- as chorioamnionitis and puerperal sepsis Uterine rupture -Warning signs: Bandl’s ring and tenderness of the lower segment of the uterus. Rebuma M.

76. 5/8/2024 77 Genital trauma Neurologic injury Death Psychological injury Postpartum hemorrhage-due to injuries or uterine atony. Fetus/Neonate Asphyxia Infection/Sepsis Trauma Death Intracranial haemorrhage from excessive moulding . Complications of Obstructed Labor Rebuma M.

77. 5/8/2024 78 Management of Obstructed Labor Preventive measures: General Resuscitation Correct dehydration, electrolyte deficit, and acidosis . Oxygen Antibiotics Catheterization Pain relief NG tube drainage of gastric contents Rebuma M.

78. 5/8/2024 79 Cross match and prepare blood Careful observation , proper assessment, early detection and management of the causes of obstruction . (B) Curative measures: Caesarean section is the safest method even if the baby is dead as labor must be immediately terminated and any manipulations may lead to rupture uterus. Management cont… Rebuma M.

79. Non-reassuring fetal heart rate pattern Objective The learner will be able to: Describe non-reassuring fetal heart rate Identify categories of non-reassuring fetal heart rate Categorize Preventive and management options 5/8/2024 Rebuma M. 80

80. Fetal heart rate tracings Auscultation of the fetal heart rate (FHR) is performed by external or internal means. External monitoring is performed using a hand-held Doppler ultrasound or external transducer, which is placed on the maternal abdomen and held in place by an elastic belt or girdle . Internal monitoring is performed by attaching a screw-type electrode to the fetal scalp with a connection to an FHR monitor. The fetal membranes must be ruptured, and the cervix must be at least partially dilated before the electrode may be placed on the fetal scalp. 5/8/2024 Rebuma M. 81

81. Cont… Reassuring fetal heart rate: Indicates there is minimal likelihood of acidemia at that point/normal/. A baseline fetal heart rate of 110 to 160 bpm Absence of FHR variability (6 to 25 bpm ) Age appropriate FHR acceleration late or variable FHR deceleration. Moderate

82. Early decelerations may or may not be present, FHR accelerations are an important finding Non-reassuring FHR patterns Includes: Absent or minimal variability with decelerations or bradycardia Absent variabilty with: late deceleration variable deceleration Bradycardia 5/8/2024 Rebuma M. 84

83. Tracing the fetal heart beat with a cardiotocograph (CTG) monitor can be used to assess fetal well being and fetal heart rate response to uterine activity, during labor and delivery Interpretation: A) Baseline FHR changes The pattern between uterine contractions 5/8/2024 Rebuma M. 85

84. Tachycardia: Mild:160-180 beats/min Severe:>180 b/min Causes -Maternal fever - Fetal hypoxia -Fetal anemia - Amnionitis Bradycardia : Mild:100-110 beats/min Severe:<100 beats/min Causes -Heart block (little or no variability) - Occiput posterior or transverse position -Serious fetal compromise . 5/8/2024 Rebuma M. 86

85. Loss of beat – to – beat variation : normally there is a change of 6-25 beats/min every minute in FHR . Absence of this beat-to-beat variation indicates fetal compromise. 5/8/2024 Rebuma M. 87

86. B) Periodic FHR changes :The pattern with uterine contractions. Types of decelerations: i. Early Decelerations: Normal , due to head compression during contractions. ( ↑ vagal tone) Onset, peak, and end coincides with the timing of the contraction (mirror image). 5/8/2024 Rebuma M. 88

87. ii. Late deceleration Decrease in the FHR starts after a lag time from the onset of contraction and ends after a lag time from its end. 5/8/2024 Rebuma M. 89

88. It denotes utero -placental insufficiency—due to:excessive uterine contraction, maternal hypoxemia, hypotension, IUGR,diabetes,abruption . hypoxemia leads to hypoxia and metabolic acidosis the delayed return to baseline worsens due to myocardial depression . 5/8/2024 Rebuma M. 90

89. iii. Variable Decelerations Abnormal ( mild, moderate or severe depending on duration), due to cord compression . Can occur at any time , and pattern change from one contraction to another. If they are repetitive, suspicion is high for the cord to be wrapped around the neck or under the arm of the fetus. 5/8/2024 Rebuma M. 91

90. FHR Variability Absent variability = Amplitude range undetectable Minimal = < 5 BPM Moderate = 6 to 25 BPM Marked = > 25 BPM 5/8/2024 Rebuma M. 92

91. Accelerations Decelerations Variability (bpm) Baseline (bpm)) Feature Present None = >5 110-160 Reassuring The absence of accelerations with an otherwise normal CTG are of uncertain significance Early deceleration 161-180 Variable deceleration Single prolonged deceleration up to 3 minutes < 5 for >40 to <90 minutes 100-109 Non-reassuring Atypical variable decelerations Late decelerations Single prolonged deceleration >3 min. < 5 for = > 90 min. < 100 ,> 180 sinusoidal pattern > = 10 min. Abnormal (Pathological) 5/8/2024 Rebuma M. 93

92. INTERVENTIONS Variable decels  → reposition mother to  knee-chest  position to get baby’s head off the cord OR use two fingers to  lift the baby’s head  off the cord until further interventions required Early decels  → sign that baby is descending into the pelvis, monitor as needed Accelerations  → reassuring (normal) sign; last for  15+ seconds  and peaks  15+ beats/min Late decels  → worrisome sign;  reposition  mother, administer IV fluids and anticipate  discontinuing/decreasing Oxytocin  or administering a  tocolytic  to decrease contractions 5/8/2024 94

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95. 5/8/2024 97 Induction and Augmentation of Labour Objectives At the end of this session, the students will be able to: -Define induction and Augmentation - Identify indications of induction and augmentationof labour - Mention standard protocols Induction Of Labour Definition: It is artificial initiation of labour using d/f methods after viability of the foetus i.e. after 28 weeks on appropriate time & favorable condition. Rebuma M.

96. 5/8/2024 98 Indications: Labour maybe induced for medical or obstetrical reasons. (I) Maternal: 1. Hypertensive disorders with pregnancy: i- Severe pre-eclampsia. ii- Eclampsia. iii- Essential hypertension. v- Chronic nephritis. 2. Antepartum haemorrhage: i- Placenta praevia type I&II. ii- Accidental haemorrhage. Rebuma M.

97. 5/8/2024 99 - Diabetes mellitus: To avoid intrauterine foetal death and dystocia due to macrosomia - Spontaneous / premature rupture of membrane Elderly primigravida Poor obstetric history (II) Foetal: 1.Post-term pregnancy. 2.Intrauterine growth retardation. 3.Intrauterine foetal death Indication cont… Rebuma M.

98. 5/8/2024 100 4.Rh- isoimmunization . 5.Gross congenital anomalies Contraindication - Unreliable EDD -Repaired fistula - Malpresentation -Active genital herpes - CPD -PP totalis - Fetal distress - Psychological distress Relative CI: -twin pregnancy -previous c/s -grand multipara > 6 -abnormal FHB pattern Rebuma M.

99. 5/8/2024 101 Precondition for Induction A .Fetal maturity and viability B .Favorability of cervix Favorability of cervix is assessed by a score system called ‘’ Bishop”score.It has to be done before induction. The total score is in the range of 0-13 There are five factors considered, each accounts a score of 0-3. The components are: -Cervical dilatation - >> effacement - >> consistency - >> Position - Fetal station Rebuma M.

100. 5/8/2024 102 Bishop scoring system Score 1 2 3 Cx Dilation in cm Closed 1-2 3-4 >5 Cx Effecement 0-30 % 40-50 % 60-70 % > 80 % Cx Consistency Firm Medium Soft - Cx Position Posterior Central/mid Anterior - Station -3 -2 -1 ,0 +1,+2 Rebuma M.

101. 5/8/2024 103 - > 9/13 is the best cervical outcome /labor will be successful - > 5/13 favorable - 5/13 relatively favorable - < 5/13 unfavorable C. C/S facility In induction - delivery interval doesn’t exceed 18 hours; if not ceaserean section is indicated. - If no labour starts in 6 hours- consult - If contractions are very strong and tetanic stop drip, sedate and consider cesarean section Bishop scoring cont… Rebuma M.

102. 5/8/2024 104 Observation of mother and fetus - The fetal heart rate - Uterine contractions - Fluid balance chart - Urine test for ketoses Progress in labour - Abdominal & cervical examination every 2-4 hours After delivery continue oxytocin drops for one hour to prevent PPH. Rebuma M.

103. Methods of Induction : I- Natural-Non Medical methods ( Cont.) 1- Relaxation techniques : advise patient to relieve tension and try to relax then use some visual aids to show how labor starts. 2- Visualization: The patient is advised to imagine her uterus contracting and she is laboring. Hypnosis/self-hypnosis helps. 3- Walking: The force of gravity pulls the weight of the baby towards the birth canal leading to dilatation and effacement of the cervix. 5/8/2024 Rebuma M. 105

104. Cont… 4- Sex : Having sex is known to induce labor. This is related to prostaglandin content of the seminal fluid and the occurrence of orgasm which stimulate uterine contractions 5- 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. 5/8/2024 Rebuma M. 106

105. Cont… 6- Bath/Castor oil/Enemas : - take a warm bath - have 3 teaspoons of castor oil mixed with some juice and an enema thereafter. This method could stimulate the uterus to contract. 7- Foods : Eating lots of pineapple is known to stimulate labor and ripen the cervix. This is possibly related to its enzyme content. Other foods with similar action include Pizza, spicy food like Mexican, and tropical fruits 5/8/2024 Rebuma M. 107

106. II- Surgical Methods - Amniotomy - Technique: -The FHR is recorded before the procedure. -A pelvic examination is performed to evaluate the cervix & station of the presenting part. The presenting part should be well fitted to the cervix. -The membranes are identified and a kocher is inserted through the cervical os by sliding it along the hand & fingers & membranes are ruptured. -The nature of the amniotic fluid is recorded (clear, bloody, thick or thin, meconium). -The FHR is recorded after the procedure. 5/8/2024 Rebuma M. 108

107. III- Surgical Methods (Cont.) Risks of amniotomy: 1- Prolapse of the umbilical cord (0.5%) 2- Chorioamnionitis: Risk increases with prolonged induction delivery interval 3- Postpartum hemorrhage: Risk is doubled compared with women with spontaneous onset of labor 4- Rupture of vasa previa 5- Neonatal hyperbilirubinemia 5/8/2024 Rebuma M. 109

108. IV- Pharmacologic Induction of Labor 1- Prostaglandin E2: (dinoprostone): It is inserted vaginally as a gel (Prepidil), as a removable tampon (Cervidil) or as a vaginal pessary. 2- Misoprostol : Route of administration: Oral, vaginal and sublingual route for induction. -Misoprostol (Cytotec) is a synthetic PGE1 analog -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. 5/8/2024 Rebuma M. 110

109. IV- Pharmacologic Induction of Labor 3- Mifepristone : Mifepristone ( Mifeprex ) is an antiprogesterone , couteract the progesterone activity. 4- Oxytocin : It is given by IV infusion using an automated pump. Oxytocin has many advantages: it is potent and easy to titrate, has a short half-life (one to five minutes) and is well tolerated. 5/8/2024 Rebuma M. 111

110. In Our set up protocol for Induction Multi and Primi have d/t dosage-primi 5IU and multi 2.5 IU. -Drop/min is start with 10 drop/min then increase the drop by 20 every 30 min. The maximum drop is 80 d/min.Then add another dose(5IU) in the same bag start with 20 drop/min. Drop 10 20 40 60 80 5/8/2024 Rebuma M. 112

111. ■ If no adequate contraction add 5 IU on the same bag 20 40 60 80 ■ If no adequate contraction add 5 IU on the same bag 40 60 80 Total dose will be 15 IU For augmentation the protocol is the same but the dose is half of the induction 5/8/2024 113 Rebuma M.

112. Induction Procedure All induction except emergency induction should be started at 8 am. -Check indication and bishop score -Explain the procedure to the patient -Enema - Light fluid diet or NPO -V/S,FHR and activity monitoring -Start oxytocin drip and label the bag -ARM -document time, color, bleeding if any. 5/8/2024 114 Rebuma M.

113. After initiation of oxytocin infusion > Follow maternal v/s & input/output > follow progress of labour > No need of incease the dose of oxytocin once adequate uterine contraction achieved > If labour not established after 6 hrs consult NB-A failed induction is diagnosed when there has been no cx change or descent of the presenting part after 6-8 hrs or 1 contraction every 3 min. > Start antibiotic if membrane ruptured and > 8hrs > Continue infusion for 1hr post partum > If the pt develop titanic type of Ux contraction, stop the oxytocin drop 115 5/8/2024 Rebuma M.

114. Complications of induction of labor Mother Failure of induction leading to c/s Uterine inertia Tetanic uterine contraction Uterine rupture Precipitated labor resulting in genital tear Intrauterine infection Post partum hemorrhage Water intoxication 5/8/2024 116 Rebuma M.

115. 2. Fetus Prematurity Birth injuries Cord prolapse Fetal distress IUFD 5/8/2024 117 Rebuma M.

116. 5/8/2024 118 Defn:Acceleration of already started labour. Indication: ♦ Prolonged labor due to -Cx arrest - Descent disorder-all are b/c of –poor Ux cont. The aim : To increase intensity of Ux contraction To clear the possibility of uncoordinated Ux contraction Augmentation of labour Rebuma M.

117. 5/8/2024 119 Precondition For Augmentation Rule out passage of meconium Rule out CPD,malposition,malpresentation There should be C/S facility Contraindication: ♣ Maposition and malpresentation ♣ CPD ♣ Active genital herpes infection ♣ Pelvic contractor ♣ NRFHR ♣ Fetal macrosomia Augmentation cont… Rebuma M.

118. Thank you! 5/8/2024 By Rebuma M. 120

119. I. Interactive presentation, case scenario [6hr] Anesthesia and Analgesics (2hrs) Review mechanism of pain Introduction Type Complications /side effects Abnormal labor [4hrs]  Prolonged latent phase  Protraction and arrest disorders  Precipitate labor Skill Development Lab [3hrs]  Prepare and administer medications (Demonstration)  Abnormal progress of labor (video, interpreting partograph ) PBL [4hrs]  Abnormal labor 5/8/2024 Rebuma M. 121

120. II. Interactive presentation, case scenario [6hrs.] Non-reassuring fetal heart rate pattern [2hr]  Introduction  Pathophysiology  Cause  Care and management Obstructed labor [2hr]  Introduction  Risk factors and causes  Care and management Skill Development Lab [2hrs]  Cephalopelvic disproportion & obstructed labor PBL [4hrs]  Obstructed labor  Non-reassuring fetal heart rate pattern 5/8/2024 Rebuma M. 122

121. Induction and Augmentation of labor [2hrs]  Indications for induction and augmentation  Contraindications for induction and augmentation

122. References: Burkman RT. Williams obstetrics . JAMA. 2010 Jul 28;304(4):474-5. El- Mowafi DM. Obstetrics Simplified . El-Happy Land Square, El-Mansoura, Egypt: Burg Abu- Samr . 1997. Marshall JE, Raynor MD. Myles' Textbook for Midwives E-Book. Elsevier Health Sciences; 2022 Sep 5 . Jacob A. A comprehensive textbook of midwifery & gynecological nursing . Jaypee Brothers Medical Publishers; 2018 Nov 10 . Beckmann CR, Herbert W, Laube D, Ling F, Smith R. Obstetrics and gynecology . Lippincott Williams & Wilkins; 2013 Jan 21. 5/8/2024 Rebuma M. 124