Programmed Labour _Intra Partum care.pptx

A guide regarding programmed labour and its effectiveness

1. Intra Partum care: For Joyful Motherhood Programmed Labour

2. Programmed Labour :is an indigenously developed protocol for labor management (Daftary et al 1977, 2001, 2003), developed with the dual objective of providing pain relief during labor and reaching the goals of safe motherhood by optimizing obstetric outcome.

3. This concept rest on three pillars: Providing optimum pain relief - Use of analgesics and antispasmodics. Ensuring adequate uterine contractions - Active management of labor Close clinical monitoring of labor events - Maintaining a PARTOGRAM

4. Gupta K et al. Int J Reprod Contracept Obstet Gynecol. 2015 Apr;4(2):457-460 Active management of labor was a concept advanced by the Irish school. In 1973, O’Driscoll and his colleagues reported on the advantages of active management of labor resulting in shorter labors, improved obstetric outcome and lowered cesarean section rates

5. Gupta K et al. Int J Reprod Contracept Obstet Gynecol. 2015 Apr;4(2):457-460 Partogram

6. Gupta K et al. Int J Reprod Contracept Obstet Gynecol. 2015 Apr;4(2):457-460

7. Patient Selection : Age between 21-30 years. 2. No identifiable medical or obstetric complications present. 3. Admission NST-satisfactory. 4.Term low risk pregnancy 5. Patient counseled and consent taken. International Journal of Reproduction, Contraception, Obstetrics and Gynecology Gupta K et al. Int J Reprod Contracept Obstet Gynecol. 2015 Apr;4(2):457-460

8. Gupta K et al. Int J Reprod Contracept Obstet Gynecol. 2015 Apr;4(2):457-460 The medication protocol for programmed labor begins only after the patient enters the Active Phase of labor. The starting point of active phase of labor is identified when the following parameters are satisfied: • The cervical dilatation is 3.0 cm or more, and the cervical effacement is > 50%. • The uterine contractions come at a frequency of at least 3/10 mins. And last for 35-45 secs. • The head should be engaged. • There should be no clinical suspicion of CPD.

9. Medications used : As per protocol—a combination of drugs are used to provide effective pain relief (labor analgesia), coupled with antispasmodic drugs which help cervical softening, yielding and dilatation to moderate driving forces. Advantage of Protocol: P rovides with benefits of drug synergism whilst at same time restricting the doses of drugs to minimal amounts commensurate with achieving progressive labor whilst at the same time safeguarding the mother and her fetus against any major drug adverse effects International Journal of Reproduction, Contraception, Obstetrics and Gynecology Gupta K et al. Int J Reprod Contracept Obstet Gynecol. 2015 Apr;4(2):457-460

10. Start an intravenous infusion line with 5% Ringer Lactate solution @ about 20 drops/min. Ensure that the pains are optimal, i.e. 3-4 sustained pains/10 minutes. If necessary, you may add 2 units of oxytocin to the drip or give a tablet of primiprost orally every hour to ensure optimal pains resulting in progressive labor. Dilute an ampoule of 30 mg. Pentazocine or Fortwin with a diluent like normal saline/distilled water, and similarly dilute an ampoule of diazepam ( Calmpose /Valium/ Anxol ). In 10 ml of diluent. Administer 1/5 of each drug, i.e. 6.0 mg of pentazocine and 2.0 mg of diazepam, slowly in bolus form through the tubing of the infusion line Protocol South Asian Federation of Obstetrics and Gynecology, January-April 2009;1(1):61-64

11. Administer inj. Tramadol (Inj. Domadol / Tramazac ) in the dose of 1 mg/kg body wt. Intramuscularly, along with an antispasmodic like Inj. Drotin 40 mg, (other alternatives include Inj. Anafortan , Buscopan , or Epidosin , as per clinician’s choice Observe progress of labor by charting maternal and fetal parameters every hour or earlier if indicated, and assess progress of labor on basis of cervical dilatation and descent of fetal head, as documented periodically on partogram . When patient is in advanced labor, and fetal head pressing down on pelvic floor, patient starts complaining of severe pain, or bearing down sensation. At this time cervix is often almost 7-8 cm dilated. This is the time to administer Inj. Ketamine if required South Asian Federation of Obstetrics and Gynecology, January-April 2009;1(1):61-64

12. Initial dose: Inj. Ketamine 0.25 mg to 0.5/kg body weight. -Dilute the drug in 10 ml of saline, and administer slowly as a bolus over a period of a few minutes until the desired effect is obtained. -All subsequent top-up doses of Ketamine are given at 20-30 min intervals. These top-up doses are half of the initial dose. -The last top-up dose of ketamine should be given after the birth of the baby. - This will relax the patient, and allow satisfactory inspection of the Vulva, Vagina, and Cervix to exclude traumatic injuries requiring repair. South Asian Federation of Obstetrics and Gynecology, January-April 2009;1(1):61-64

13. MANAGEMENT OF THIRD STAGE OF LABOR 1. Inject Inj. Prostodin 125 mg IM after the birth of the baby. or 2. Inject 10 units of Oxytocin diluted in 20 ml saline through the umbilical vein of the placenta. OR administer it slow intravenous to the mother. South Asian Federation of Obstetrics and Gynecology, January-April 2009;1(1):61-64

14. Anaesthesia During Labour : The proven obstetric analgesia is epidural anesthesia. In places where epidural analgesia cannot be provided, tramadol, a centrally acting non opioid analgesic has been used as a labor analgesic. Ketamine, a dissociative anesthetic, is gaining popularity as it provides excellent pain relief and patient satisfaction International Journal of Reproduction, Contraception, Obstetrics and Gynecology Gupta K et al. Int J Reprod Contracept Obstet Gynecol. 2015 Apr;4(2):457-460

15. Clinical Evidence

16. (Programmed labour ) South Asian Federation of Obstetrics and Gynecology, January-April 2009;1(1):61-64

17. Gupta K et al. Int J Reprod Contracept Obstet Gynecol. 2015 Apr;4(2):457-460

18. Funnel plot of comparison: Antispasmodics versus control, outcome: Duration of first stage of labour (min) Thirteen studies (Ajmera 2006; Al Qahtani 2011; Batukan 2006; Cromi 2011; Dahal 2013; Gupta 2008; Khosla 2003; Makvandi 2010; Samuels 2007; Sekhavat 2012; Singh 2004; Warke 2003; Yilmaz 2009) involving 1995 women were included in the random- eKects meta-analysis. Antispasmodics reduced duration of first stage of labour by an average of 74.34 minutes (mean diKerence (MD) -74.34 minutes; 95% confidence interval (CI) -98.76 to -49.93; T2 = 2083.23; I2 = 83%). Rohwer AC, Khondowe O, Young T. Antispasmodics for labour. Cochrane Database Syst Rev. 2013 Jun 5;2013(6):CD009243. doi : 10.1002/14651858.CD009243.pub3. PMID: 23737030; PMCID: PMC6823273.

19. Antispasmodics vs Control Rohwer AC, Khondowe O, Young T. Antispasmodics for labour. Cochrane Database Syst Rev. 2013 Jun 5;2013(6):CD009243. doi : 10.1002/14651858.CD009243.pub3. PMID: 23737030; PMCID: PMC6823273.

20. Effect of valethamate bromide in accelerating labor: a prospective randomized controlled trial (Turkey) This prospective randomized study aimed to investigate the effect of valethamate bromide on the length of labor Clin. Exp. Obstet. Gynecol. XLV, n. 5, 2018 A single dose of 16 mg valethamate bromide was administered via intravenous route in randomly selected 35 nulliparous and 37 multiparous women The median time from complete cervical dilatation to the delivery was 20 (5-70) minutes in the groups received valethamate bromide and 25 (5-70) minutes in the groups that did not receive valethamate bromide

21. Median time from complete cervical dilatation to delivery was 20 (5-70) minutes in groups received valethamate bromide and 25 (5-70) minutes in the groups that did not receive valethamate bromide Study conclusion: Valethamate bromide significantly shortens the second stage of labor in nulliparous women

22. Clin. Exp. Obstet. Gynecol. XLV, n. 5, 2018 Side effects not statistically significant in Val br vs Placebo grp

23. A total of 130 pregnant women in the labor ward preparing for delivery were enrolled in this study. Data were taken from patient receiving Hyoscine ( Buscopan ) and Valethamate ( Epidosin ). Patients were from the age group of 18-35 years. The mean age was 25.5 ± 4.36 years. No statistical significance was found when ADR was compared between the age group of 18-25 years and 26-35 years. Therefore, ADR reported were irrespective of the age of the patients and no life threatening or severe forms of ADR were seen with hyoscine and valethamate during cervical dilation

24. International Journal of Reproduction, Contraception, Obstetrics and Gynecology Deepshikha et al. Int J Reprod Contracept Obstet Gynecol. 2020 May;9(5):1986-1991 Group A- Drotaverine Group B- Valethamate Headache and cervical tear are less in valethamate group Drotaverine hydrochloride versus valethamate bromide for cervical dilatation in labour: a comparative study

25. Advantages: South Asian Federation of Obstetrics and Gynecology, January-April 2009;1(1):61-64

26. Thank You

27. Additional slides on Epidosin as textbook brand K D Tripathi

28. Evidence on Epidosin

29. Available data KDT 8 th ed

30. Valethamate : KDT 8 th ed Uses: of this anticholinergic-smooth muscle relaxant is to hasten dilatation of cervix when the same is delayed during labour, and as visceral antispasmodic. Dose: 8 mg i.m. , 10 mg oral repeated as required. VALAMATE 8 mg in 1 ml inj , EPIDOSIN 8 mg inj., 10 mg tab Available data KDT 8 th ed

31. Comparison of injection drotaverine and injection valethamate bromide on duration and course of labor International Journal of Reproduction, Contraception, Obstetrics and Gynecology Changede PR. Int J Reprod Contracept Obstet Gynecol. 2016 Jun;5(6):1836-1842