Induction of Labour_Flying Dutchman Style
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Transcript of Induction of Labour_Flying Dutchman Style
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Induction of LabourNasr Timol Unit 4
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Definition
The initiation of labour with the purpose of
affecting a vaginal delivery, before spontaneouslabour begins.
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Natural onset of labour is associated with twosets of changes: 1 cervical
1 myometrial
Cervix Softens
Shortens (Effacement)Widens (Dilatation)
Myometrium Contracts
Aim of Induction is to mimic this physiologicalprocess as closely as possible.
Ripening
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Methods of Induction
Medical
Prostaglandins
Active Ingredient Trade Name Preparation
Prostaglandin E Prandin E2 Vaginal Gel
Prepidil Gel Intracervical Gel
Prostin E2 Oral Tablet
Misoprostol Cytotec Oral/Vaginal Tablet
Prostaglandin F Prostin F2 Alpha IV or Extra/Intra Amniotic
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Surgical
Amniotomy
Amnihook
Kochers Forceps
Alternative
Membrane Stripping Foleys Catheter
Methods of Induction
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Indications
Maternal Hypertension/Pre Eclampsia
Preterm Rupture of Membranes
Chorioamnionitis
Maternal Problems exacerbated by Pregnancy
Logistical Factors
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Foetal Suspected Foetal Jeopardy (Severe IUGR)
Post dates pregnancy
Foetal demise
Indications
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Contraindications
Medical Induction Asthma
Glaucoma
Grandmultiparity
Previous Uterine Surgery
Indication for C-section
Multiple Pregnancy
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Surgical Induction Cord Presentations
Intrauterine Death (unless Abruptio Placentae)
Mother is HIV positive
Placenta Praevia
Contraindications
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Procedure
Assessment of patient Medical and Obstetric history
Medical Examination
Assessment of Cervix Bishops Score
Foetal Maturity
Reactive CTG with no regular uterine contractions
Theater and Neonatal Facilities
Informed Consent Procedure
Complications
Risks
C-Section if needed
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Bishops Score
Status of the Cervix is currently the most
important determinant of ease of induction.
Assessed using the Bishops ScoreModified Bishops Score
0 1 2 3
Dilatation 4cm
Effacement >4cm 2-4cm 1-2cm
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Procedure
Modified Bishops Score >8 Prostaglandins
Artificial Rupture of Membranes
Modified Bishops Score 6-8 Prostaglandin Vaginal Gel
1mg inserted in the posterior fornix of the vagina Re-evaluated after 6hours
If minimal change then 2mg dose may be
administered
A maximum of 3mg may be used
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Procedure
Modified Bishops Score
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Protocol for using Misoprostol
Specific Exclusions: Parity >3
Previous uterine Surgery
Contractions are already present
Monitoring: CTG before induction
- 1-2 hours after or earlier if contractions occur
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Protocol (contd.)
Unfavourable Cervix, Membranes Intact Parity 0 Vaginal Route50ug, Single Dose
Parity 1-3 Oral Route
20ug solution every 2hrs until contractionsoccur.
Maximum of 4 doses(80ug)Repeat courses are allowed.
P0 : oral or vaginal regimen may be repeated
P1-3 : only option is to repeat the oral regimen
Solution is made by dissolving a 200ug tablet in 200mls of
tap water.Augmentation with oxytocin is rarely needed and should beused only with close monitoring and never within 6 hours of
misoprostol administration.
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Favourable Cervix, Membranes Intact Parity 0-3 Oral regimen
Protocol (contd.)
Membranes Ruptured Parity 0-3 Oral regimen
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Amniotomy Procedure
Patient should be nil per mouth
Pelvic Examination Assess the cervix and pelvis
Confirm Presentation
Exclude cord presentation
Insert a finger through the cervix to dilate it and
sweep the membranes of the lower segment. An assistant should push the foetal head into the
cervix to reduce the risk of cord prolapse
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Amniotomy Procedure
Rupture the forewaters Amniohook
Kochers Forceps : Hold the forceps in the left hand and guideit through the cervix with the examining fingers of the right
hand. The membranes are gripped between the teeth of the
forceps and traction applied to tear them. A free flow of
amniotic fluid or the presence of foetal hair between the
blades of the forceps
= successful amniotomy.
Presenting part should be supported during the
procedure and the liqour allowed to drain slowly
Exclude cord prolapse and check foetal heart rate
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Complications
Prostaglandins Hypotension
Uterine Hyperstimulation Foetal Distress
Uterine Rupture
Surgical
Maternal Trauma Foetal Trauma
Cord Prolapse
Prolonged Rupture of Membranes
Ascending Infection
Increase MTCT of HIV
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References
Guidelines for the Management of the
Patient in Labour, J Moodley
Obstetrics in Southern Africa, HS Cronje