Www.obgyntoday.info Dr. Mona Shroff MD INDUCTION OF LABOUR.

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Dr. Mona Shroff MD

INDUCTION OF LABOUR

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Dr Mona Shroff

DEFINITION

Artificial stimulation of uterine contractions before

spontaneous onset of labour with the purpose of

accomplishing successful vaginal delivery


Dr Mona Shroff

INDICATIONS

MATERNALPreeclampsia,

eclampsiaPROMPostterm pregAbruptio placentaChorioamnionitisMedical

conditions-DM,Heart ds, Renal ds,Chr. HT etc

FETALIUFDFetal anomaly

incompatible with life

Severe IUGRRh

isoimmunisationMacrosomia


Dr Mona Shroff

CONTRAINDICATIONS

Severe degree CPDMajor degree placenta praeviaTransverse liePrevious classical CS,MyomectomyPrevious>= 2 LSCSGrand multiparityActive genital herpesHypersensitivity to inducing agent


Dr Mona Shroff

RISKS OF INDUCTION

Failure leading to CSUterine hyperstimulationFetal distress,deathRupture uterusIntrauterine infection,sepsisIatrogenic delivery of preterm infantPrecipitate/dysfunctional labourInc. risk of operative vaginal deliveryInc. risk of birth traumaInc. risk of PPH


Dr Mona Shroff

Adverse Effects

Tachysystole Criteria: >10 contractions in 20 minutesDinoprostone Tachysystole Incidence: 33%Misoprostol Tachysystole Incidence

Intravaginal gel or tablet: 31 to 49%Oral crushed form or tablet: 16 to 22%


Dr Mona Shroff

Hyperstimulation Criteria

Exaggerated uterine response (i.e. Tachysystole)Concerning Fetal Heart Rate tracing

Late Decelerations

Fetal Tachycardia >160 beats per minute

Dinoprostone Hyperstimulation Incidence: 17%Misoprostol Hyperstimulation Incidence

Intravaginal gel or tablet: 8%Oral crushed form or tablet: 1 to 2%

Uterine Rupture in VBAC Risk: 2.5% in Trial of Labor after Cesarean


Dr Mona Shroff

PREREQUISITES

Establish indication clearlyInformed consentConformation of gestational ageAssessment of fetal size & presentationPelvic assessmentCervical assessment (BISHOPs score)Availability of trained personnel


Dr Mona Shroff

MOD. BISHOPS SCORE

SCORE 0 1 2 3DILATATION 0 1-2 3-4 >4

EFFACEMENT 0-30% 40-50% 60-70% >80%

STATION -3 -2 -1/0 +1,+2,+3

CONSISTENCY firm medium soft

POSITION posterior

mid anterior


Dr Mona Shroff

METHODS OF INDUCTION

NATURALBreast/nipple stimulationSexual intercourseMembrane strippingAmniotomyAcupuncture/acupressure

MECHANICALBalloon cathetersLamineria tentsSynthetic osmotic dilators

CHEMICAL

NONHORMONALHerbs,evening primrose oilHomeopathic prepEnemasCastor oil

HORMONALOxytocinProstaglandins –

PGE2,MisoprostolRelaxinNitric oxide donorsmifepristone


Dr Mona Shroff

Stripping of the Membranes

Stripping of the membranes causes an increase in the activity of phospholipase and prostaglandin as well as causing mechanical dilation of the cervix, which releases prostaglandins. The membranes are stripped by inserting the examining finger through the internal cervical os and moving it in a circular direction to detach the inferior pole of the membranes from the lower uterine segment. [Evidence level C]


Dr Mona Shroff

contd.

Risks of this technique include infection, bleeding, accidental rupture of the membranes, and patient discomfort. The Cochrane reviewers concluded that stripping of the membranes alone does not seem to produce clinically important benefits, but when used as an adjunct does seem to be associated with a lower mean dose of oxytocin needed and an increased rate of normal vaginal deliveries. [Evidence level A, RCT]


Dr Mona Shroff

Amniotomy.

It is hypothesized that amniotomy increases the production of, or causes a release of, prostaglandins locally. Risks associated with this procedure include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding from placenta previa or low-lying placenta, and possible fetal injury.


Dr Mona Shroff

Balloon catheters

The Atad Ripener Device in place with the two balloons inflated. The uterine balloon is at the internal os and the cervicovaginal balloon is at the external os.


Dr Mona Shroff

Prostaglandins

M/A :Act on the cervix to enable ripening by a number of different mechanisms. They alter the extracellular ground substance of the cervix, and PG increases the activity of collagenase in the cervix. They cause an increase in elastase, glycosaminoglycan, dermatan sulfate, and hyaluronic acid levels in the cervix. A relaxation of cervical smooth muscle facilitates dilation. prostaglandins allow for an increase in intracellular calcium levels, causing contraction of myometrial muscle..


Dr Mona Shroff

contd.

Risks associated with the use of prostaglandins include uterine hyperstimulation and maternal side effects such as nausea, vomiting, diarrhea, and fever. Currently, two prostaglandin analogs are available for the purpose of cervical ripening, dinoprostone gel (CERVIPRIME: 0.5 mg ) and dinoprostone inserts (PRIMIPROST :10 mg ).


Dr Mona Shroff

Technique for Placement of Dinoprostone Gel

Patient selection: Patient is afebrile. No active vaginal bleeding is present. Fetal heart rate tracing is reassuring. Patient gives informed consent. Bishop score is < 4. Bring gel to room temperature before application, per manufacturer's instructions.


Dr Mona Shroff

Initiate Fetal Heart Rate and tocometry Start 15-30 minutes before gel insertedContinue monitoring for 30-120 minutes after

Insertion Technique Use one syringe of gel (0.5 mg )Introduce gel into cervix

Just below level of internal osIntracervical is preferred over posterior fornix (if leaking p/v posterior Fx)

Patient remains supine for 30 minutes


Dr Mona Shroff

Dosing Repeat every 6 hours up to 3 doses in 24 hours

End points Bishop Score of 8 or greaterStrong uterine contractions

Drug interactions Wait 6-12 hours before starting Pitocin


Dr Mona Shroff

PGE2 GEL

Www.obgyntoday.info Dr. Mona Shroff MD INDUCTION OF LABOUR.

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