Induction of Labour_Flying Dutchman Style

8/2/2019 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

Documents

Induction of Labour_Flying Dutchman Style