Induction of lobourBy :- Hasanain Ghaleb Khudhair

4th stage medical student

College of Medicine/karbala university-Iraq

Supervisor :- Dr. Mousa Mohsin Ali AL-Allak

Consult gynecologist and obstetrician

College of Medicine/karbala university-Iraq

Department of gynecology and obstetric

29/ 3/ 2016

Questions welcome at any time

Scenario 1

Primigravida ,,, 42w by first trimester US Antinatal care normal Fetus well growth, longitudinal lie, cephalic presentation Mother wishes to have labour induced Apart of some irregular uterine contraction she has not gone to spontaneous

labour.

Opinion ?? Indication??

Scenario 2

Gravid 3, Para 2, two previous caesarian deliveries Antinatal care normal Fetus well growth, longitudinal lie, cephalic presentation Mother wishes to have labour induced Apart of some irregular uterine contraction she has not gone to spontaneous

labour

Opinion?? Contraindication??

Scenario 3

Primigravida ,,, 42w by second trimester US Antinatal care normal Fetus well growth, longitudinal lie, cephalic presentation Mother wishes to have labour induced Apart of some irregular uterine contraction she has not gone to spontaneous

labour. Induction of labour was performed _______ she came with C/S

Whats the explanation?? Complication??

Objuctives

Definition Indications Contraindications The Bishop score METHODS OF INDUCTION Risk of induction of labour

Definition planned initiation of uterine contractions prior to its spontaneous

onset.

Vaginal Fetal viable

when it is agreed that the mother or fetus will benefit from a higher probability of healthy outcome than if birth is delayed.

Approximately one in five deliveries in the United Kingdom occur following induction of labour.

Indications

Prolonged pregnancy Fetal growth restriction Prelabour rupture of membranes (term, infection)

Diabetes mellitus Twin pregnancy continuing beyond 38 weeks ‘Social’ reasons

Pre-eclampsia and other maternal hypertensive disorders (earlier)

Deteriorating maternal illnesses Unexplained antepartum hemorrhage Intrahepatic cholestasis of pregnancy

Contraindications

absolute contraindications

placenta praevia severe fetal compromise. Transverse lie Cord presentation and prolapse Pelvic structural deformity/CPD

Breech presentation is a relative contraindication to IOL, and women with a previous history of caesarean birth need to be informed of the greater risk of uterine rupture.

Bishop score

Bishop score

Bishop score

As the time of spontaneous labour approaches, the cervix becomes softer, shortened, moves forward and starts to dilate. This reflects the natural preparation for labour.

Bishop produced a scoring system to quantify how far this process had progressed prior to the IOL.

High scores are associated with an easier, shorter induction that is less likely to fail.

Low scores point to a longer IOL that is more likely to fail and result in Caesarean section.

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”METHODS OF INDUCTION

Natural-Non Medical methods

1-Relaxation techniques: relieve tension and visual aids to show how labor starts.

2-Visualization: imagine her uterus contracting.

3-Walking: The force of gravity

4-Nipple stimulation: 2 minutes alternating with 3 minutes of rest

5-Bath/Castor oil/Enemas:

Surgical Methods

Sweeping/Stripping of Membranes Finger inserted in internal os is moved circumferentially,

when cervix is sufficiently dilated or try to open the cervix or cervical massage, when closed

Releases phospoholipase A2 and ↑ production of PGF2α

Concerns:• Patient discomfort• Bleeding• Accidental rupture of membranes• Initiation of irregular uterine contractions.

Amniotomy • Artificial rupture of membranes • Alone is not recommended as a method of

induction of labor

Complications: 1- cord prolapse 2- if sudden rupture of membranes in polyhydramnios there is risk of placental abruption 3-infection.

Pharmacological Methods

• Prostaglandins• Oxytocin• Mifepristone• Relaxin.

ProstaglandinsProstaglandins used in induction are PGE2 (Dinoprostone) and PGE1 (Misoprostol).

side effectsBronchospasm

Shivering

Contraindications??? (+glaucoma)

How they act? (Uterus and cervix) Different mechanisms of cervical ripening are involved:

• They alter the extracellular ground substance of cervix

• PGE2 increases activity of collagenase in cervix

• Relaxation of smooth muscle of cervix facilitates dilatation.

Benefits of misoprostol• Inexpensive• Stored at room temperature• No refrigeration required, therefore easily transported• Shorter induction to delivery interval• Lower cesarean section rates.

Risks and Side Effects of Prostaglandins

Uterine hyperstimulationDefined as either occurrence of uterine contractions each lasting > 60 seconds, or occurrence of> 4 contractions in 10 minutes, regardless of the state of the fetus

Tocolytics should always be available

Uterine rupture• Risk– 5.6% with misoprostol– 0.2% with dinoprostone.

Uterine tachysystole after PGE2

Pain relief after induction of labor• Simple analgesics by oral route• Epidural analgesia can be offered.

Oxytocin

IV oxytocin is used for induction of labor since 1950

Oxytocin activates the phospholipase C- inositol pathway and increases intracellular calcium levels, stimulating contractions in myometrial smooth muscle

Side effects

1. Are principally dose related

2. Uterine tachysystole or category II or III FHR tracings are the most common side effects

3. Hypotension may occur following a rapid IV injection of oxytocin, so is always diluted when used for induction.

Low dose

• Decreased uterine tachysystole

High dose

• Shorter labor duration

• Less chances of chorioamnionitis

• Decreased number of cesarean sections for dystocia

• Increased chances of uterine tachysystole.

Risks of induction of labour

1. Greater pain in labour2. Uterine hyperstimulation3. Cord prolapse4. Greater risk of uterine rupture during VBAC5. Failure ?6. Increased need for Caesarean or instrumental

delivery7. Fetal compromise

references

1. Clinics in Obstetrics (book)2. Ten teacher (book)3. Dr. mousa lecture 2015 (lecture)4. Google image (website)5. core-clinical-cases-in-og-signed (book)6. Stewart RD, Bleich AT, Lo Jy, et al. Defining uterine

tachysystole: how much is too much?. Am J Obstet Gynecol. 2012 Oct;207(4):290.e1-6. (article)

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Any Questions????