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Induction OF labor
 

Induction OF labor

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    Induction OF labor Induction OF labor Presentation Transcript

    • INDUCTION & AUGUMENTATION OF LABOR Afework A. (MD) ARH,Gyn-obs January ,2012
    • Introduction Labor - The process of uterine contractions leading to progressive effacement and dilatation of the cervix and birth of the baby.  Induction - Iatrogenic stimulation of uterine contractions to accomplish delivery prior to the onset of spontaneous labor , with or without ruptured membrane.  Augmentations -Iatrogenic stimulation of spontaneous contractions that are considered in adequate because of failure of progress of dilation and descent.
    • Induction of Labor one of the most commonly performed obstetrical procedures ,  Between 1990 and 2006, the frequency of labor induction approximately doubled, rising from 9.5% to 22.5%, the annual incidence of labor induction or augmentation in the US almost doubled from 20 % in 1989 to 38% in 2002, Induction is associated with increased complications as compared to spontaneous labor.
    • Indications Labor may be induced for either maternal or fetal indications. Induction of labor is undertaken when both of the following criteria are met : 1.continuing the pregnancy is believed to be associated with greater maternal or fetal risk than intervention to deliver the pregnancy, 2.there is no contraindication to vaginal birth.
    • Indications cont… The magnitude of risk is influenced by factors such as : -gestational age, -presence/absence of fetal lung maturity, - severity of the clinical condition, and - cervical status
    • Indications cont… Common INDICATIONS include 1. PROM 2. Severe preeclampsia, eclampsia 3. Post term 4. APH sec. to AP 5. Chorioamnionitis 6. IUFD (fetal demise) 7. Fetal compromise -IUGR -Isoimmunization -oligohydraminos -Non reassuring antepartem fetal test -gross congenital anomalies
    • Indications cont… 8.Maternal medical conditions -DM -Renal disease -Chronic pulmonary disease 9.Logistic factors -Risk of rapid labor -Distance from hospital -Psychosocial indications -Advanced cervical dilation
    • Contraindications Absolute contraindications 1. Prior classic C/S or transfundal uterine surgery 2. Active genital herpes infection 3. Placenta previa(grade III , IV) or vasa previa 4. Umbilical cord prolapse 5. Transverse or oblique fetal lie 6. Absolute cephalopelvic disproportion (as in women with pelvic deformities)
    • Contraindications cont… Relative contraindications 1. Breech presentation 2. Cervical carcinoma 3. Multiple pregnancy 4. Prior LUST C/S 5. Grand multiparity 6. Fetal macrosomia
    • Evaluation before Labor Induction PARAMETER CRITERA MATERNAL Confirm indication for induction Review contraindications to labor and/or vaginal delivery Perform clinical pelvimetry to assess pelvic shape and adequacy of bony pelvis Assess cervical condition (assign Bishop score) Review risks, benefits and alternatives of induction of labor with patient FETAL/ NEONATAL Confirm gestational age Assess need to document fetal lung maturity status Estimate fetal weight (either by clinical or ultrasound examination) Determine fetal presentation and lie Confirm fetal well-being
    • Evaluation cont…  Criteria for Confirmation of Gestational Age and Fetal Pulmonary Maturity I.Clinical criteria 1.≥39 weeks' gestation have elapsed since the first day of the LNMP in a women with a regular menstrual cycle. 2.Fetal heart tones have been documented for ≥20 weeks' gestation by nonelectronic fetoscope or for ≥30 weeks by Doppler ultrasound. II.Laboratory determination 1.≥36 weeks' gestation have elapsed since a positive serum Hcg test. 2.Ultrasound estimation of GA is considered accurate if it is based on crown- rump measurements obtained at 6 to 11 weeks' gestation or it is based on BPD measurements obtained before 20 weeks' gestation. III.Fetal pulmonary maturity 1. Lecithin/sphingomyelin (L/S) ratio >2:1 2. Presence of phosphatidylglycerol (PG) 3. TDxFLM assay ≥70 mg surfactant per 1 g albumin present 4. Presence of saturated phosphatidylcholine (SPC) ≥ 500 ng/mL in nondiabetic patients (≥1000 ng/mL for pregestational diabetic patients)
    • Evaluation cont…  CERVICAL Condition assessement -The condition of the cervix or "favorability“ is important to the success of labor induction - One quantifiable method predictive of an outcome of labor induction is that described by Bishop (1964). - This system tabulates a score based upon the station of the presenting part and four characteristics of the cervix: 1.dilatation 2. effacement 3.consistency, and 4. position
    • Modified Bishop scoring system 0 1 2 3 Dilation, cm Closed 1-2 3-4 >=5 Effacement, % 0-30 40-50 60-70 ≥80 Station* -3 -2 -1,0 +1,+2 Cervical consistency Firm Medium Soft Position of the cervix Posterior Midposition Anterior
    • Evaluation cont… If the Bishop score is high (≥8), the likelihood of vaginal delivery is similar whether labor is spontaneous or induced The cervix is favorable when the score is > 6 and labor is usually successfully induced with oxytocine When score is < 5 cervix is unfavorable and cervical ripening should be done
    • Methods of Cervical Ripening I.PHARMACOLOGIC METHODS 1. PGE2 (dinoprostone) 2. PGE1 (misoprostol) 3.Mifepristone (progesterone receptor antagonist) II. MECHANICAL METHODS 1.Membrane stripping (sweeping) 2.Amniotomy ( ARM) 3.Hygroscopic dilators (Laminaria) 4.Transcervical balloon catheters
    • 16 Dinoprostone ( PGE2) PGE2 Gel (dinoprostone) – Used widely for cervical ripening – Causes dissolution of collagen bundles and increase in sub mucosal water content – PG induced cervical ripening often includes initiation of labor. – Low dose PG • Increases chance of successful induction • Decreases incidence of prolonged labor • Reduces total and maximum oxytocine dose –
    • 17 • Preparation – Interacervical (0.3 – 0.5mg) – Interavaginal (3 – 5mg) – Dinoprostone vaginal insert (cervidil) 10mg. provides slower release 0.3mg/hr  One advantage of the insert is it can be removed in case of Hyper stimulation.
    • 18 • Administration – Administer at or near labor ward – The woman remains recumbent for at least 30 minutes – Observe the patient from 30min to 2hrs – Monitor FHB and contraction – If no contraction transfer or discharge the patient . – Discontinue PG and begin oxytocin infusion if • Membranes rupture • Cervical ripening has been achieved • Labor has started • Or 12 hours has passed
    • 19 • Side effects – Hyper stimulation > 6 cont 10min – Fever – Vomiting – Diarrhea – Precaution should be taken when using it in patients with • Glaucoma • B-Asthma • Hepatic or renal failure
    • 20 Misoprostole (PGE1) • Available as 100ug tab for prevention of peptic ulcer • Less expensive from dinoprostone • Intera vaginal administration of 25ug not more frequent than every 3-6hrs is effective in women with unfavorable cervix
    • Membrane stripping  Stripping the membranes mechanically dilates the cervix which releases prostaglandins.  The membranes are stripped by inserting the examining finger through the internal os & moving it in a circular direction to detach the inferior pole of the membranes from the lower uterine segment.  Risks include : - patient’s discomfort, -infection, - bleeding from undiagnosed placenta previa or low lying placenta,and -accidental ROM.
    • Amniotomy (ARM)  Also referred as surgical induction  Indications • Induce labor • Use of internal fetal monitoring • Intra uterine assessment of uterine counteraction  Risks 1- Prolapse of the umbilical cord (0.5%) 2- Chorioamnionitis: Risk increases with prolonged induction- delivery interval 3- Postpartum hemorrhage: Risk is doubled compared with women with spontaneous onset of labor 4- Rupture of vasa previa 5- Neonatal hyperbilirubinemia 6-Increase perinatal HIV transmission
    • Hygroscopic dilators  absorb endocervical and local tissue fluids, causing the device to expand within the endocervix and provide mechanical pressure.  Can be either: -natural osmotic dilators (e.g., Laminaria japonicum) or -synthetic osmotic dilators (e.g., Lamicel).  Advantages: 1- Outpatient placement 2- No need for fetal monitoring  Risks: fetal and/or maternal infection
    • Balloon Catheters  A fluid filled balloon is inserted inside the cervix.  The Balloon provide mechanical pressure directly on the cervix which respond by ripening and dilation.  A Foley catheter (26 Fr) or specifically designed balloon devices can be used  Can be applied: - With extra-amniotic saline infusion, or - With concomitant oxytocin administration
    • Transcervical balloon catheter
    • 26 Labor induction and Augmentation with Oxytocine • Oxytocine is the first polypeptide hormone synthesized • FHB and contraction should be observed during pitocine use. • Variety of methods for stimulation of uterine contraction with oxytocine has been used • The goal is to achieve effective uterine contraction that’s sufficient to produce cervical change and fetal descent while avoiding uterine hyper stimulation and /or non reassuring FHB
    • 27 • Contractions must be evaluated continuously Discontinue pitocine – if contractions are >5/10min or >7/15min or If they last longer than 60-90 seconds or if FHB becomes non reassuring  Uterine response occurs 3-5 minutes after beginning of infusion of oxytocine – steady plasma level is achieved 40minuts later
    • 28 • Response depends on – Previous uterine activity – Uterine sensitivity – Cervical status • Different regimens are used for oxytocine infusion . – Low dose – High dose
    • 29 Oxytocine Regimen for stimulation of labor S/n Regiment Starting dose (mu/min) Incremental increase mu/min Dosage interval (min) Max. dose (mu/min) 1 Low dose 0.5-1 1 30-40 20 2 High dose 1-2 2 15 40 6 6,3,1 15-40 42
    • 30 WHO oxytocine infusion rate for induction of labor ) Time since induction hrs Oxytoinconc Drops/min Approx – dose/miu/min Vol infused Total vol infused 0 2.5iu/500ml 10 3 0 0 ½ Same 20 5 15 15 1 >> 30 8 30 45 1 ½ >> 40 10 45 90 2 >> 50 13 60 150 2 ½ >> 60 15 75 225 3 5Iu/500ml (10miu/ml) 30 15 90 315 3 ½ >> 40 20 45 360 4 >> 50 25 60 420 4½ >> 60 30 75 495 5 10Iu/500ml (20miu/ml) 30 30 90 585 5½ Same 40 40 45 630 6 >> 50 50 60 690 6½ >> 60 60 75 765 7 >> 60 60 90 855 N:B increase the rate of infusion until good contraction is established and maintain it at that rate
    • 31 Rapid escalation for primigranida only infusion rate for induction of labor Time since induction hrs Oxytoicn conc. Drops/min Approx – dose/miu/min 0 2-5iu/500ml 15 4 ½ >> 30 8 1 >> 45 11 1 ½ >> 60 15 2 5Iu/500ml (10miu/ml) 30 15 2 ½ Same 45 23 3 >> 60 30 3 ½ 10Iu/500ml (20miu/ml) 30 30 4 >> 45 45 4½ >> 60 60 5 >> 60 60
    • 32 Complications of induction of labor 1. Mother – Failure of induction leading to c/s – Uterine inertia – Tetanic uterine contraction – Uterine rupture – Precipitated labor resulting in genital tear – Intrauterine infection – Post partum hemorrhage – Water intoxication
    • 33 2. Fetus – Prematurity – Birth injuries – Cord prolapse – Fetal distress – IUFD
    • THANK YOU!