Induction of labour


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Induction of labour

  1. 1. Induction of Labour(IOL) Dr.V.Ravimohan
  2. 2. Based on <ul><li>NICE guideline on IOL </li></ul><ul><li>IOL guideline from Society of Obstetricians & Gynaecologists of Canada </li></ul>
  3. 3. Basic facts <ul><li>1: 5 pregnancies are induced </li></ul><ul><li>Following pharmacological intervention (whether or not surgical induction was also attempted) </li></ul><ul><ul><li>2/3 delivered without further intervention </li></ul></ul><ul><ul><li>15% had instrumental deliveries </li></ul></ul><ul><ul><li>22% had caesaren section </li></ul></ul>
  4. 4. What could a patient expect ? <ul><li>Opportunity to make informed decisions about induction of labour </li></ul><ul><ul><ul><ul><li>in partnership with their healthcare professionals. </li></ul></ul></ul></ul><ul><li>Evidence-based written information tailored to the needs of the individual woman. </li></ul>
  5. 5. What should the patient know ? <ul><ul><li>Reasons for induction </li></ul></ul><ul><ul><li>Risks and Benefits </li></ul></ul><ul><ul><li>Alternative options if the woman declines IOL </li></ul></ul><ul><ul><li>induction </li></ul></ul><ul><ul><ul><ul><li>When, Where and How </li></ul></ul></ul></ul><ul><ul><li>Arrangements for </li></ul></ul><ul><ul><ul><li>support </li></ul></ul></ul><ul><ul><ul><li>pain relief </li></ul></ul></ul><ul><ul><li>IOL could be unsuccessful and then what the options would be. </li></ul></ul>
  6. 6. 38 WEEKS VISIT <ul><li>Discuss membrane sweep </li></ul><ul><ul><li>What a membrane sweep is </li></ul></ul><ul><ul><li>It makes  spontaneous labour, and  the need for IOL </li></ul></ul><ul><ul><li>Possible </li></ul></ul><ul><ul><ul><li>discomfort </li></ul></ul></ul><ul><ul><ul><li>vaginal bleeding </li></ul></ul></ul><ul><li>Induction of labour between 41 +0 and 42 +0 weeks </li></ul><ul><li>Explain expectant management. </li></ul>
  7. 7. Prolonged Pregnancy <ul><li>induction of labour between 41 +0 and 42 +0 weeks </li></ul><ul><li>exact timing depends </li></ul><ul><ul><li>woman’s preferences </li></ul></ul><ul><ul><li>local circumstances. </li></ul></ul><ul><li>If declined </li></ul><ul><ul><li>At least twice weekly </li></ul></ul><ul><ul><ul><li>CTG </li></ul></ul></ul><ul><ul><ul><li>USS for Maximum Pool depth </li></ul></ul></ul>
  8. 8. Preterm prelabour rupture of membranes <ul><li>>>34 +0 -Consider IOL based on the following </li></ul><ul><ul><li>Maternal risks (Sepsis, Caesarean section) </li></ul></ul><ul><ul><li>Fetal risks(Sepsis, Prematurity) </li></ul></ul><ul><ul><li>Neonatal facilities </li></ul></ul>
  9. 9. Prelabour rupture of membranes (PROM) <ul><li>Options: </li></ul><ul><ul><li>IOL with vaginal PGE2 </li></ul></ul><ul><ul><li>Expectant management. </li></ul></ul><ul><li>IOL is appropriate approximately 24 hours after PROM </li></ul>
  10. 10. IOL in Patient with Previous caesaren section <ul><li>Options: </li></ul><ul><ul><li>Prostaglandins(PGE2) </li></ul></ul><ul><ul><li>Artificial rupture of membranes </li></ul></ul><ul><li>Patient should be explained about </li></ul><ul><ul><li>increased risk of uterine rupture </li></ul></ul><ul><ul><li>Emergency caesarean section </li></ul></ul>
  11. 11. IOL in Intrauterine death <ul><li>Indication for early intervention </li></ul><ul><ul><li>ruptured membranes </li></ul></ul><ul><ul><li>infection </li></ul></ul><ul><ul><li>bleeding </li></ul></ul><ul><li>Methods of IOL </li></ul><ul><ul><li>Oral Mifepristone </li></ul></ul><ul><ul><li>Misoprostol/Prostaglandins </li></ul></ul>
  12. 12. Suspected Macrosomia <ul><li>This is not an indication for induction of labour on its own. </li></ul>
  13. 13. Maternal request <ul><li>IOL should not routinely be offered on maternal request alone </li></ul><ul><ul><li>Unless there is an exceptional circumstance. (Ex: woman’s partner is soon to be posted abroad with the armed forces) </li></ul></ul>
  14. 14. Membrane Sweep <ul><li>If os is open </li></ul><ul><ul><li>Pass a finger through the os and separate the membrane </li></ul></ul><ul><li>If os is closed </li></ul><ul><ul><li>massaging around the cervix in the vaginal fornices may achieve a similar effect. </li></ul></ul><ul><li>Timing: </li></ul><ul><ul><li>Primi 40-41 weeks </li></ul></ul><ul><ul><li>Multi 41 weeks </li></ul></ul>
  15. 15. Bishop score Points Factor 0 1 2 3 Dilatation(cm) 0 1-2 3-4 5-6 Effacement 0-30 40-50 60-70 >80 Station -3 -2 -1 or 0 +1 or +2 Consistency Firm Medium Soft Position Posterior Mid Position Anterior
  16. 16. Pharmacological Agents <ul><li>Prostaglandin E 2 </li></ul><ul><ul><li>Gel </li></ul></ul><ul><ul><li>Tablet </li></ul></ul><ul><ul><li>Controlled-release pessary </li></ul></ul><ul><li>Mifepristone & Misoprostol are only IOL in Intrauterine fetal death. </li></ul>
  17. 17. Regimens <ul><li>One cycle of vaginal PGE2 tablets or gel: </li></ul><ul><ul><li>one dose </li></ul></ul><ul><ul><li>followed by a second dose after 6 hours if labour is not established </li></ul></ul><ul><ul><ul><li>up to a maximum of 2 doses </li></ul></ul></ul><ul><li>One cycle of vaginal PGE2 controlled-release pessary: </li></ul><ul><ul><li>one dose over 24 hours. </li></ul></ul>
  18. 18. Controlled-release pessary <ul><li>Theoretical advantages </li></ul><ul><ul><li>the ability of insertion without the use of a speculum </li></ul></ul><ul><ul><li>a slow continuous release of prostaglandin, only one dose being required </li></ul></ul><ul><ul><li>the ability to use oxytocin 30 minutes after its removal </li></ul></ul><ul><ul><li>the ability to remove the insert if required (such as with excessive uterine activity). </li></ul></ul>
  19. 19. Surgical Methods <ul><li>Amniotomy </li></ul><ul><li>Foley Catheter induction </li></ul><ul><ul><li>no. 18 Foley catheter </li></ul></ul><ul><ul><li>introduced into the intra cervical canal under sterile technique past the internal os </li></ul></ul><ul><ul><li>The bulb is then inflated with 30 to 60 cc of water </li></ul></ul><ul><ul><li>Further research is needed in this area. </li></ul></ul>
  20. 20. Before IOL <ul><li>Bishop score should be assessed and recorded </li></ul><ul><li>A normal fetal heart rate pattern should be confirmed using electronic fetal monitoring. </li></ul>
  21. 21. Complications <ul><li>Uterine hyperstimulation </li></ul><ul><ul><li>Tocolysis should be considered </li></ul></ul><ul><li>Failed IOL(see the next slide) </li></ul><ul><li>Cord Prolapse </li></ul><ul><ul><li>Check the engagement of the head </li></ul></ul><ul><ul><li>Check for cord presentation prior to amniotomy </li></ul></ul><ul><li>Uterine rupture </li></ul>
  22. 22. Definitions <ul><li>Tachysystole ->5contractions in10 minutes (or more than 10 in 20 minutes) </li></ul><ul><li>Hypertonus - contraction lasting >120 seconds </li></ul><ul><li>Hyperstimulation - excessive uterine activity with a nonreassuring fetal heart rate tracing. </li></ul>
  23. 23. Failed induction <ul><ul><li>Options </li></ul></ul><ul><ul><ul><li>Further attempt to induce labour </li></ul></ul></ul><ul><ul><ul><ul><li>timing should depend on </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>clinical situation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>woman’s wishes </li></ul></ul></ul></ul></ul><ul><ul><ul><li>caesarean section </li></ul></ul></ul>
  24. 24. Further reading <ul><li>NICE guideline </li></ul><ul><li>SOGC guideline </li></ul>
  25. 25. <ul><li>My Website </li></ul><ul><li>My Blog </li></ul><ul><li>My twitter </li></ul>