Induction of labour

Induction of Labour(IOL) Dr.V.Ravimohan

Based on
NICE guideline on IOL
IOL guideline from Society of Obstetricians & Gynaecologists of Canada

Basic facts
1: 5 pregnancies are induced
Following pharmacological intervention (whether or not surgical induction was also attempted)
2/3 delivered without further intervention
15% had instrumental deliveries
22% had caesaren section

What could a patient expect ?
Opportunity to make informed decisions about induction of labour
in partnership with their healthcare professionals.
Evidence-based written information tailored to the needs of the individual woman.

What should the patient know ?
Reasons for induction
Risks and Benefits
Alternative options if the woman declines IOL
induction
When, Where and How
Arrangements for
support
pain relief
IOL could be unsuccessful and then what the options would be.

38 WEEKS VISIT
Discuss membrane sweep
What a membrane sweep is
It makes  spontaneous labour, and  the need for IOL
Possible
discomfort
vaginal bleeding
Induction of labour between 41 +0 and 42 +0 weeks
Explain expectant management.

Prolonged Pregnancy
induction of labour between 41 +0 and 42 +0 weeks
exact timing depends
woman’s preferences
local circumstances.
If declined
At least twice weekly
CTG
USS for Maximum Pool depth

Preterm prelabour rupture of membranes
>>34 +0 -Consider IOL based on the following
Maternal risks (Sepsis, Caesarean section)
Fetal risks(Sepsis, Prematurity)
Neonatal facilities

Prelabour rupture of membranes (PROM)
Options:
IOL with vaginal PGE2
Expectant management.
IOL is appropriate approximately 24 hours after PROM

IOL in Patient with Previous caesaren section
Options:
Prostaglandins(PGE2)
Artificial rupture of membranes
Patient should be explained about
increased risk of uterine rupture
Emergency caesarean section

IOL in Intrauterine death
Indication for early intervention
ruptured membranes
infection
bleeding
Methods of IOL
Oral Mifepristone
Misoprostol/Prostaglandins

Suspected Macrosomia
This is not an indication for induction of labour on its own.

Maternal request
IOL should not routinely be offered on maternal request alone
Unless there is an exceptional circumstance. (Ex: woman’s partner is soon to be posted abroad with the armed forces)

Membrane Sweep
If os is open
Pass a finger through the os and separate the membrane
If os is closed
massaging around the cervix in the vaginal fornices may achieve a similar effect.
Timing:
Primi 40-41 weeks
Multi 41 weeks

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

Pharmacological Agents
Prostaglandin E 2
Gel
Tablet
Controlled-release pessary
Mifepristone & Misoprostol are only IOL in Intrauterine fetal death.

Regimens
One cycle of vaginal PGE2 tablets or gel:
one dose
followed by a second dose after 6 hours if labour is not established
up to a maximum of 2 doses
One cycle of vaginal PGE2 controlled-release pessary:
one dose over 24 hours.

Controlled-release pessary
Theoretical advantages
the ability of insertion without the use of a speculum
a slow continuous release of prostaglandin, only one dose being required
the ability to use oxytocin 30 minutes after its removal
the ability to remove the insert if required (such as with excessive uterine activity).

Surgical Methods
Amniotomy
Foley Catheter induction
no. 18 Foley catheter
introduced into the intra cervical canal under sterile technique past the internal os
The bulb is then inflated with 30 to 60 cc of water
Further research is needed in this area.

Before IOL
Bishop score should be assessed and recorded
A normal fetal heart rate pattern should be confirmed using electronic fetal monitoring.

Complications
Uterine hyperstimulation
Tocolysis should be considered
Failed IOL(see the next slide)
Cord Prolapse
Check the engagement of the head
Check for cord presentation prior to amniotomy
Uterine rupture

Definitions
Tachysystole ->5contractions in10 minutes (or more than 10 in 20 minutes)
Hypertonus - contraction lasting >120 seconds
Hyperstimulation - excessive uterine activity with a nonreassuring fetal heart rate tracing.

Failed induction
Options
Further attempt to induce labour
timing should depend on
clinical situation
woman’s wishes
caesarean section

Further reading
NICE guideline
SOGC guideline

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Induction of labour

by Ravimohan Ravimohan on Oct 31, 2011

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Induction of labour — Presentation Transcript