Ind madina


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Ind madina

  1. 1. Induction of Labour-Evidence Based Dr Khalid Sait FRCSC Professor of Obstetrics and Gynecology King Abdulaziz University Hospital Jeddah Saudi Arabia
  2. 2. Definitions Grades of Evidence: -Ia- Evidence obtained from Meta-analysis of multiple RCTs -Ib-Evidence obtained from a single RCT -II-1 Evidence obtained from well-designed controlled trials without randomization -II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group -II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence
  3. 3. Definitions (Cont.) -III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees Levels of Recommendations: A: The recommendation is based on good and consistent scientific evidence B: The recommendation is based on limited or inconsistent scientific evidence. C: The recommendation is based primarily on consensus and expert opinion.
  4. 4. Why induction is important? Transition from passive to active medical role
  5. 5. Objectives At the end of this presentation, you should be: 1-Aware of the indications and contraindications for induction of labor 2-Aware of the different methods of induction of labor 3-Able to select the appropriate method of labor induction for an individual patient.
  6. 6. Indications 1-Severe hypertensive disorders of pregnancy 2-Postterm pregnancy and macrosomia 3-Intra-uterine growth retardation 4-Oligohydramnios 5-Premature rupture of membranes 6-Chorioamnionitis 7-Some cases of antepartum hemorrhage 8-Diabetes mellitus with vasculopathy
  7. 7. Safety of Elective Induction 9-Congenital fetal malformations incompatible with life 10-Rh incompatibility 11-Maternal diseases. e.g. cardiac disease and T.B. 12-Bad obstetric history 13-Elective inductions: Induction of labor is a medical procedure and should only be carried out for medical reasons. Induction of labor for social reasons is better avoided as it is hard to justify should any legal issue arises.
  8. 8. Contraindications 1-Placenta previa and vasa previa 2-Abnormal fetal lie / presentation. e.g. transverse lie and breech presentation 3-Umbilical cord prolapse and fetal distress 4-Previous classical Cesarean section or other transfundal uterine surgery 5-Active herpes infection 6-Pelvic Structural abnormality 7-Invasive cervical cancer 8-Contraindicaton specific to the inducing drug used.
  9. 9. Risks of Inducing Labour For the mother: Distress, fear or anxiety. Possible failure of labour induction. Uterine hypotonic inertia or inactive leading to prolonged labour Hypertonic contractions that could cause rupture of the uterus, premature separation of the placenta, or tearing of the cervix Intrauterine infections Postpartum haemorrhage (following childbirth). Amniotic fluid embolization (plug).
  10. 10. Risks of Inducing Labour The fetus may be exposed to: Physical injury Lack of oxygen (hypoxia) Premature delivery, if dates are not calculated correctly Umbilical cord prolapse (falling down). Infection.
  11. 11. PREREQUISITES Establish indication clearly Informed consent Conformation of gestational age Assessment of fetal size & presentation Pelvic assessment Cervical assessment (BISHOPs score) Availability of trained personnel
  12. 12. Factors Influencing positively in Labour Induction Cervical ripening - Uterine sensitivity – Parity -
  13. 13. Factors Influencing positivily Labour Induction Mother's age - Foetal maturity - Indications -
  14. 14. MOD. BISHOPS SCORE SCORE 0 1 2 3 DILATATION 0 1-2 3-4 >4 EFFACEMENT 0-30% 40-50% 60-70% >80% STATION -3 -2 -1/0 +1,+2,+3 CONSISTENCY firm medium soft POSITION posterior mid anterior
  15. 15. Selection Criteria For making Cervical Ripening unripe cervix. Bishop score <5
  17. 17. I-Natural-Non Medical methods (Cont.) 1-Relaxation techniques: 2-Visualization: 3-Walking:. 4-Sex: 5-Nipple stimulation:. 6-Bath/Castor oil/Enemas: 7-Foods: 8-Cumin Tea: 9-Several herbs:
  18. 18. I-Natural-Non Medical methods (Cont.) 10-Acupressure: . ( Evidence level B, systematic review of non-RCTs )
  19. 19. II-Mechanical methods 1-Hygroscopic 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 Technique of insertion
  20. 20. II-Mechanical methods (Cont.) 2- Placement of Balloon Dilators : Technique of balloon placement: Evidence level B, systematic review of non-RCTs
  21. 21. III-Surgical Methods 1-Stripping the membranes: Risks include patient’s discomfort, infection, bleeding from undiagnosed placenta previa or low lying placenta,and accidental ROM. The Cochrane reviewers concluded that stripping the membranes, when used as an adjunct, decreases the mean dose of oxytocin needed and increases the rate of normal vaginal deliveries. ( Evidence level A)
  22. 22. III-Surgical Methods (Cont.) 2-Amniotomy – Risks of amniotomy: 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
  23. 23. IV-Pharmacologic Induction of Labor 2- Misoprostol: Pharmacokinetics: Route of administration: Oral, vaginal and sublingual route for induction. Rectal route is used to prevent and treat postpartum hemorrhage. Bioavailability: Extensively absorbed from the GIT Metabolism: De-esterified to prostaglandin F analogs Half life: 20–40 minutes Excretion: Mainly renal 80%, remainder is fecal: 15%
  24. 24. IV-Pharmacologic Induction of Labor (Cont.) 2-Misoprostol: -Misoprostol (Cytotec) is a synthetic PGE1 analog that has been found to be a safe and inexpensive agent for cervical ripening. -Clinical trials indicate that the safe optimal dose and dosing interval is 25 mcg intravaginally every 4-6 hours. A maximum of 6 doses was suggested. Higher doses or shorter dosing intervals are associated with a higher incidence of side effects, especially hyperstimulation syndrome. -Misoprostol should not be used in women with previous CS because of increased rates of uterine rupture (- Evidence level B).
  25. 25. IV-Pharmacologic Induction of Labor (Cont.) -The Cochrane reviewers concluded that use of misoprostol resulted in an overall lower incidence of CS. In addition, there appears to be a higher incidence of vaginal delivery within 24 hours of application and a reduced need for oxytocin augmentation. ( Evidence level A).
  26. 26. IV-Pharmacologic Induction of Labor (Cont.) 3-Mifepristone: Mifepristone (Mifeprex) is an antiprogesterone agent which counteracts the inhibitory effect of Progesterone on the uterus. Few studies with small number of women enrolled, have shown that women treated with mifepristone in a dose of 600 mg are more likely to have a favorable cervix and deliver within 48 to 96 hrs when compared with placebo and also they these were less likely to undergo C.S. Information about fetal outcomes & maternal side effects is scarse and cannot be used to recommend the use of mifepristone for cervical ripening.
  27. 27. IV-Pharmacologic Induction of Labor (Cont.) 4-Oxytocin: It is given by IV infusion using an automated pump. Oxytocin has many advantages: it is potent and easy to titrate, has a short half-life (one to five minutes) and is well tolerated. Low Dose Protocol: 1-Prepare 5 IU of oxytocin/500 mL 5% dextrose. 2-Start infusion at a rate of 1-1.5 mU/minute (6-9 mL/hr) and increase by 1-1.5 mU/minute every 30 minutes until adequate labor was established.i.e. 3 contractions in 10 mins, each lasts between 60-90 seconds 1 mL = 15 drops 3-This protocol have the advantage of less hyperstimulation but with long induction delivery interval
  28. 28. IV-Pharmacologic Induction of Labor (Cont.) High Dose Protocol: 1-Prepare15 IU of oxytocin/500 mL 5% dextrose. 2-Start IV solution infusion at a rate of 4.5-6 mU/minute (9-12 mL/hour) and increased by 4.5 mU/minute every 30 minutes for a maximum of 40 milliunits per minute. 3-This protocol have the advantage of shorter induction delivery interval but with more hyperstimulation
  29. 29. IV-Pharmacologic Induction of Labor (Cont.) Oxytocin Protocol -If infusion volumes were found to be excessive, prepare double strength solution. -If no progress occurred after 8–12 hours of starting induction, either discontinue the oxytocin and reapply a cervical ripening agent or re-initiate oxytocin the next day. -Continuous electronic FHR monitoring during induction is essential to monitor fetal response to labor and uterine response to the inducing agent. If severe FHR abnormalities or hyperstimulation occurred, decrease/discontinue the oxytocin infusion.
  30. 30. IV-Pharmacologic Induction of Labor (Cont.) Side effects of oxytocin use: 1-Uterine hyperstimulation and subsequent FHR abnormalities. 2-Abruptio placentae and uterine rupture. 3-Water intoxication may occur with high concentrations of oxytocin infused with large quantities of hypotonic solutions. Therefore; prolonged administration with doses higher than 40 mu of oxytocin per minute and infusion of fluids in any 10 hours should not excced 1500 ml. A rapid intravenous injection of oxytocin may cause hypotension.
  31. 31. IV-Pharmacologic Induction of Labor 1-Prostaglandin E2: (dinoprostone):. It acts on the cervical connective tissue and relaxes muscle fibres of the cervix. The clinical application of Prostaglandins began late 1960s, although their action had been observed in the laboratory since the 1930s.
  32. 32. Vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinical reasons for not using it. PGE2 can cause uterine hyperstimulation, fetal distress and Cesarean section In today's clinical practice, Prostaglandins are used primarily for Labour management, namely cervical ripening and Labour induction. Prostaglandins
  33. 33. Prostaglandins For Cervical Ripening & Labour Induction Prostin E2 Vaginal Gel (1 &2 mg Dinoprostone): Prostin E2 Vaginal Tablets (3 mg Dinoprostone): Passary ( Propess)
  34. 34. Prostin E2 Vaginal Gel Product Profile Indications Prostin E2 Vaginal Gel is indicated for induction of Labour at term or near-term pregnant women who have favorable induction features with bishop scores of 4 to 7.
  35. 35. Directions For Use Introduce the syringe containing 1 mg gel in the posterior vaginal Fornix and well away from the cervical os, to avoid administration into the cervical canal. The mother asked to remain lying on back for at least 30 minutes. If labour is not established after 6 hours, a second dose of 1 mg or 2 mg may be administered. The maximum total dose is 3 mg over 6 hours period.
  36. 36. Site of insertion Posterior Fornix Vaginal Gel Posterior Fornix
  37. 37. Adverse Effects Tachysystole
  38. 38. Failed induction •  If induction fails, healthcare professionals should discuss this with the woman and provide support. •  The woman s condition and the pregnancy in general should be fully reassessed. •  Fetal wellbeing should be assessed using electronic fetal monitoring.
  39. 39. The subsequent management options include: • a further attempt to induce labour (the timing should depend on the clinical situation and the woman’s wishes) • caesarean section. Failed induction
  40. 40. Thanks