Post dates and induction

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o&g update course 2012 hospital segamat

o&g update course 2012 hospital segamat

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  • 1. POST DATESPOST DATES ANDAND INDUCTION OF LABOURINDUCTION OF LABOUR DR. ARIVENDRAN M.D ( UKM ) MRCOG (UK )
  • 2. DEFINITION • POSTDATES : Pregnancy after 40 weeks ( after EDD ) • POSTTERM : Pregnancy after 42 weeks ( EDD plus 14 days )
  • 3. INTRODUCTION • Post-mature births do not have any harmful effects on the mother; however, the fetus can begin to suffer from malnutrition. • After the 42nd week of gestation, the placenta, which supplies the baby with nutrients and oxygen from the mother, starts aging and will eventually fail.
  • 4. • A number of key morbidities are greater in infants born to postterm pregnancies including meconium and meconium aspiration, neonatal academia, low Apgar scores, macrosomia, and, in turn, birth injury
  • 5. AETIOLOGY • The causes of post-term births is unknown. • But post-mature births are more likely when the mother has experienced a previous post-mature birth. • Due dates are easily miscalculated when the mother is unsure of her last menstrual period, so in reality the baby is not technically post-mature ( MOST LIKELY ) • Post-mature births can also be attributed to irregular menstrual cycles.
  • 6. TAKE HOME MESSAGETAKE HOME MESSAGE • PLEASE ALWAYS TRY DO A DATING SCAN IN THE FIRST TRIMESTER OR THE EARLIEST OPPORTUNITY AVAILABLE • A DATING SCAN IN THE FIRST TRIMESTER IS ALWAYS MORE RELIABLE THAN HER LAST MENSTRUAL PERIOD • PLEASE CHECK THE PATIENT’S DATES BEFORE INDUCING
  • 7. SIGNS OF POST MATURITY • Dry skin • Overgrown nails, Creases on the baby's palms and soles of their feet, • Minimal fat • Brown, green, or yellow discoloration of their skin
  • 8. SIGNS OF POST MATURITY • Some postmature babies will show no or little sign of postmaturity.
  • 9. COMPLICATIONS OF POST DATES FETAL RISKS • Reduced placental perfusion • Calcium is deposited on the walls of blood vessels and proteins are deposited on the surface of the placenta • Limits the blood flow through the placenta and ultimately leads to placental insufficiency and the • Fetus is no longer properly nourished.
  • 10. • OLIGOHYDARMNIOS • MECONIUM ASPIRATION SYNDROME
  • 11. MATERNAL COMPLICATIONS • Increased incidence of forceps assisted, vacuum assisted or cesarean • Difficulty in delivering the shoulders, shoulder dystocia, becomes an increased risk. • Increased psychological stress • Need for induction
  • 12. METHODS OF MONITORING FETAL MOVEMENT CHART Regular movements of the baby is the best sign indicating that it is still in good health. The mother should keep a "kick- chart" to record the movements of her baby. If there is a reduction in the number of movements it could indicate placental deterioration
  • 13. METHODS OF MONITORING CARDIOTOCOGRAPH (CTG) Electronic fetal monitoring uses a cardiotocograph to check the baby's heartbeat and is typically monitored over a 30-minute period.
  • 14. METHODS OF MONITORING ULTRASOUND SCAN ( AFI ) If the placenta is deteriorating, then the amount of fluid will be low and induced labor is highly recommended. However, ultra sounds are not always accurate ( operator dependant ) Actual placenta won't start to deteriorate until about 48 weeks.
  • 15. METHODS OF MONITORING BIOPHYSICAL PROFILE A biophysical profile checks for the baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid surrounding the baby.
  • 16. METHODS OF MONITORING DOPPLER FLOW STUDY Doppler flow study is a type of ultrasound that measures the amount of blood flowing in and out of the placenta
  • 17. TALKING POINTS FOR DISCUSSION • WHAT IS THE REASON FOR THE INDUCTION ?WHAT IS THE REASON FOR THE INDUCTION ? • WHAT ARE THE ALTERNATIVES TO INDUCTIONWHAT ARE THE ALTERNATIVES TO INDUCTION INCLUDING WAITING ?INCLUDING WAITING ? • WOULD I BE AT RISK OR WOULD MY BABY BE ATWOULD I BE AT RISK OR WOULD MY BABY BE AT RISK ?RISK ? • HOW DOES AN INDUCTION OCCUR ?HOW DOES AN INDUCTION OCCUR ? • WHAT ARE THE RISKS OR SIDE EFFECTSWHAT ARE THE RISKS OR SIDE EFFECTS ASSOCIATED WITH INDUCTION ?ASSOCIATED WITH INDUCTION ? • WHAT IS THE NEXT STEP IF INDUCTION FAILS ?WHAT IS THE NEXT STEP IF INDUCTION FAILS ?
  • 18. WHAT IS THE REASON FOR INDUCTION ? • Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy. • The exact timing should take into account the woman’s preferences and local circumstances.
  • 19. UNCOMPLICATED PREGNANCY • Give women every opportunity to go into labour spontaneously. • Offer membrane sweeps: - to nulliparous women at 40 week antenatal visit - to all women at 41 week antenatal visit - 1 week prior to women you plan to induce - if assessing the cervix. • Offer induction between 41 and 42 weeks, depending on woman’s preferences
  • 20. EVIDENCED BASED PRACTICE • Sweeping the membranes in women at term reduced the delay between randomisation and spontaneous onset of labour, or between randomisation and birth, by a mean of 3 days. • Sweeping the membranes increased the likelihood of both spontaneous labour within 48 hours
  • 21. WHAT ARE THE ALTERNATIVES TO INDUCTION INCLUDING WAITING ? • Membrane sweeping reduced the frequency of using other methods to induce labour (‘formal induction of labour’). • From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth.
  • 22. WOULD I BE AT RISK OR WOULD MY BABY BE AT RISK ? • The risk of Stillbirth increases from 1/3000 ongoing pregnancies at 37 weeks to 3/3000 ongoing pregnancies at 42 weeks to 6/3000 ongoing pregnancies at 43 weeks • With routine induction, perinatal death was reduced and the rate of caesarean section was reduced
  • 23. HOW DOES AN INDUCTION OCCUR ? •NATURAL METHODS •MECHANICAL METHODS •PHARMACOLOGICAL METHODS
  • 24. NATURAL METHODS • CERVICAL STRETCH AND MEMBRANE SWEEPING
  • 25. NATURAL METHODS • NIPPLE STIMULATION • SEXUAL INTERCOURSE • ACUPUNCTURE
  • 26. MECHANICAL METHODS • FOLLEYS CATHETER
  • 27. MECHANICAL METHODS
  • 28. MECHANICAL METHODS • DILAPAN • LAMINARIA • HYDROPHILIC DILATOR
  • 29. PHARMACOLGICAL METHODS • PROSTIN • DINOPROSTONE • PROSTAGLANDIN E2
  • 30. PROSTIN INDUCTION
  • 31. WHAT ARE THE RISKS AND SIDE EFFECTS ASSOCIATED WITH INDUCTION ? • UTERINE HYPERSTIMULATION • FETAL DISTRESS • FAILED INDUCTION
  • 32. WRITTEN CONSENT • MEDICOLEGAL • COMPULSARY
  • 33. WHICH IS THE NEXT STEP IF INDUCTION FAILS ? • EXPECTANT MANAGEMENT • REINDUCTION • LOWER SEGMENT CASEREAN SECTION
  • 34. FAILED INDUCTION If induction fails, the subsequent management options include: • – a further attempt to induce labour or to wait (the timing should depend on the clinical situation and the woman’s wishes) • – caesarean section
  • 35. BISHOP’S SCORE • Bishop score, also Bishop's score, is a pre-labour scoring system to assist in predicting whether induction of labour will be required and be successful • The Bishop score grades patients who would be most likely to achieve a successful induction
  • 36. MODIFIED BISHOP SCORE • According to the Modified Bishop's pre-induction cervical scoring system, effacement has been replaced by cervical length in cm • Points are added or subtracted according to special circumstances as follows: • One point is added for: ▫ 1. Existence of pre-eclampsia ▫ 2. Every previous vaginal delivery • One point is subtracted for: ▫ 1. Postdate pregnancy ▫ 2. Nulliparity (no previous vaginal deliveries) ▫ 3. PPROM; preterm premature (prelabor) rupture of membranes
  • 37. INDICATIONS FOR INDUCTION IN HOSPITAL SEGAMAT • POSTDATES 7 DAYS ( 41 WEEKS ) • GDM ON TREATMENT AT 38 WEEKS • PIH ON TREATMENT AT 38 WEEKS • GDM NOT ON TREATMENT / DIET CONTROL AT EDD • PROM AFTER 12 – 24 HOURS
  • 38. LOCAL SETTING • CONSENT TAKEN BY MEDICAL OFFICERS IN CLINIC OR ON ADMISSION • DAILY PROSTIN INSERTION (max 3 doses) • PRIMIDS – 3 mg, • MULTIPS – 1.5 mg • DONE IN THE WARD BY MEDICAL OFFICERS
  • 39. • CTG PRIOR TO PROSTIN INSERTION • PREFERABLY AT 6 AM IN THE MORNING THUS CTG POST PROSTIN CAN BE REVIEWED DURING MORNING ROUNDS • PREV LSCS AND GRANDMULTIPARA – FOLLEY’S CATHETER ( kept for 24 hours ) • IF BISHOP SCORE FAVOURABLE >8, ARM AND PITOCIN
  • 40. THANK YOU FOR YOUR KIND ATTENTION !!!!