obstetrics

1. INDUCTION OF LABOUR
Induction of labour
Planned initiation of labour prior to
spontaneous onset labour.
Augmentation of labour
Stimulating the uterus during labour to
increase thefrequency,duration andstrength
of contractions.
• the woman to lie on

2. COMMON INDICATIONS
• Induction of Labour(IOL) is performed when the risk to foetus
and or mother of the pregnancy continuing outweigh those of
bringing the pregnancy to an end.
• Post date(ie.12 days or more beyond EDD)
• Foetal growth restriction
• Evidence of placenta insufficiencyeg.oligohydraminos.
• Pre-eclampsia
• Other maternal hypertensive disorder
• Deteriorating maternal illness
• Prolong prelabour rupture of membranes.
• Unexplained antepartum haemorrhage.
• Diabetes mellitus.
• Twin pregnancy continuing >38 wks.
• Rhesus iso- immunization.
• Social reason

3. • Review the indication
• Assess cervix by using Bishop score
• Assess fetal wellbeing
• Explain the procedure,methods,complication
• Get informed consent.

4. Score 0 1 2 3
Dilation of
cervix(cm)
0 1 or 2 3 or 4 5 or more
Consistency
of cervix
Firm Medium Soft ----
Length of
cervical
canal(cm)
>2 cm 2-1 1-o.5 <o.5
Position of
cervix
Posterior Central Anterior -----
Station of
presenting
part
-3 -2 -1 or 0 Below spines
Modified Bishop score

5. INDUCTION OF LABOUR
ASSESSMENT OF THE CERVIX
•-The success of induction of labour is related to the condition
of the cervix at the start of induction.
•- To assess the condition of the cervix, a cervical exam is
performed to do a Bishopscore.
• If the cervix is favourable (has a score of 6 or more), labour
is usually successfully induced with oxytocin alone.
• If the cervix is unfavourable (has a score of 5 or less), ripen
the cervix using prostaglandins or a Foley catheter before
induction.

6. METHODS OF INDUCTION OF LABOUR
• 1.Medical induction; PG/Oxytocin
• 2.Surgical induction; ARM/
• 3.Combined methods;ARM followed by
syntocinon/sytocinon followed by ARM

7. ARTIFICIAL RUPTURE OFMEMBRANE(ARM)
Traditional method is ARM (If membranes are intact, recommended
practise in induction of labour is to first perform artificial rupture of
membranes).
In some cases, this is all that is needed to induce labour. Membrane
rupture, often sets off the following chain of events:
-Amniotic fluid is expelled
-- Uterine volume is decreased
-Prostaglandins are produced, stimulating labour
-Uterine contractions begins
Note: In areas where HIV and/or hepatitis are highly prevalent, it is
prudent to leave the membranes intact for as long as possible to reduce
perinatal transmission of HIV.
•Review the indication.
• Listen to and note the fetal heart rate.

8. ARTIFICIAL RUPTURE OF MEMBRANES(continue)
• Ask the woman to lie on her back with her legs bent, feet
together and knees apart.
• Wearing high-level disinfected or sterile gloves, use one
hand to examine the cervix and note the consistency,
position, effacement and dilatation.
• Use the other hand to insert an amniotic hook or a Kocher
clamp into the vagina.
• Guide the clamp or hook towards the membranes along
the fingers in the vagina.

9. • Place two fingers against the membranes and
gently rupture the
• membranes with the instrument in the other hand.
Allow the amniotic
• fluid to drain slowly around the fingers.
• • Note the colour of the fluid (clear, greenish,
bloody). If thick meconium
• is present, suspect fetal distress
• • After ARM, listen to the fetal heart rate during
and after a contraction. If
• the fetal heart rate is abnormal (less than 100 or
more than 180 beats
• per minute), suspect fetal distress.

10. If membranes have been ruptured for 18
hours, give prophylactic antibiotics to help reduce Group
B streptococcus infection in the neonate
- penicillin G 2 million units IV;
- OR ampicillin 2 g IV, every six hours until delivery;
- If there are no signs of infection after delivery,
discontinue
antibiotics.
• If good labour is not established one hour after ARM,
begin oxytocin Infusion .
If labour is induced because of severe maternal disease
(e.g. sepsis or eclampsia), begin oxytocin infusion at the
same time as ARM.

11. • ARM(continue)
Place two fingers against the membranes and gently rupture
the membranes with the instrument in the other hand. Allow
the amniotic fluid to drain slowly around the fingers.
• Note the colour of the fluid (clear, greenish, bloody). If thick
meconium is present, suspect fetal distress
• After ARM, listen to the fetal heart rate during and after a
contraction. If the fetal heart rate is abnormal (less than 100
or more than 180 beats per minute), suspect fetal distress

12. OXYTOCIN
• Use oxytocin with great caution, as fetal distress
can occur from hyperstimulation and, rarely,
uterine rupture can occur.
•.Multiparous women are at higher risk for uterine
rupture.

13. • Cautiously administer oxytocin in IV fluids (dextrose or
normal saline).
•-Gradually increasing the rate of infusion until good labour
is established (three contractions in 10 minutes, each
lasting more than 40 seconds). Maintain this rate until
delivery. The uterus should relax between contractions.
• Monitor the woman’s pulse, blood pressure and
contractions, and check the fetal heart rate

14. Be sure induction is indicated, as failed induction is
usually
followed by caesarean section.
• Women receiving oxytocin should never be left
alone.
•Increase the rate of oxytocin infusion only to the
point where a good contraction pattern is
established and then maintain the infusion at that
rate.

15. PROSTAGLANDINS
• Monitor uterine contractions and fetal heart rate of all
women undergoing induction of labour with
prostaglandins
• Prostaglandins are highly effective in ripening the
cervix during induction of labour.
• Monitor the woman’s pulse, blood pressure and
contractions, and check the fetal heart rate.
• Record findings on a partograph.
• Review for indications.
• Prostaglandin E2 (PGE2) is available in several forms
(3 mg pessary or 2–3 mg gel). The prostaglandin is
placed high in the posterior fornix of the vagina and
may be repeated after six hours if required

16. Prostaglandin(continue)
• Discontinue use of prostaglandins and begin oxytocin
infusion if:
• - membranes rupture;
• - cervical ripening has been achieved;
• - good labour has been established;
• - OR 12 hours have passed.

17. • MISOPROSTOL
• • Use misoprostol to ripen the cervix only in highly
selected situations
• such as:
• severe pre-eclampsia or eclampsia when the cervix
is unfavourable
• and safe caesarean section is not immediately
available or the baby is too premature to survive
• fetal death in-utero if the woman has not gone into
spontaneous labour after four weeks and platelets
are decreasing.

18. Do not use oxytocin within 8 hours of using misoprostol.
Monitor uterine contractions and fetal heart rate.
- - Place misoprostol 25 mcg in the posterior fornix of the
vagina.
Repeat after six hours, if required;
If there is no response after two doses of 25 mcg,
increase to 50 mcg every six hours.
• Do not use more than 50 mcg at a time and do not
exceed four doses (200 mcg).

19. FOLEY CATHETER
• The Foley catheter is an effective alternative
to prostaglandins for cervical ripening and
labour induction. It should, however, be
avoided in women with obvious cervicitis or
vaginitis.

20. • Gently insert a high-level disinfected or sterile
speculum into the vagina.
• Hold the catheter with a high-level disinfected or
sterile forceps and gently introduce it through the
cervix. Ensure that the inflatable bulb of the catheter is
beyond the internal os.
• Inflate the bulb with 10 mL of water.
• Coil the rest of the catheter and place it in the vagina.
• Leave the catheter in place until contractions begin, or
for at least 12hours.
• Deflate the bulb before removing the catheter and
then proceed with oxytocin infusion.

21. COMPLICATION OF INDUCTION OF LABOUR
COMPLICATION OF MEDICAL&SURGICAL INDUCTION
• Failed induction ending with Caesarean section
• Longer duration of labour,greater use of epidural
• More assisted delivery
• PPH d/t prolong labour&atony.
COMPLICATION OF MEDICAL INDUCTION
• Hyper stimulation of uterus(from prostaglandin adminstration or use of syntocin)
• Foetal hypoxia and need for caesarean section.
• Uterine rupture esply: in those with previous scar.
• Systemic side effect of prostaglandin
• Antidiuretic effect of oxytocin

22. • Infection-Amnionitics,Accidental injury to placenta
,cervix,uterus,fetal parts,versapraevia.
• Amniotic fluid embolism
COMPLICATION OF SURGICAL INDUCTION
• Cord prolapse if ARM is done when presenting part is high.
COMPLICATION OF MEDICAL&SURGICAL INDUCTION
•Failed induction ending with Caesarean section
•Longer duration of labour,greater use of epidural
•More assisted delivery
•PPH d/t prolong labour&atony.

23. CONTRAINDICATION
• Grossly contracted pelvis.
• Persistent malpresentation.
• Pregnancy with previous caesarean section.
• Elderly primigravida with associated complicating factor
• High risk pregnancy with compromised fetus
• Pelvic tumor thatwill prevent descent of fetal head