induction of labour, medical, surgical and combined

1. Induction Of Labor
PROCEDURE
PREPARED BY:
NIKITA SHARMA

2. INDUCTION OF LABOUR
• It means initiation of uterine contractions
(after the period of viability) by any
method (medical, surgical or combined)
for the purpose of vaginal delivery.

3. AUGMENTATION OF
LABOUR
 It is the process of stimulation of
uterine contractions (both in
frequency and intensity) that are
already present but found to be
inadequate.

4. ARTICES
 Screening
 Stethoscope
 Mask
 Apron
 Gloves
 Mackintosh
 Betadine
 Iv set
 Disposable syringes
 Distilled water
 Oxytocin/ cerviprime /
mifepristone
Bowl and swabs
Kocher forcep
Sponge holding
forceps
Kidney tray
Perineal pads

5. Indications for induction of labor:
• Maternal indications
• Post-term (main indication]
• P.I.H (Timing depend )on the[ severity]
• Diabetes Mellitus (increase risk
• of baby loss and mortality rate)
• Medical conditions (as renal, respiratory and
cardiac diseases)
• Placenta insufficiency (as moderate or sever
placenta abruption but commonly C.S)
• Prolonged pre-labor rupture of membranes.
• Rheuses isoimmunization.
• Maternal request.

6. Indications for Induction of
Labor cond..
• Fetal Indications:
• Suspected fetal compromise
(I.U.G.R)
• Intrauterine death (I.U.F.D).

7. Contraindications
•
•
•
•
•
•
•
•
Placenta previa and vasa previa
Abnormal fetal lie / presentation. e.g. transverse lie and breech
presentation
Umbilical cord prolapse and fetal distress
Previous classical Cesarean section or other transfundal
uterine surgery
Active herpes infection
Pelvic structural abnormality
Invasive cervical cancer
Contraindicaton specific to the inducing drug used.

8. Criteria Before Induction
• Sure estimation of weeks of gestation.
• Evidence of fetal maturity.
• Absence of cephalopelvic disproportion.
• An engaged head in longitudinal lie.
• Cervix is ready for delivery.
• High score Bishop's score.

9. BISHOP SCORE

10. Induction with caution
• Multiple pregnancy.
• Hydraminos.
• Grand parity.
• Maternal age of >35years.
• Previous cesarean section.
*Those conditions are at risk for ruptured of uterus.

11. Methods of Induction of Labor:
• Medical
• Surgical
• combined

12. Surgical Methods
1-Stripping the membranes:
- Stripping the membranes mechanically dilates the cervix which
releases prostaglandins. The membranes are stripped by
inserting the examining finger through the internal os &
moving it in a circular direction to detach the inferior pole of
the membranes from the lower uterine segment.
-
-

14. Surgical Methods (Cont.)
2-Amniotomy - Technique:
-The FHR is recorded before the procedure.
-A pelvic examination is performed to evaluate the cervix & station of the
presenting part. The presenting part should be well fitted to the cervix.
-The membranes are identified and a kocher is inserted through the cervical os
by sliding it along the hand & fingers & membranes are ruptured.
-Nature of the amniotic fluid is recorded
[clear,bloody,thick,thin,or meconium]
-The FHR is recorded after the procedure.

15. KOCHER FORCEP

16. AMNIHOOK

17. MECHANICAL METHOD

18. MECHANICAL DILATORS

19. TRANSCERVICAL BALOON
CATHETER

20. EXTRA-AMNIOTIC SALINE
INFUSION

21. MEDICAL METHODS
1-Prostaglandin E2: (dinoprostone): It is inserted vaginally as
a gel (Prepidil), as a removable tampon (Cervidil) or as a
vaginal pessary. It acts on the cervical connective tissue and
relaxes muscle fibres of the cervix. Dinoprostone should
only be administered at hospital and the patient is expected
to stay recumbent and monitored, at least, for the first 30
minutes after insertion. Contractions usually start within 60
minutes of commencing induction and peak within 4 hours.
If optimal response is not achieved by 6 hours, another
dose can be administered. The maximum allowed dose is 3
doses be administered per 24 hours.

22. DINOPROST

23. MEDICAL METHODS
Cervidil contains 10 mg of dinoprostone and provides a
lower constant release of medication (0.3 mg per hour)
than Prepidil does. Cervidil have the advantage of
being removed more easily if uterine hyperstimulation
occurs. In addition, it does not require refrigeration.
PGE2 can cause uterine hyperstimulation, fetal
distress and Cesarean section.

24. MEDICAL METHODS
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%

25. 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 (Reference 8 -
Evidence level B).
MEDICAL METHODS

26. 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.
MEDICAL METHODS

27. Oxytocin Infusion:
• Oytocin infusion in an isotonic solution is
used to stimulate uterine contractions after
rupture of the membranes. The dose and
increasing rate depend on each agency
protocols.

28. 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.
MEDICAL METHODS

29. Oxytocin (Syntocinon):
Action
Acts directly on
myofibrils,
producing
uterine
contraction.
Stimulate milk
ejection by the
breast.
Side effects
Hypo- or
hyper-tention,
dysrhythmia,
Abruptio
placenta,
decreases
uterine blood
flow,
convulsions,
nausea,
vomiting,
Asphyxia for
baby.
Nursing role
1 Assess:
-respiration, BP, Pulse,
-length, intensity, duration
of contraction.
-FHR (acceleration,
deceleration, distress)
-Signs of water
intoxication: (confusion,
anuria, drowsiness,
headache.
2Teach patient to: report
increase blood loss,
abdominal cramp, fever,
foul-smelling lochia.

30. Thank you!