GRAND MULTIPARA FIGO definition - GM taken as delivery of 5th to 9th Infant, 10th and above taken as great GM Prevalence - Gulf countries and African sub-continent Risks with increasing parity - Maternal Dysfunction labor Uterine rupture Morbid adherence of placenta Unstable lie & presentation Precipitate deliveries UV Prolapse Medical condition due to increasing age Fetal 1 Low APGAR score 2 Meconium aspiration syndrome

1. CONTROVERSIES
in
INDUCTION OF LABOR
DR. DIPTI NABH
DR SHARDA JAIN
D.G.F.’S CME ON INDUCTION OF LABOUR ON 8TH NOVEMBER 2016

2. GRAND MULTIPARA
FIGO definition - GM taken as delivery of 5th to 9th Infant, 10th and
above taken as great GM
Prevalence - Gulf countries and African sub-continent
Risks with increasing parity -
Maternal
1. Dysfunction labor
2. Uterine rupture
3. Morbid adherence of placenta
4. Unstable lie & presentation
5. Precipitate deliveries
6. UV Prolapse
7. Medical condition due to increasing age
Fetal
1 Low APGAR score
2 Meconium aspiration syndrome

3. Dysfunctional labor in GRAND MULTIPARA
Why???
1 Uterine Damage.
2 Myometrial thinning and fibrosis
3 Endometrial thinning.
4 Problems with pelvic stability
5 Lax abdominal wall.
6 Spherical Uterus

4. GRAND MULTIPARA
Induction of Labour ..should not be
done readily
1. Oxytocin – has unpredictable response in GM associated
with increased risk of adverse maternal outcome..UT
Rupture
2. Vaginal protoglandin – with misoprostol …. high
probability of uterine rupture to be kept in mind.
3. Protoglandin gel - Use is safer than the tablets in GM as its
main effect is in cervical ripening & its contractive effects
is considered minimal .

5. PREVIOUS LSCS
Term pregnancy with caesarean delivery – choice
ERCD, TOLAC for VBAC
Hesitation and Anxiety
Why???
1. Fear of catastrophic complications
2. Lack of RCT
3. ACOG guidelines clause changed from - availability
of clinician --- readily to immediately

6. PREVIOUS LSCS
• Factor associated with successful VBAC
1- Previous vaginal birth
2- spontaneous labor
Risk factor for unsuccessful VBAC
1. Induced labor
2. No previous vaginal birth
3. BMI >30
4. Previous C- section for dystocia
5. VBAC after 41 weeks
6. Birth weight > 4 kg
7. Previous classical c-section
8. Previous Preterm LSCS
9. Delivery interval less than 2 year from previous LSCS

7. PREVIOUS LSCS
Contraindication to VBAC
1. Classical c-section
2. Uterine incision involving the whole length of
uterus corpus
3. two or more previous c-section deliveries

8. PREVIOUS LSCS
Key points
Decision making
• Indication for c-section – Recurrent / Non Recurrent
• Intra & post operative complications in previous
delivery.
• Reduced inter-delivery interval.
• Current pregnancy complications

9. PREVIOUS LSCS
Of the various method available there is
No Perfect Method
• Vaginal misoprostol is a relative contraindication
except in IUD
• Vaginal PG E2 is the preferred method of choice.
• Trial of labour for 6 to 8 hours
• Augmentation of Labour not
recommended

10. Definition
Full term – 39 0/7 – 40 6/7
Late term – 41 0/7 – 41 6/7
Post term – beyond 42 weeks
Management
• Wait for spontaneous labour
• Expectant Management
TILL 41 WKS with
Antepartum fetal surveillance.
• Induction of labour
POST TERM PREGNANCY

11. POST TERM PREGNANCY
Spontaneous Labour
Preferred that patient goes into spontaneous labor by
39 wks
Suggested minimally invasive interventions :
1 Sweeping of membrane - release of prostaglandins.
2. Unprotected coitus – prostaglandins in semen.
3. Nipple stimulation
4. Acupuncture.
No RCT carried out
Not proven facts.

12. POST TERM PREGNANCY
Antepartum Fetal Surveillance
• Antepartum testing begun after 41 weeks.
• Preferred method of choice
Combination of NST with AFI – 2 times a week
• Doppler ultrasonography has no proven advantage

13. POST TERM PREGNANCY
Decision is straight-forward
• In case of non reassuring Surveillance
• Conditions where post-datism is not allowed
• Oligohydramnios
• IUGR
• Maternal Disease
• High Risk Pregnancy

14. POST TERM PREGNANCY
Induction of Labour
• Low Risk Pregnancy
• Certainty of gestational age
• Cervical examination findings favourable
• Estimated fetal weight less than 4 Kg.
• Past OH
• Patient preference

15. POST TERM PREGNANCY
Induction of Labour
Risk Associated with IOL
a) Placental function declines around term
– State of relative fetal hypoxia
– IUGR
– Oligohydramnios with cord compression
– Biophysical parameters of fetal well being affected
– Meconium aspiration syndrome
– Low 5 minutes APGAR score
b) Some placenta continue to function beyond due date
– LFD
– Shoulder dystocia
– Prolong labour
– Pelvic floor trauma
– Increased instrumental delivery
– C-Sections
– Increase maternal morbidity - PPH
– - INFECTION

16. POST TERM PREGNANCY
Induction of Labour
PG
1 PG E2 Gel
2 PG E1 Tablet
3 PG E2 Vaginal insert – IS BEST
Oxytocics
Use with caution. Less effective than PGE2
Mechanical Method
Poor success rate. Not used
Constant Surveillance
Appropriate setting to deal with emergency and complication.
Duration
48 hrs. for fair trial of labour.

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