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Induction and Augmentaion of labour
- 1. Induction and augmentation of labour Nghitukuhamba Tangi Elikana Kalipi 7th year medical student Cavendish University Zambia Moderator: Dr Mulube
- 2. Table of contents 1. Introduction. 2. Induction of labour. Indications, contraindications and pre-requisites of induction of labour. Methods of induction of labour. Complications of induction of labour. 3. Augmentation of labour. Indications and contraindications of augmentation of labour. Methods of augmentation of labour. Complications of augmentation of labour.
- 4. 2. Induction of labour Induction of labour (IOL) Initiation of uterine contractions, after the period of fetal viability (>28 weeks), for the purpose of vaginal delivery. Overall induction rate is around ~10%. The purpose of induction of labour is when the risks of continuation of pregnancy either to the mother or fetus is more. Induction for the maternal interest may compel to ignore the fetal interest. Before induction, ensure: The correct gestation, and fetal pulmonary maturation.
- 5. Induction of labour continued.. Indications for IOL Maternal Pre-eclampsia, eclampsia, and chronic hypertension. Abruptio placentae. Chorioamnionitis. Maternal medical complications (diabetes mellitus, chronic renal disease, intrahepatic cholestasis of pregnancy). Pre-labour rupture of membranes (PROM). Fetal Prolonged pregnancy. Intrauterine growth restriction (IUGR). Intrauterine fetal demise (IUFD). Rhesus isoimmunization. Fetus with a major congenital anomaly. Unstable lie (after correction to longitudinal lie).
- 6. Induction of labour continued.. Contraindication of IOL Contracted pelvis and cephalopelvic disproportion (CPD). Malpresentation (Breech, transverse, or oblique lie). Previous cesarean section or hysterotomy. Uteroplacental factors (Unexplained vaginal bleeding, vasa previa, placenta previa). Active genital herpes infection. High risk pregnancy with fetal compromise. Heart disease. Pelvic tumor. Elderly primigravida with obstetric or medical complications. Umbilical cord prolapse. Cervical carcinoma. Grand multiparity (parity >5)
- 7. Induction of labour continued.. Pre-requisites for IOL Maternal To confirm indication. To exclude contraindication. To assess Bishop score. Perform clinical pelvimetry to assess pelvic adequacy. Adequate counselling about risks, benefits and alternatives to IOL with the woman. Fetal To ensure gestational age. To estimate fetal weight. To ensure fetal lung maturity. To ensure fetal presentation and lie. To confirm fetal well-being.
- 8. Induction of labour continued.. The Bishop score This is a scoring system used to assess the condition of the cervix prior to induction of labour. It allows assessment of the likelihood of success. If favorable, a score of >6 or more, and if unfavorable, a score of <5 or less. Modified Bishop Score [Total score =13] Score 0 1 2 3 Position Posterior Central Anterior - Dilatation (cm) 0 1 or 2 3 or 4 5 or more Length (cm) >2 2 to 1 1 to 0.5 <0.5 Consistency Firm Medium Soft Station -3 -2 -1 or 0 Below spines
- 9. Induction of labour continued.. Methods of IOL Classification 1. Non-pharmacological methods. 2. Pharmacological methods. 3. Other methods
- 10. Induction of labour continued.. Methods of IOL 1. Non-pharmacological methods i. Transcervical balloon catheter. ii. Stripping of membranes. iii. Artificial rupture of membranes (ARM)/Amniotomy. iv. Extra amniotic normal saline infusion. v. Osmotic dilators (Laminaria or tent).
- 11. Induction of labour continued.. Methods of IOL 2. Pharmacological methods i. Oxytocin (Syntocinon)™. ii. Prostaglandins (PGE₁, PGE₂, PGF₂α). iii. Progesterone receptor antagonist (Mifepristone/RU-486). 3. Other methods i. Nipple stimulation. ii. Herbs (Evening primrose oil).
- 12. Induction of labour continued.. Principles of IOL To induce cervical ripening, and to induce uterine contraction. LOCAL GUIDELINES ON INDUCTION OF LABOUR Cervical ripening: Misoprostol (PGE₁) 25 µg PV every 6 hours OR Misoprostol (PGE₁) 25 µg PO every 2 hours (200 µg dissolved in 200 ml of water) OR Intracervical balloon/foley catheter inflated with 50-60 ml of water and left in situ for 24 hours. If labour does not start after 24 hours, consider induction of labour to have failed.
- 13. Induction of labour continued.. Complications of IOL Failed induction of labour. Uterine hyperstimulation/Tachysystole (>5 contractions in 10 min over 30 min). Fetal distress/death. Uterine rupture. Intrauterine infection. Iatrogenic preterm labour. Precipitate/dysfunctional labour. Increased risk of operative delivery. Increased risk of PPH. Increased risk of birth trauma.
- 14. 3. Augmentation of labour [Active management of labour] Augmentation of labour (AOL) The process of stimulating the uterus to increase the frequency, duration and intensity of uterine contractions after the onset of spontaneous labour.
- 15. Augmentation of labour continued.. Indications for AOL Poor progress of labour due to insufficient uterine contractions. Contraindications of AOL Malpresentation (Breech, transverse or oblique lie). Severe cephalopelvic disproportion (CPD). Presence of fetal compromise. Multigravida.
- 16. Augmentation of labour continued.. Methods of AOL i. Artificial rupture of membranes (Amniotomy) alone OR ii. Oxytocin (Syntocinon)™ alone OR iii. Artificial rupture of membranes (Amniotomy) and oxytocin (Syntocinon)™. How to give oxytocin (syntocinon)™ : 2.5 IU in 1L of normal saline at 10-15 dpm, titrating with contractions. Stop the infusion when contractions become regular.
- 17. Augmentation of labour continued.. Complications of AOL Uterine hyperstimulation/Tachysystole. Fetal distress/death. Uterine rupture.
- 18. References Kenny, L.C., Myers, J.E. (2016). Obstetrics by Ten Teachers. 20th Ed, CRC Press, NW. Dutta, D.C. (2020). DC Dutta’s Textbook of OBSTETRICS. 8th Ed, The Health Sciences Publisher, New Delhi.