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Induction and augmentation of Labor.ppt
1. Induction and augmentation of Labor
1
General
Induction is indicated when the benefits to either
the mother or the fetus out weighs those of
continuing the pregnancy.
Induction is associated with increased
complications as compared to spontaneous labor.
2. Definition
2
Induction – Induction of labor is the artificial
stimulation of uterine contractions before the
spontaneous onset of true labor at 28 or more
weeks of gestation to achieve vaginal delivery.
Augmentations
- Augmentation of labor is stimulation of the uterus
to increase its frequency, duration and/or strength
of spontaneously initiated labor.
6. Indications
6
Common indications
1. Post term pregnancy
2. Diabetes mellitus
3. RH iso immunization
4. Preeclampsia, eclampsia
5. PROM
6. Chronic hypertension
7. IUFD
8. Placental insufficiency
9. IUFD
10. APH secondary to AP
7. Contraindications
7
Cephalo pelvic disproportion
Placenta previa grade III, IV
Scared uterus e.g. myomectomy classic c/s
Transverse lie
Breech presentation
Grand multiparty
Over distended uterus
Multiple pregnancy
Prematurity
8. Pre induction cervical Ripening
8
Success of induction of labor is related to the
condition of the cervix at the start of induction.
Cervical ripening is a process that culminates in
physical softening and elasticity of the cervix.
Quantifiable method of assessment of cervical
ripening is using bishop’s score
11. Methods of cervical ripening
11
1. Pharmacological Techniques
Prostaglandin E2
PGE2 Gel (dinoprostone)
Used widely for cervical ripening
Causes dissolution of collagen bundles and increase
in sub mucosal water content
PG induced cervical ripening often includes initiation
of labor.
Low dose PG
Increases chance of successful induction
Decreases incidence of prolonged labor
Reduces total and maximum oxytocin dose –
12. Contd …
12
Preparation
Interacervical (0.3 – 0.5mg)
Interavaginal (3 – 5mg)
Dinoprostone vaginal insert (cervidil) 10mg.
provides slower release 0.3mg/hr
One advantage of the insert is it can be removed in
case of Hyper stimulation.
13. Contd …
13
Administration
Administer at or near labor ward
The woman remains recumbent for at least 30
minutes
Observe the patient from 30min to 2hrs
Monitor FHB and contraction
If no contraction transfer or discharge the patient .
Discontinue PG and begin oxytocin infusion if
Membranes rupture
Cervical ripening has been achieved
Labor has started
Or 12 hours has passed
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14
Side effects
Hyper stimulation > 6 cont. 10min
Fever
Vomiting
Diarrhea
Precaution should be taken when using it in patients
with
Glaucoma
B-Asthma
Hepatic or renal failure
15. Contd …
15
Prostaglandin E1(misoprostol)
Available as 100ug tab for prevention of peptic ulcer
Less expensive from dinoprostone
Intra vaginal administration of 25ug not more
frequent than every 3-6hrs is effective in women with
unfavorable cervix
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16
2. Mechanical techniques
1.Foley catheter
1. Inflation of the balloon
2. Inflation of the balloon with extra amniotic saline
infusion.
This results in:-
• Rapid improvement of bishops score and shorter
labor
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17
2. Hygroscopic cervical Dilators (Laminaria)
Osmotic cervical dilators
Improve cervical status rapidly
Low cost
Ease of placement
Can be removed quickly
18. Contd ……
18
3. Membrane Stripping
Commonly practiced
Increased PG synthesis occurs after stripping the
membrane
19. Induction procedures
19
1. Amniotomy. (Artificial Rupture of
Membranes)
Also referred as surgical induction
Is a recommended practice in both induction and
augmentation.
Prerequisites:-
− Appropriate indication
− Engaged fetal head (relative)
− No contraindications such as cord presentation, vasa
previa
− No fetal distress (unless immediate vaginal delivery
is possible)
Indications:-
Induce labor
Use of internal fetal monitoring
20. Contd ….
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Contraindications:-
- Cord presentations
- Placenta previa
- Vasa previa
- Active genital herpes(intact fetal membranes or < 4 hrs
of rupture
- Presenting part above the pelvic inlet (relative)
Risks :-
- cord prolapse
- Increased risk of infection
- Increase perinatal HIV transmission
21. Contd ….
21
2. Oxytocin infusion
Oxytocin is the first polypeptide hormone
synthesized
Record maternal & fetal conditions and progress
of labor..
The goal is to achieve effective uterine
contraction that’s sufficient to produce cervical
change and fetal descent while avoiding uterine
hyper stimulation and /or non reassuring FHB .
22. Contd ….
22
Start oxytocin infusion, and monitor the dose and rate
of infusion strictly as follows:-
Add 2 IU of oxytocin into 1000 ml of N/S or R/L solution
and adjust the number of drops every 30 minutes.
Starting with a low dose of oxytocin and increase every
30 minutes till adequate uterine contraction is achieved
or maximum dose is reached.
Label the bottle and keep timely record30 of the drops
used.
Aim to maintain the lowest possible dosage consistent
with adequate uterine contraction.
Monitor mother, fetus and labor according to labor
protocol.
Continue the oxytocin infusion for at least one hour
postpartum.
24. Contd …
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Discontinue Pitocin:-
If contractions are >5/10min or >7/15min or
If they last longer than 90 seconds(tetanic) or
If FHB becomes non reassuring
Uterine response occurs 3-5 minutes after beginning
of infusion of oxytocin – steady plasma level is
achieved 40minuts later
25. Contd ….
25
Response depends on : -
Previous uterine activity
Uterine sensitivity
Cervical status
Different regimens are used for oxytocin infusion .
Low dose
High dose
27. Complications of induction of
labor
27
1. Mother
Failure of induction leading to c/s
Uterine inertia
Tetanic uterine contraction
Uterine rupture
Precipitated labor resulting in genital tear
Intrauterine infection
Post partum hemorrhage
Water intoxication
Amniotic fluid embolism
28. Contd ….
28
2. Fetus
Prematurity
Birth injuries
Cord prolapse
Fetal distress
IUFD
Failed induction
Definition:- failure to initiate good uterine
contraction. It is diagnosed if adequate uterine
contractions are not achieved after 6 to 8 hours
of oxytocin use of the maximum dose.
29. Contd …
29
Tetanic contractions
Definition: Six or more contractions in 10 min and/ or
durations of 90 or more seconds; averaged over a 30-
minute window.
Management
− Stop oxytocin infusion
− Use tocolytics if available
− Assess fetal & maternal conditions for (fetal distress or
ruptured Ux)
− If both mother and fetus are in good condition, restart at
half dose of
the last dose causing tetanic contractions.
30. WHO
oxytocin infusion rate for induction of labor )
30
Time since
induction
hrs
Oxytoinconc Drops/min Approx. –
dose/miu/min
Vol infused Total Vol
infused
0 2.5iu/500ml 10 3 0 0
½ Same 20 5 15 15
1 >> 30 8 30 45
1 ½ >> 40 10 45 90
2 >> 50 13 60 150
2 ½ >> 60 15 75 225
3 5Iu/500ml
(10miu/ml)
30 15 90 315
3 ½ >> 40 20 45 360
4 >> 50 25 60 420
4½ >> 60 30 75 495
5 10Iu/500ml
(20miu/ml)
30 30 90 585
5½ Same 40 40 45 630
6 >> 50 50 60 690
6½ >> 60 60 75 765
7 >> 60 60 90 855
N:B increase the rate of infusion until good contraction is established and maintain it at that rate
31. Rapid escalation for primigravida only infusion rate for
induction of labor
31
Time since
induction hrs
Oxytocin conc. Drops/min Approx. –
dose/miu/min
0 2-5iu/500ml 15 4
½ >> 30 8
1 >> 45 11
1 ½ >> 60 15
2 5Iu/500ml
(10miu/ml)
30 15
2 ½ Same 45 23
3 >> 60 30
3 ½ 10Iu/500ml
(20miu/ml)
30 30
4 >> 45 45
4½ >> 60 60
5 >> 60 60