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http://sandymillin.wordpress.com/iateflwebinar2024
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2. IOL means initiation of uterine contraction (after the period of
viability ) by any method (medical , surgical or combined ) for
the purpose of vaginal delivery
It is a process of stimulation of uterine contraction ( both in
frequency and intensity) that are already present but found to be
inadequate
PURPOSES OF INDUCTION OF IOL
Risk of continuation of pregnancy either to the mother or fetus
is more
3. Hypertensive disorders of pregnancy
Maternal medical complications – DM , chronic renal disease
Post maturity
Abruptio placenta
IUGR
Rh-isoimmunisation
Premature rupture of membrane
Fetus with congenital anamoly
IUD
Polyhydramnios and oligohydramnios
Unstable lie after correction into longitudinal lie
4. Contracted pelvis and CPD
Malpresentations (breech , transverse or oblique lie)
Previous classical caesarean section or hysterotomy
Uteroplacental factors : unexplained , vaginal bleeding , vasa praevia , placenta praevia
High risk pregnancy with fetal compromise
Active genital herpes infection
Heart disease
Pelvic tumour
Elderly primigravidae with obstetric or medical complications
Umbilical cord prolapse
Cervical carcinoma
5. MATERNAL –
To confirm the indication for IOL
Exclude the contraindication of IOL
Assess Bishop score ( >6,favourable)
Perform clinical pelvimetry to assess pelvic adequacy
Adequate counseling about the risks , benefits and alternatives of IOL with
the women and the family members
6. To ensure fetal gestational age
To estimate fetal weight ( clinical and USG)
Ensure fetal lung maturation status
Ensure fetal presentations and lie
Confirm fetal well being
7. 0 1 2 3
Dilatation, cm closed 1 - 2 3- 4 >=5
Effacement ,% 0-30 40-50 60 - 70 >/80
Station -3 -2 -1 , 0 +1,+2
Cervical
consistency
Firm Medium Soft
Position of
the cervix
Posterior Midposition Anterior
9. Period of gestation – term or post term
Pre -induction score –Bishop score > 6 is favourable
Cervical ripening – favourable in parous women and in case with PROM
Sensitivity to uterus – positive oxytocin sensitivity test is favourable to IOL
Other positive factors – maternal height >5” inches , EFW <3 kgs
10. Series of complex biochemical changes in the cervix which is
mediated by the hormones. Ultimately the cervix become soft
and pliable.
METHODS OF CERVICAL RIPENING –
PHARMACOLOGICAL METHODS
Prostaglandins – Dinoprostone , Misoprostol
Oxytocin
Progesterone receptor antagonist
Mifepristone
11. NON PHARMOCOLOGICAL METHODS –
Stripping of membrane
Amniotomy (ARM)
Mechanical dilators , osmotic dilators
Transcervical balloon catheter
Extra – amniotic saline infusion
15. It acts locally on the contiguous cells and both causes the
myometrial contraction
Intracervical application of Dinoprostone(PGE2- 0.5 mg) gel is
the gold standard for cervical ripening
It may be repeated after 6 hours for 3-4 doses if required
The women should be in bed for 30 minutes following
application and is monitored for uterine activity and fetal heart
rate
16. ROUTE - Transvaginally or orally
DOSE - 25ug vaginally every 4 hours is found either superior or
similarly effective to that of PGE2 for cervical ripening and
labour induction . Maximum doses is 6-8
SIDE EFFECTS – tachysystole, meconium passage, fetal heart
rate irregularities and uterine rupture
Contraindicated – previous LSCS
17. ACTION : Uterine activity (CONTRACTION) , Produce cervical
dilatation and effect delivery (WHEN RIPEN)
Oxytocin is effective for IOL when cervix is ripe
DOSE – 0.5 – 2.5 mu/min , with increases of 1 or 2 mu/minute
every 20-30 minutes until a maximum administration rate of
16 – 32 mU / minute is reached or adequate uterine activity is
present
18. It blocks both progesterone and glucocorticoid receptor
RU 486 , 200 mg daily for 2 days has been found to ripen the
cervix and to reduce labour
Onapristone is a more selective progesterone receptor antagonist
19. METHODS
1. Artificial rupture of membrane
Low rupture of membrane
High rupture of membrane (rare)
2. Stripping of membrane
20. INDICATION :
Abruptio placenta
Chronic hydramnios
Severe pre – eclamptia / eclamptia
CONTRAINDICATIONS :
IUFD
Maternal AIDS
Genital active Herpes Infection
21. Preliminaries : empty the bladder .
The procedure can be done in labour room or in OT if the risk
of cord prolapsed is high
Actual steps
1. Position the patient in lithotomy position
2. Full surgical asepsis to be maintained
3. Two fingers are introduced into the vagina smeared with antiseptic
ointment
4. The index finger is passed through the cervical canal beyond the
internal os
22.
23.
24. 5. The membranes are swept free from the lower segment as far as
reached by the fingers
6. With one or two fingers still in the cervical canal with the palmer
surface upwords , a long kocher’s forceps with the blades
closed or an amnion hook is introduced along the palmer
aspect of the fingers up to the membranes
7. The blades are opened to seize the membranes and are torn by
twisting movements
8. Amnihook is used to scratch over the membranes. This is
followed by visible escape of amniotic fluid.
25. ARM --- to be done in morning hours when patient is empty
stomach --- risk of cord prolapse --- immidiate LSCS may be
taken .
Precautions -----
Timing --- when cervix is dilated > 3 cm
colour of amniotic fluid for meconium staining
Syntocinon drip started after 12 hrs / earlier
Watch for any bleeding in cases of APH , bleeding increases
or decreases
26. Advantages :
Increases frequency and intensity of uterine contractions
Release of prostaglandins
Facilitates decent of presenting part
Allows for internal monitoring
Ability to assess amniotic fluid
Disadvantages :
Increased risk for infection
Possibility of prolapsed umbilical cord
27.
28. More effective than any single procedure
Shortens the induction – delivery interval thereby minimizes the
risk of infections and lessens the period of observation
Rh immunisation – is the development of antibodies against the Rh antigens present on the surface of RBCs
Vasa previa – A condition in which blood vessels within the placenta or the umbilical cord are trapped between fetus and the opening to the birth canal
PGE2 – DINOPROSTON , PGE1 – ALPROSTADIL
Contiguous range of cells is a group. Of highlighted cells that are adujscent to each other.