obstetrics II class handout.pptx

AMBO University School/college health science
• Module Name: Obstetrics II
YEAR IV
INSTITUTION:
AMBO UNIVERSITY
COLLEGE OF
HEALTH SCIENCE
DEPARTMENT OF
MIDWIFERY.
• BY: Rebuma M. (MSc.)
09/02/2024 Rebuma M. 1

ANALGESIA AND
ANESTHESI
A

AMBO University School/college name here
9/2/24
What is the difference
between analgesia and
anesthesia

Introduction
Relief of pain during labor and delivery is an essential
part in good obstetric care.
Choice of anesthesia depends upon the patient’s
conditions and the associate disorders.
Anesthesia following full meal may cause maternal
death due to vomiting and aspiration of gastric contents.
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-Analgesia is pain relief without loss of consciousness
and without total loss of feeling or movement
-anesthesia is defined as the loss of physical sensation
with or without loss of consciousness.
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NERVE SUPPLY OF THE GENITAL
TRACT:-
•Uterus is under both nervous and hormonal control.
• Hypothalamus controls the uterine activity through the
reticular formation which balances the effects of
the two autonomic divisions.
MOTOR NERVE SUPPLY:-
The uterus receives both sympathetic and
parasympathetic nerve fibers.
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 The sympathetic nerve fibers arise from lower
thoracic and upper lumbar segments of the spinal
cord.
 The parasympathetic fibers arise from sacral 2, 3
and 4 segments of the spinal cord.
 Sensory stimuli from the uterine body: are
transmitted through the pelvic, superior
hypogastric and aorticorenal plexus to the10th
,
11th
and 12th
dorsal and the first lumbar segments
of the spinal cord.
 Sensory stimuli from cervix pass through the pelvic
plexus along the pelvic parasympathetic nerves to
sacral segments 2, 3 and 4 of the spinal cord.
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Sensory stimuli from upper vagina pass to 2, 3 and 4
sacral parasympathetic segments and from lower vagina pass
through the pudendal nerve.
The perineum receives both motor and sensory
innervation from sacral roots 2, 3 and 4 through the pudendal
nerve.
The branches of ilioinguinal and genital branch of
genitofemoral nerves supply the labia majora and also carry
the impulses from the perineum.
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HORMONAL CONTROL:-
 It is generally agreed that intact nerve supply is not essential for the initiation and
progress of labor. Oxytocin, a hormone derived from posterior pituitary maintains the
uterine activity during labor.
 Progesterone is the pregnancy–stabilizing hormone.
 Labor commences when it is withdrawn.
 Adrenalin with its beta activity inhibits the contraction of uterus, while its
alpha activity excites it.
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 Pain during labor results from a combination of
uterine contractions and cervical dilatation.
 The intensity of labor pain depends on the intensity
and duration of uterine contractions, degree of dilatation of
cervix, distension of perineal tissue, parity and the pain
threshold of the woman.
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 It is psychological method of antenatal preparation
designed to prevent or at least to minimize pain and
difficulty during labor.
 Patient is taught about the physiology of pregnancy and
labor in antenatal (mother craft) classes.
 Relaxation exercises are practiced.
 Husband or the partner is also involved in the management.
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• Every case of labor does not require
analgesia and only sympathetic explanation may be
all that is required.
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COMMONLY USED LOCAL
ANESTHESIA IN OBSTETRICS
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When complete relief of pain is needed
throughout labor, epidural analgesia is the
safest and simplest method for procuring it.
It provides sensory and motor blocked of the
regions.
A lumbar puncture is made between L2 and L3
with the epidural needle (Tuohy needle).
I .REGIONAL (NEURAXIAL) ANESTHESI
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• With the patient on her left side, the back of the patient
is cleansed with antiseptics before injection.
• When the epidural space is ensured, a plastic catheter is passed
through the epidural needle for continuous epidural analgesia.
• A local anesthetic agent (0.5% bupivacaine) is injected into
the epidural space.
• Full dose is given after a test dose when there is no toxicity.
• For cesarean delivery a block from T4 to S1 is needed.
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Advantages of regional Anesthesia
 The patient is awake and can enjoy the birth time
 Newborn APGAR score generally good
Lower risk of maternal aspiration
Postoperative pain control is better
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PARACERVICAL NERVE BLOCK
• is useful for pain relief during the first stage
of labor
• antiseptic safe guards, a long needle (15 cm
or more) is passed into the lateral fornix, at
the 3 and 9 o’clock
• Five to ten milliliter of 1% lignocaine are
injected at the site of the cervix and the
procedure is repeated on the other side.
• Although used from 5 cm dilatation of the
cervix, it is most useful toward the end of
the first stage of labor to remove the desire to
bear down earlier.
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PUDENDAL NERVE BLOCK
 It is a safe and simple method of analgesia during delivery.
 Pudendal nerve block does not relieve the pain of labor but affords perineal analgesia and
relaxation.
 Pudendal nerve block is mostly used for forceps and vaginal breech delivery.
i. The pudendal nerve may be blocked by either the transvaginal or the
transperineal route.
Transvaginal route: is commonly preferred.
o The index and middle fingers of one hand are introduced into the vagina, the finger tips are
placed on the tip of the ischial spine of one side.
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oThe needle is passed along the groove of the
fingers and guided to pierce the vaginal wall
on the apex of ischial spine and thereafter to
push a little to pierce the sacrospinous
ligament just above the ischial spine tip.
oAfter aspirating to exclude blood, about 10
mL of the solution is injected.
oThe similar procedure is adopted to block
the nerve of the other side by changing the
hands.
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SPINAL ANESTHESIA
obtained by injection of local anesthetic agent into the subarachnoid space
of the L3 or L4 lumbar interspace
It has less procedure time and high success rate.
For normal delivery or for outlet forceps with episiotomy, ventouse
delivery, block should extend from T10 (umbilicus) to S1.
Hyperbaric bupivacaine (5–10 mg) or lignocaine (25–50 mg) is used.
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The blood pressure and respiratory rate should be recorded every
3 minutes for the first 10 minutes and every 5 minutes thereafter.
Oxygen should be given for respiratory depression and
hypotension.
Sometimes vasopressor drugs may be required if a marked fall in
blood pressure occurs.
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Perineal infiltration:
 For episiotomy: Perineal infiltration anesthesia is
extensively used prior to episiotomy.
 A 10 mL syringe, with a fine needle and about 8–
10 mL 1% lignocaine hydrochloride (Xylocaine) are
required.
 The perineum on the proposed episiotomy site is
infiltrated in a fanwise manner starting from the middle of
the fourchette.
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Each time prior to infiltration, aspiration to exclude blood
is mandatory.
Episiotomy is to be done about 2–5 minutes following infiltration.
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Cesarean section may have to be done either as
an elective or emergency procedure.
Ryel’s tube aspiration of gastric contents is to be
done, especially when the stomach contains food.
Induction of anesthesia is done with the injection of
thiopentone sodium 200–250 mg (4 mg/kg) as a
2.5% solution intravenously.
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Uterine contractility may be diminished by volatile anesthetic agents
like ether, halothane.
Halothane, isoflurane cause cardiac depression, hepatic necrosis and
hypotension.
Uterine incision-Delivery (U-D) interval is more predictive
of neonatal status (Apgar score).
Prolonged U-D interval of more than 3 minutes results in lower
Apgar scores and neonatal acidosis.
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Muscle relaxants: Succinylcholine is commonly
used immediately after the induction drug to
facilitate intubation.
It is a short acting muscle relaxant with rapid
onset of action.
Intubation:
An assistant is asked to apply cricoid
pressure as soon as the consciousness is lost.
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Intubation is done with a cuffed endotracheal
tube and the cuff is inflated.
Presence of obesity, severe edema, neck
abnormalities, short stature or airway
abnormalities make intubation difficult.
Anesthesia is maintained with 50% nitrous
oxide, 50% oxygen and a trace (0.5%) of
halothane.
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Complications of general anesthesia:
Aspiration of gastric contents (Mendelson’s syndrome) is a
serious and life threatening one.
Delayed gastric emptying due to high level of serum
progesterone, decreased motility and maternal
apprehension during labor is the predisposing factor.
is due to aspiration of gastric acid contents (pH < 2.5)
with the development of chemical pneumonitis, lung
damage, atelectasis and bronchopneumonia.
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Management:
Immediate suctioning of oropharynx and nasopharynx is done to
remove the inhaled fluid.
Bronchoscopy may be needed if there is any large
particulate matter.
Continuous positive pressure ventilation to maintain arterial
oxygen saturation of 95% is done.
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Abnormal labor
Objectives
At the end of the session the learners will be able to:
• Define abnormal labor or dystocia
• Identify etiologies of abnormal labor
• Discuss on classification of abnormal labor
• Describe the diagnosis and management options
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Physiology of normal labor
• Labor -is a clinical diagnosis defined as uterine
contractions resulting in progressive cervical
effacement and dilatation, which results in birth
of the baby
-often accompanied by a bloody discharge,
bloody show.
• Stages- first stage -latent
-active
-second stage
-third stage
-fourth stage
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Definition:
Dystocia(abnormal labor)
 literally means difficult labor (child birth)and is
characterized by abnormally slow progress of labor.
 Most common cause of primary c/s.
 More common for primi (25-30 %) multipara (10-15
%).
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Abnormal labor( Dystocia)
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Induced labor.
Multiple gestation.
Malpresentation.
Pre/Post term.
Assisted delivery.
Precipitous labor.
Poor progress or arrest.
Abnormal labor
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Classifications of abnormal labor patterns
– Four major groups
• Prolongation disorders
• Protraction disorders
• Arrest Disorders
• Precipitate labor
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Prolongation Disorders
• Only one prolongation disorder
• Prolonged latent phase of labor
• A latent phase lasting longer than 20 hrs. for nulliparous and 14 hrs. for
multiparas.
– Challenge in diagnosis is often due to the problem in diagnosing the
exact time of onset of labor
Causes:
1- Power (Inefficient uterine contraction)
a) Hypertonic uterine dysfunction
b) Hypotonic uterine dysfunction
2- Excessive use of sedative or analgesia.
Rebuma M.

Hypertonic:-
contractions are:
-painful
-ineffective and
-associated with increased uterine tone.
There is a high resting basal tone between contractions. Therefore,
uterine circulation does not return to normal between contractions and
consequently fetal distress is more common.
Hypotonic :-
- contractions are less painful and characterized by easily indentable
uterus during the contractions and occur more frequently during the active
phase.
They are considered as the most common cause of poor progress in
labor.
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Risk factors:
-Extreme reproductive age (too young or too old).
-Primigravida.
-Unusually anxious women.
-Uterine over distention, e.g. multiple gestation,
polyhydraminos.
-Minor degrees of cephalo-pelvic disproportion.
-Malposition of the fetal head.
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Cont….
Management
depend on the cause :
* hypertonic activity respond erratically to oxytocin but
usually respond to therapeutic rest with 15-20mg morphine
sulphate or pethidine
* hypotonic activity respond well to IV(infusion)
oxytocin.
* excessive sedation or analgesia resolved spontaneously after
their effect have disappeared.
* ARM .
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Protraction Disorders
Two protraction disorders
• Protracted cervical dilatation
– A dilatation< 1.2 cms per hour in the primigravida and <1.5
cms per hour in the multigravida during active labor
• Protracted descent
– Descent < 1 cms per hour in the primigravida and <2 cms per
hour in the multigravida
Rebuma M.

Management
 generally these disorders don’t respond to oxytocin
stimulation or therapeutic rest or ARM , they should be
treated expectantly as long as the fetal HR is satisfactory
and labor continues to progress.
 If due to hypotonic activity it will respond to oxytocin.
 over sedation , normal labor will resume if the effect of
drug is allowed to wear off.
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Arrest Disorders
• Arrest of Cervical Dilatation
– No cervical dilatation for 2 or more hours in the active phase of labor
• Arrest of descent
– No descent for more than 1 hours
Rebuma M.

Management of labor abnormalities
- Expectant management — Most women with
prolonged second stage ultimately deliver
vaginally
- Treatment of hypo contractile uterine activity
- Assisted vaginal delivery
- Cesarean delivery
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• Definition: Strong and frequent contractions causing
abnormally rapid progress of delivery within 1 hr in multipara
and 3 hrs in primipara.
• Over-efficient contractions in the absence of obstruction.
• Risk factors:
• Strong uterine contractions.
• Small sized fetus.
• Minimal soft tissue resistance.
• Previous history of precipitate labor.
Precipitate labor
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Precipitate labor
• Complications:
• Maternal:
• Laceration: Cervix, vagina, and perineum.
• Uterine inversion – postpartum hemorrhage
• Uterine atony – postpartum hemorrhage
• Amniotic fluid embolism
• Fetal:
• Intracranial hemorrhage
• Fetal distress
• Delivery in inappropriate place
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Precipitate labor
• Management:
1. Stop oxytocin infusion (if used).
2. Tocolytics (Mg sulfate, terbutaline).
3. Episiotomy to avoid fetal and birth canal injuries.
4. Observe for PPH.
5. Observe fetus for injuries.
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Partograph and Criteria
for Active Labor
• Label with patient identifying
information
• Note fetal heart rate, color of
amniotic fluid, presence of
moulding, contraction pattern,
medications given
• Plot cervical dilation
• Alert line starts at 4 cm--from
here, expect to dilate at rate of 1
cm/hour
• Action line: if patient does not
progress as above, action is
required
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Quiz
1.case≠1: A 32 yo G1P0 36 wks presented
with contractions. Looks uncomfortable and is
contracting every 3minutes but cervix is 2cm
dilated and 50 % effaced. was seen the
previous day with similar complaints and
findings.
a. What is the diagnosis? (1%)
b.Management option: (1%)
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b.Management: (1%)
a.Diagnosis: (1%)
2.Case≠2:28 yo P0111 at 42 weeks presented in labor. She has
history of previous MVA and pelvic fracture. contracting every
2-3 minutes.6cm dilation x4hrs.confirmed adequate labor with
intrauterine pressure catheter. membranes ruptured, EFW
3200gm.constricted pelvic inlet with non engaged fetal head.
presentation vertex
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Obstructed Labor Cont…
Outline
• Define obstructed labor
• Discuss the etiology of obstructed labor
• Describe the diagnosis of obstructed labor
• Outline complications of obstructed labor
• Outline steps in the management of obstructed
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 Obstructed labor – a neglected case of labor in which
there is failure of descent of fetal presenting part through
the birth canal for mechanical reasons in the presence of
adequate uterine contractions.
 Major cause of maternal and perinatal mortality and
morbidity in low-resource settings with inadequate or
inaccessible intrapartum care.
Definitions – Obstructed labor
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Etiology of Obstructed Labor
• (I) Maternal causes:
1-Bony obstruction : e.g.
- Contracted pelvis.
- Tumours of pelvic bones.
2-Soft tissue obstruction:
i) Uterus: - Impacted subserous pedunculated fibroid.
ii) Cervix: cervical dystocia.
iii) Vagina: − Septa. − Stenosis. − Tumours.
iv) Ovaries : Impacted ovarian tumours.
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(II) Foetal causes:
1- Malpresentations and malpositions : e.g.
- Persistent occipito- posterior and deep transverse arrest,
-Persistent mento-posterior and transverse arrest of the
Face presentation.
- Brow,
- Shoulder,
- Impacted frank breech.
2- Large sized foetus ( macrosomia).
3- Congenital anomalies : e.g.
- Hydrocephalus.
- Foetal ascitis.
- Foetal tumours.
4- Locked and conjoined twins.
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(A) History: of
- prolonged labour,
- frequent and strong uterine contractions,
- rupture membranes.
(B) General examination :
shows signs of maternal distress as:
- exhaustion,
- high temperature (≥ 38 o
C),
- rapid pulse,
- signs of dehydration : dry tongue and cracked lips.
Diagnosis of Obstructed Labor
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(C) Abdominal examination:
1- The uterus :
- is hard and tender,
- frequent strong uterine contractions with no relaxation
in between (tetanic contractions).
- rising retraction ring is seen and felt as an oblique
groove across the abdomen.
2- The foetus :
- foetal parts cannot be felt easily.
- FHS are absent or show foetal distress due to
interference with the utero-placental blood flow.
Diagnosis cont…
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(D) Vaginal examination:
1- Vulva: is oedematous.
2- Vagina : is dry and hot.
3- Cervix: is fully or partially dilated, oedematous and
hanging.
4- The membranes : are ruptured and offensive liquor
5- The presenting part: is high and not engaged or
impacted in the pelvis. If it is the head it shows
excessive moulding and large caput.
6-High station
7- The cause of obstruction can be detected.
Diagnosis cont…
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(E) Differential diagnosis:
1- Full bladder.
2- Fundal myoma.
Diagnosis cont…
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Obstructed labor versus Parity
Primigravid labor
 Uterine inertia following
obstruction
 Labor can continue for days
 Sepsis and shock are causes
of death
 Fistula is a major
complications
Multiparous labor
 Increased uterine
contractions
 Uterine rupture within
hours
 Death often faster
compared to the
primigravida
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Complications of Obstructed Labor
Maternal
 Hypovolemia/Shock
 Maternal distress and ketoacidosis.
 Infection/Sepsis- as chorioamnionitis
and puerperal sepsis
 Uterine rupture
-Warning signs: Bandl’s ring and
tenderness of the lower segment of the
uterus.
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 Genital trauma
 Neurologic injury
 Death
 Psychological injury
 Postpartum hemorrhage-due to injuries or uterine atony.
Fetus/Neonate
 Asphyxia
 Infection/Sepsis
 Trauma
 Death
 Intracranial haemorrhage from excessive moulding.
Complications of Obstructed Labor
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Management of Obstructed Labor
(A)Preventive measures:
General
 Resuscitation
 Correct dehydration, electrolyte deficit, and acidosis.
 Oxygen
 Antibiotics
 Catheterization
 Pain relief
 NG tube drainage of gastric contents
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 Cross match and prepare blood
Careful observation , proper assessment, early detection and
management of the causes of obstruction.
(B) Curative measures:
Caesarean section is the safest method even if the baby is dead as
labor must be immediately terminated and any manipulations may
lead to rupture uterus.
Management cont…
Rebuma M.

Non-reassuring fetal heart rate pattern
Objective
The learner will be able to:
• Describe non-reassuring fetal heart rate
• Identify categories of non-reassuring fetal heart rate
• Categorize Preventive and management options
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Fetal heart rate tracings
• Auscultation of the fetal heart rate (FHR) is
performed by external or internal means.
• External monitoring is performed using a hand-
held Doppler ultrasound or external transducer,
which is placed on the maternal abdomen and held
in place by an elastic belt or girdle.
• Internal monitoring is performed by attaching a
screw-type electrode to the fetal scalp with a
connection to an FHR monitor. The fetal
membranes must be ruptured, and the cervix must
be at least partially dilated before the electrode
may be placed on the fetal scalp.
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Cont…
I. Reassuring fetal heart rate:
Indicates there is minimal likelihood of acidemia at that
point/normal/.
• A baseline fetal heart rate of 110 to 160 bpm
• Absence of FHR variability (6 to 25 bpm)
• Age appropriate FHR acceleration
• late or variable FHR deceleration.
• Moderate

• Early decelerations may or may not be present, FHR
accelerations are an important finding
II. Non-reassuring FHR patterns
Includes:
• Absent or minimal variability with decelerations or bradycardia
• Absent variabilty with:
• late deceleration
• variable deceleration
• Bradycardia
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• Tracing the fetal heart beat with a cardiotocograph (CTG)
monitor can be used to assess fetal well being and fetal heart
rate response to uterine activity, during labor and delivery
Interpretation: A) Baseline FHR changes
The pattern between uterine contractions
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i. Tachycardia:
• Mild:160-180 beats/min
• Severe:>180 b/min
Causes
-Maternal fever
-Fetal hypoxia
-Fetal anemia
-Amnionitis
ii. Bradycardia:
• Mild:100-110 beats/min
• Severe:<100 beats/min
Causes
-Heart block (little or no variability)
-Occiput posterior or transverse position
-Serious fetal compromise.
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iii. Loss of beat – to – beat variation:
normally there is a change of 6-25 beats/min every minute in
FHR. Absence of this beat-to-beat variation indicates fetal
compromise.
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B) Periodic FHR changes :The pattern with uterine contractions.
Types of decelerations:
i. Early Decelerations:
Normal, due to head compression during contractions. (↑ vagal tone)
Onset, peak, and end coincides with the timing of the contraction (mirror image).
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ii. Late deceleration
• Decrease in the FHR starts after a
lag time from the onset of
contraction and ends after a lag
time from its end.
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• It denotes utero-placental insufficiency—due to:excessive
uterine contraction, maternal hypoxemia, hypotension,
IUGR,diabetes,abruption.
• hypoxemia leads to hypoxia and metabolic acidosis the delayed return
to baseline worsens due to myocardial depression.
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iii. Variable Decelerations
Abnormal (mild, moderate or severe depending on duration), due to cord
compression.
Can occur at any time, and pattern change from one contraction to another. If they
are repetitive, suspicion is high for the cord to be wrapped around the neck or
under the arm of the fetus.
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FHR Variability
Absent variability =
Amplitude range undetectable
Minimal = < 5 BPM
Moderate = 6 to 25 BPM
Marked = > 25 BPM
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Accelerations Decelerations Variability (bpm) Baseline (bpm)) Feature
Present None = >5 110-160 Reassuring
The absence of accelerations with
an otherwise normal CTG are of
uncertain significance
• Early deceleration
• 161-180 Variable deceleration
• Single prolonged deceleration
up to 3 minutes
< 5 for >40 to <90 minutes 100-109 Non-reassuring
Atypical variable decelerations
Late decelerations
Single prolonged deceleration >3 min.
< 5 for = > 90 min. < 100 ,> 180
sinusoidal pattern >
= 10 min.
Abnormal
(Pathological)
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• INTERVENTIONS
Variable decels → reposition mother to knee-chest position to get baby’s
head off the cord OR use two fingers to lift the baby’s head off the cord until
further interventions required
Early decels → sign that baby is descending into the pelvis, monitor as
needed
Accelerations → reassuring (normal) sign; last for 15+ seconds and
peaks 15+ beats/min
Late decels → worrisome sign; reposition mother, administer IV fluids and
anticipate discontinuing/decreasing Oxytocin or administering a tocolytic to
decrease contractions
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Induction and Augmentation of Labour
Objectives
At the end of this session, the students will be able to:
-Define induction and Augmentation
- Identify indications of induction and
augmentationof labour
- Mention standard protocols
Induction Of Labour
Definition:
It is artificial initiation of labour using d/f methods after viability of the
foetus i.e. after 28 weeks on appropriate time & favorable condition.
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Indications: Labour maybe induced for medical or obstetrical
reasons.
(I) Maternal:
1. Hypertensive disorders with pregnancy:
i- Severe pre-eclampsia.
ii- Eclampsia.
iii- Essential hypertension.
v- Chronic nephritis.
2. Antepartum haemorrhage:
i- Placenta praevia type I&II.
ii- Accidental haemorrhage.
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- Diabetes mellitus:
To avoid intrauterine foetal death and dystocia due to macrosomia
- Spontaneous / premature rupture of membrane
Elderly primigravida
- Poor obstetric history
(II) Foetal:
1.Post-term pregnancy.
2.Intrauterine growth retardation.
3.Intrauterine foetal death
Indication cont…
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4.Rh- isoimmunization.
5.Gross congenital anomalies
Contraindication
- Unreliable EDD -Repaired fistula
- Malpresentation -Active genital herpes
- CPD -PP totalis
- Fetal distress
- Psychological distress
Relative CI: -twin pregnancy -previous c/s
-grand multipara > 6 -abnormal FHB pattern
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Precondition for Induction
A .Fetal maturity and viability
B .Favorability of cervix
Favorability of cervix is assessed by a score system called
‘’Bishop”score.It has to be done before induction. The total score is in the
range of 0-13
There are five factors considered, each accounts a score of 0-3.
The components are: -Cervical dilatation
- >> effacement
- >> consistency
- >> Position
- Fetal station
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Bishop scoring system
Score
0 1 2 3
Cx Dilation in cm Closed 1-2 3-4 >5
Cx Effecement 0-30 % 40-50 % 60-70 % > 80 %
Cx Consistency Firm Medium Soft -
Cx Position Posterior Central/mid Anterior -
Station -3 -2 -1 ,0 +1,+2
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103
- > 9/13 is the best cervical outcome /labor will be successful
- > 5/13 favorable
- 5/13 relatively favorable
- < 5/13 unfavorable
C. C/S facility
In induction
- delivery interval doesn’t exceed 18 hours; if not
ceaserean section is indicated.
- If no labour starts in 6 hours- consult
- If contractions are very strong and tetanic stop drip, sedate and
consider cesarean section
Bishop scoring cont…
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Observation of mother and fetus
- The fetal heart rate
- Uterine contractions
- Fluid balance chart
- Urine test for ketoses
Progress in labour
- Abdominal & cervical examination every 2-4 hours After
delivery continue oxytocin drops for one hour to prevent PPH.
Rebuma M.

Methods of Induction:
I-Natural-Non Medical methods (Cont.)
1-Relaxation techniques: advise patient to relieve tension and try to relax then
use some visual aids to show how labor starts.
2-Visualization: The patient is advised to imagine her uterus contracting and
she is laboring. Hypnosis/self-hypnosis helps.
3-Walking: The force of gravity pulls the weight of the baby towards the birth
canal leading to dilatation and effacement of the cervix.
09/02/2024 Rebuma M. 105

Cont…
4-Sex: Having sex is known to induce labor. This is related to prostaglandin
content of the seminal fluid and the occurrence of orgasm which stimulate
uterine contractions
5-Nipple stimulation: The lady moves her palm and applies some pressure
in a circular fashion over her areola and massaging nipple between thumb
and forefingers for a period of 2 minutes alternating with 3 minutes of
rest. The procedure is performed for 20 minutes.
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Cont…
6-Bath/Castor oil/Enemas: - take a warm bath
- have 3 teaspoons of castor oil mixed with some juice and an
enema thereafter. This method could stimulate the uterus to contract.
7-Foods: Eating lots of pineapple is known to stimulate labor and ripen the
cervix. This is possibly related to its enzyme content. Other foods with
similar action include Pizza, spicy food like Mexican, and tropical fruits
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II-Surgical Methods
-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.
-The nature of the amniotic fluid is recorded (clear, bloody, thick or thin, meconium).
-The FHR is recorded after the procedure.
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III-Surgical Methods (Cont.)
Risks of amniotomy:
1- Prolapse of the umbilical cord (0.5%)
2- Chorioamnionitis: Risk increases with prolonged induction delivery interval
3- Postpartum hemorrhage: Risk is doubled compared with women with
spontaneous onset of labor
4- Rupture of vasa previa
5- Neonatal hyperbilirubinemia
09/02/2024 Rebuma M. 109

IV-Pharmacologic Induction of Labor
1-Prostaglandin E2: (dinoprostone): It is inserted vaginally as a gel
(Prepidil), as a removable tampon (Cervidil) or as a vaginal pessary.
2-Misoprostol:
Route of administration: Oral, vaginal and sublingual route for induction.
-Misoprostol (Cytotec) is a synthetic PGE1 analog
-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.
09/02/2024 Rebuma M. 110

IV-Pharmacologic Induction of Labor
3-Mifepristone:
• Mifepristone (Mifeprex) is an antiprogesterone, couteract the
progesterone activity.
4-Oxytocin:
It is given by IV infusion using an automated pump. Oxytocin has many
advantages: it is potent and easy to titrate, has a short half-life (one to five
minutes) and is well tolerated.
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• In Our set up protocol for Induction
Multi and Primi have d/t dosage-primi 5IU and multi 2.5 IU.
-Drop/min is start with 10 drop/min then increase the drop by 20
every 30 min.
The maximum drop is 80 d/min.Then add another dose(5IU) in the
same bag start with 20 drop/min.
Drop
10
20
40
60
80
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■ If no adequate contraction add 5 IU on the same bag
20
40
60
80
■ If no adequate contraction add 5 IU on the same bag
40
60
80
Total dose will be 15 IU
For augmentation the protocol is the same but the dose is half of the
induction
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Rebuma M.

Induction Procedure
All induction except emergency induction should be started at 8 am.
-Check indication and bishop score
-Explain the procedure to the patient
-Enema
- Light fluid diet or NPO
-V/S,FHR and activity monitoring
-Start oxytocin drip and label the bag
-ARM -document time, color, bleeding if any.
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Rebuma M.

After initiation of oxytocin infusion
> Follow maternal v/s & input/output
> follow progress of labour
> No need of incease the dose of oxytocin once adequate uterine
contraction achieved
> If labour not established after 6 hrs consult
NB-A failed induction is diagnosed when there has been no cx change or
descent of the presenting part after 6-8 hrs or 1 contraction every 3 min.
> Start antibiotic if membrane ruptured and > 8hrs
> Continue infusion for 1hr post partum
> If the pt develop titanic type of Ux contraction, stop the oxytocin
drop
115
09/02/2024 Rebuma M.

•Complications of induction of labor
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
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Rebuma M.

2. Fetus
 Prematurity
 Birth injuries
 Cord prolapse
 Fetal distress
 IUFD
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Defn:Acceleration of already started labour.
Indication:
♦ Prolonged labor due to
-Cx arrest
- Descent disorder-all are b/c of –poor Ux cont.
The aim :
 To increase intensity of Ux contraction
 To clear the possibility of uncoordinated Ux contraction
Augmentation of labour
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Precondition For Augmentation
 Rule out passage of meconium
 Rule out CPD,malposition,malpresentation
 There should be C/S facility
Contraindication:
♣ Maposition and malpresentation
♣ CPD
♣ Active genital herpes infection
♣ Pelvic contractor
♣ NRFHR
♣ Fetal macrosomia
Augmentation cont…
Rebuma M.

Thank you!
09/02/2024
By Rebuma M.
120

I. Interactive presentation, case scenario [6hr]
1. Anesthesia and Analgesics (2hrs)
• Review mechanism of pain
• Introduction
• Type
• Complications /side effects
2. Abnormal labor [4hrs]
 Prolonged latent phase
 Protraction and arrest disorders
 Precipitate labor
Skill Development Lab [3hrs]
 Prepare and administer medications (Demonstration)
 Abnormal progress of labor (video, interpreting partograph)
PBL [4hrs]
 Abnormal labor
09/02/2024 Rebuma M. 121

II. Interactive presentation, case scenario [6hrs.]
3. Non-reassuring fetal heart rate pattern [2hr]
 Introduction
 Pathophysiology
 Cause
 Care and management
4. Obstructed labor [2hr]
 Introduction
 Risk factors and causes
 Care and management
Skill Development Lab [2hrs]
 Cephalopelvic disproportion & obstructed labor
PBL [4hrs]
 Obstructed labor
 Non-reassuring fetal heart rate pattern
09/02/2024 Rebuma M. 122

5. Induction and Augmentation of labor [2hrs]
 Indications for induction and augmentation
 Contraindications for induction and augmentation

References:
• Burkman RT. Williams obstetrics. JAMA. 2010 Jul 28;304(4):474-5.
• El-Mowafi DM. Obstetrics Simplified. El-Happy Land Square, El-
Mansoura, Egypt: Burg Abu-Samr. 1997.
• Marshall JE, Raynor MD. Myles' Textbook for Midwives E-Book.
Elsevier Health Sciences; 2022 Sep 5.
• Jacob A. A comprehensive textbook of midwifery & gynecological
nursing. Jaypee Brothers Medical Publishers; 2018 Nov 10.
• Beckmann CR, Herbert W, Laube D, Ling F, Smith R. Obstetrics and
gynecology. Lippincott Williams & Wilkins; 2013 Jan 21.
09/02/2024 Rebuma M. 124

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