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What is new in induction of labour.pptx
- 1. What is new in induction of labour? PSSL congress Dr. Indunil Piyadigama VOG – BH Kahawatta
- 2. Induction of labour • Artificially stimulating the onset of labour, prior to the spontaneous onset • This is achieved by stimulating uterine contractions and or progressive cervical effacement and dilatation • One of the commonest interventions in obstetrics - 30% in the UK
- 3. Sequale of induction of labour 65% of induced women will give birth without further interventions 15% will have instrumental delivery 20% emergency caesarean sections
- 4. Why is it a necessary intervention? • 20% of women will not deliver till 41 weeks • 10% of women will continue pregnancy beyond 42 weeks (294 days). These are the post term • Beyond 41 increased perinatal death up to 7/1000 • RCOG recommends induction at 41+0 • NICE recommends at 41+0 – 42+0 • This results in fewer perinatal deaths and meconium aspiration syndrome • There is no increased risk of caesarean section rates at this level
- 5. ARRIVE study Severe neonatal complication Low risk nulliparous woemen between 38 weeks 0 days and 38 weeks 6 days Induction at 39 weeks 0 days 39 weeks 4 days (3062) 4.3% RR 0.80; 95% CI 0.64 to 1.00 18.6% RR, 0.84; 95% CI, 0.76 to 0.93. Expectant management (3044) 5.4% 22.2% Randomised Caesarean delivery
- 6. Early induction Maternal Fetal Membrane or placental
- 7. Maternal • Age > 40 years • More than 35 years risk of intrauterine death (IUD) at 39 weeks similar to 41 weeks in 25-29 years group of women • Induction is recommended at 39-40 weeks (RCOG) • Hypertension • Chronic hypertension/ PIH/ Preeclampsia – 37 weeks (HYPITAT study) • GDM • IOL offered from 37 weeks for women with Type 1 and Type 2 DM (NICE) • Obstetric cholestasis • Bile acids >100 mmol/L induction at 37 weeks
- 8. • Maternal requests • Can be considered from 39 weeks (NICE) • Obsity • Late stillbirth risk is elevated in women with a raised BMI • Caesarean section rates might be lower in IOL at 39 weeks (RCOG guideline) • The WINDOW trial is currently comparing outcomes for low-risk obese women who are being randomized to IOL at 39 weeks or expectant management until 41 week
- 9. Fetal • Fetal growth restriction • Babies below the 10th centile by 39 weeks gestation • Less than the 3rd centile by 37 weeks (Saving Babies Lives version 2) • Large for gestation age • EFW of greater than 3500mg at 36 weeks, or more than 95th centile beyond 36 weeks gestation (NICE) • Reduced fetal movements • AFFIRM study - No benefit • Using CPR may have better outcomes • IUD
- 10. Membrane and placental • PROM • Greater than 37 weeks’ gestation with no spontaneous onset of labour occurring within 24 h • Immediate induction in GBS carriage • PPROM • 37 weeks (PPROMPT trial) • <37 weeks if any signs or symptoms of chorioamnionitis are present
- 11. Problems with induction • 70% of women do not like induction of labour • May be less efficient and more painful • Unnecessary inductions will lead to undesired complications and added health costs • Hyperstimulation and rupture • Fetal distress • Caesarean sections reduced at 41 weeks. However, increased from 34 to 41 weeks • Adverse effects of drugs – Hyponatraemia, fever • Umbilical cord prolapse
- 13. Methods of induction Mechanical Pharmacological
- 14. Mechanical induction Advantages • Lower risk of fetal heart rate abnormalities • Low risk of systemic side effects • Convenient storage • The risk of hyperstimulation is reduced The key disadvantage • Discomfort during insertion • Do not result in an increase in the risk of ascending infection
- 15. Mechanical methods Baloon cathter Extraamniotic saline infusion • SOLVE trial - Dilapan -S vs Propess have the same rate of caesarean section and neonatal adverse events Hygroscopic dilators (Dilapan -S) • Amniotomy alone or in combination with oxytocin may be used as a primary method for induction of labour if the Bishop score is more than 6 (NICE) ARM
- 16. Prostaglandin • Dinoprostone gel 1-2mg • Dinoprostone tablets 3mg • Carvidil - 10mg dinoprostone in a mesh Dinoprostone - PGE2 • Traditionally, used only for inducing labours with IUD • Now recommended as one of the options for pharmacological IOL • Low dose oral misoprostol is commercially available now in the UK • Low dose misoprostol is associated with lower caesarean rates for fetal heart rate abnormalities and poor progress of labour (Metaanalysis of 611 studies) Misoprostol – PGE1
- 17. Oxytocin Exogenous oxytocin is Syntocinon Cochrane review concluded that prostaglandins were more successful in achieving a vaginal birth within 24 hour Oxytocin induction may increase the rate of interventions in labour
- 18. Antiprogesterones • Mifepristone (RU486) • Only recommended following intrauterine fetal death and it is used as a priming agent prior to the administration of misoprostol
- 19. Factors influencing the method of induction Bishop’s score Presence or absence of a uterine scar Parity Obstetricians’ preference Patient factors
- 20. Conclusion • Induction is necessary • This is best undertaken when continuation of the pregnancy is thought to be associated with greater maternal or fetal risk than induction of labour • Women should be appropriately counselled regarding indications, risks, benefits and alternatives • Women should be offered a choice of a pharmacological or a mechanical method for their IOL
- 21. Thank you