L12- Induction of Labor.ppt. .

L12- Induction of Labor.ppt. .

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  INDUCTION OF INDUCTION OF LABOUR LABOUR KingKhalid University Hospital King Khalid University Hospital Department of Obstetrics & Gynecology Department of Obstetrics & Gynecology Course 482 Course 482
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  INTRODUCTION INTRODUCTION DEFINITION DEFINITION  Induction oflabour is Induction of labour is defined as an intervention designed to defined as an intervention designed to artificially initiate uterine contractions artificially initiate uterine contractions leading to progressive dilatation and leading to progressive dilatation and effacement of the cervix and birth of effacement of the cervix and birth of the baby. This includes both women the baby. This includes both women with intact membranes and women with intact membranes and women with spontaneous rupture of the with spontaneous rupture of the membranes but who are not in labour. membranes but who are not in labour.
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  INDICATIONS INDICATIONS  Post-term pregnancy Post-termpregnancy   most common most common  PROM PROM  IUGR IUGR  Non-reassuring fetal suvillence Non-reassuring fetal suvillence  Maternal medical conditions Maternal medical conditions   DM, renal disease, DM, renal disease, HPT, gestational HPT, significant pulmonary HPT, gestational HPT, significant pulmonary disease, antiphospholipid syndrome disease, antiphospholipid syndrome  Chrioamnionitis Chrioamnionitis  Abruption Abruption  Fetal death Fetal death
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  RISKS of IOL RISKSof IOL    rate of operative vaginal deliveries rate of operative vaginal deliveries    rate of CS rate of CS  Excessive uterine activity Excessive uterine activity  Abnormal fetal heart rate patterns Abnormal fetal heart rate patterns  Uterine rupture Uterine rupture  Maternal water intoxication Maternal water intoxication  Delivery of preterm infant due to Delivery of preterm infant due to incorrect estimation of GA incorrect estimation of GA  Cord prolapse with ARM Cord prolapse with ARM
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  CONTRAINDICATIONS CONTRAINDICATIONS (Contraindications to laboror vaginal delivery) (Contraindications to labor or vaginal delivery)  Previous myomectomy entering the cavity Previous myomectomy entering the cavity  Previous uterine rupture Previous uterine rupture  Fetal transverse lie Fetal transverse lie  Placenta previa Placenta previa  Vasa previa Vasa previa  Invasive Cx Ca Invasive Cx Ca  Active genital herpes Active genital herpes  Previous classical or inverted T uterine Previous classical or inverted T uterine incision incision  2 or more CS 2 or more CS
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  PREREQUISITES PREREQUISITES To assess thefollowing To assess the following  Indication / any contraindications Indication / any contraindications  GA GA  Cx favourability (Bishop score) Cx favourability (Bishop score)  Pelvis, fetal size & presentation Pelvis, fetal size & presentation  Membranes status Membranes status  Fetal heart rate monitoring prior to IOL Fetal heart rate monitoring prior to IOL  Elective induction should be avoided Elective induction should be avoided due the potential complications due the potential complications
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  Cx ripening priorto IOL Cx ripening prior to IOL Indication Indication   if the Bishop score is if the Bishop score is ≤ 6 ≤ 6  The state of the Cx is an important predictor of The state of the Cx is an important predictor of successful IOL successful IOL Methods : Methods :  Intracervical PGE2 gel Intracervical PGE2 gel  0.5 mg/6hrs----3 doses 0.5 mg/6hrs----3 doses  Intravaginal PGE2 gel Intravaginal PGE2 gel  1-2 mg/6hrs----3doses 1-2 mg/6hrs----3doses PGE2 gel PGE2 gel   the rate of not being delivered in 24 hrs the rate of not being delivered in 24 hrs   the use of oxytocin for augmentation of labor the use of oxytocin for augmentation of labor PGE2 gel PGE2 gel   the rate of uterine hyperstimulation the rate of uterine hyperstimulation  Misoprostol Misoprostol   Should not be used for term fetuses Should not be used for term fetuses  Mechanical methods Mechanical methods
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  Cx ripening priorto IOL Cx ripening prior to IOL Mechanical methods Mechanical methods Foley Catheter Foley Catheter  It is introduced into the cervical canal past the It is introduced into the cervical canal past the internal os, the bulb is inflated with 30-60 cc of water internal os, the bulb is inflated with 30-60 cc of water  It is left for up to 24 hrs or until it falls out It is left for up to 24 hrs or until it falls out  Contraindications Contraindications  Low laying placenta, antepartum Low laying placenta, antepartum Hg, ROM, or cervicitis Hg, ROM, or cervicitis  No difference in operative delivery rate, or maternal No difference in operative delivery rate, or maternal or neonatal morbidity compared to PG gel or neonatal morbidity compared to PG gel Hydroscopic dilators Hydroscopic dilators (Eg.Laminaria tents) (Eg.Laminaria tents)  Higher rate of infections Higher rate of infections
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  IOL IOL 1-Oxytocin with Amniotomy 1-Oxytocinwith Amniotomy  IV IV  Half life 5-12 min Half life 5-12 min  A steady state uterine response occurs in 30 min or > A steady state uterine response occurs in 30 min or >  Fetal heart rate & uterine contractions must be monitored Fetal heart rate & uterine contractions must be monitored  If there is hyperstimulation or nonreassuring fetal heart If there is hyperstimulation or nonreassuring fetal heart rate pattern rate pattern   D/C infusion D/C infusion  Women who receive oxytocin were more likely to be Women who receive oxytocin were more likely to be delivered in 12-24 hrs than those who had amniotomy delivered in 12-24 hrs than those who had amniotomy alone alone & less likely to have operative delivery & less likely to have operative delivery
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  IOL IOL 2-PGE2 2-PGE2  For womenwith favorable Cx For women with favorable Cx   PGE2 PGE2   the rate of the rate of operative delivery & failed IOL when compared to operative delivery & failed IOL when compared to Oxytocin Oxytocin  PGE2 PGE2     GIT side-effects, pyrexia & uterine GIT side-effects, pyrexia & uterine hyperactivity hyperactivity 3-Sweeping of the membranes 3-Sweeping of the membranes  Vaginally the examining finger is placed through the Vaginally the examining finger is placed through the os of the Cx & swept around to separate the os of the Cx & swept around to separate the membranes from the lower uterine segment membranes from the lower uterine segment     local PGF2 local PGF2 α α production & release from decidua production & release from decidua & membranes & membranes   onset of labor onset of labor    the rate of delivery in 2-7 days the rate of delivery in 2-7 days    the rate of post-term the rate of post-term    the use of formal induction methods the use of formal induction methods  If there is urgent indication for IOL sweeping is not If there is urgent indication for IOL sweeping is not the method of choice the method of choice
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  Specific circumstances orindications Specific circumstances or indications Prelabor SROM at term Prelabor SROM at term  6-19% 6-19%  IOL with oxytocin IOL with oxytocin   risk of maternal risk of maternal infections (chorioamnionitis& endometritis) & infections (chorioamnionitis& endometritis) & neonatal infections neonatal infections  PG also PG also  maternal infections & neonatal maternal infections & neonatal NICU admissions NICU admissions IOL after CS IOL after CS  PG should not be used as it can result in PG should not be used as it can result in rupture uterus rupture uterus  Oxytocin or foley catheter may be used Oxytocin or foley catheter may be used