INDUCTION OF LABOUR. DEFINITION. Artificial stimulation of uterine contractions before spontaneous onset of labour with the purpose of accomplishing successful vaginal delivery. FETAL IUFD Fetal anomaly incompatible with life Severe IUGR Rh isoimmunisation Macrosomia. INDICATIONS.
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Artificial stimulation of uterine contractions before spontaneous onset of labour with the purpose of accomplishing successful vaginal delivery
Severe degree CPD
Major degree placenta praevia
Previous classical CS,Myomectomy
Previous>= 2 LSCS
Active genital herpes
Hypersensitivity to inducing agent
Failure leading to CS
Iatrogenic delivery of preterm infant
Inc. risk of operative vaginal delivery
Inc. risk of birth trauma
Inc. risk of PPH
Criteria: >10 contractions in 20 minutes
Dinoprostone Tachysystole Incidence: 33%
Misoprostol Tachysystole Incidence
Intravaginal gel or tablet: 31 to 49%
Oral crushed form or tablet: 16 to 22%
Exaggerated uterine response (i.e. Tachysystole)
Concerning Fetal Heart Rate tracing
Fetal Tachycardia >160 beats per minute
Intravaginal gel or tablet: 8%
Oral crushed form or tablet: 1 to 2%
Uterine Rupture in VBAC
Risk: 2.5% in Trial of Labor after Cesarean
Establish indication clearly
Conformation of gestational age
Assessment of fetal size & presentation
Cervical assessment (BISHOPs score)
Availability of trained personnel
Herbs,evening primrose oil
Nitric oxide donors
mifepristoneMETHODS OF INDUCTION
Synthetic osmotic dilators
Stripping of the membranes causes an increase in the activity of phospholipase and prostaglandin as well as causing mechanical dilation of the cervix, which releases prostaglandins. The membranes are stripped by inserting the examining finger through the internal cervical os and moving it in a circular direction to detach the inferior pole of the membranes from the lower uterine segment. [Evidence level C]
Risks of this technique include infection, bleeding, accidental rupture of the membranes, and patient discomfort. The Cochrane reviewers concluded that stripping of the membranes alone does not seem to produce clinically important benefits, but when used as an adjunct does seem to be associated with a lower mean dose of oxytocin needed and an increased rate of normal vaginal deliveries. [Evidence level A, RCT]
It is hypothesized that amniotomy increases the production of, or causes a release of, prostaglandins locally. Risks associated with this procedure include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding from placenta previa or low-lying placenta, and possible fetal injury.
The Atad Ripener Device in place with the two balloons inflated. The uterine balloon is at the internal os and the cervicovaginal balloon is at the external os.
M/A :Act on the cervix to enable ripening by a number of different mechanisms.
They alter the extracellular ground substance of the cervix, and PG increases the activity of collagenase in the cervix.
They cause an increase in elastase, glycosaminoglycan, dermatan sulfate, and hyaluronic acid levels in the cervix. A relaxation of cervical smooth muscle facilitates dilation.
prostaglandins allow for an increase in intracellular calcium levels, causing contraction of myometrial muscle..
Risks associated with the use of prostaglandins include uterine hyperstimulation and maternal side effects such as nausea, vomiting, diarrhea, and fever.
Currently, two prostaglandin analogs are available for the purpose of cervical ripening, dinoprostone gel (CERVIPRIME: 0.5 mg ) and dinoprostone inserts (PRIMIPROST :10 mg ).
Patient selection: Patient is afebrile. No active vaginal bleeding is present. Fetal heart rate tracing is reassuring. Patient gives informed consent. Bishop score is < 4.
Bring gel to room temperature before application, per manufacturer's instructions.
Start 15-30 minutes before gel inserted
Continue monitoring for 30-120 minutes after
Use one syringe of gel (0.5 mg )
Introduce gel into cervix
Just below level of internal os
Intracervical is preferred over posterior fornix (if leaking p/v posterior Fx)
Patient remains supine for 30 minutes
Repeat every 6 hours up to 3 doses in 24 hours
Bishop Score of 8 or greater
Strong uterine contractions
Wait 6-12 hours before starting Pitocin