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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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definition
DEFINITION

Artificial stimulation of uterine contractions before spontaneous onset of labour with the purpose of accomplishing successful vaginal delivery

indications
FETAL

IUFD

Fetal anomaly incompatible with life

Severe IUGR

Rh isoimmunisation

Macrosomia

INDICATIONS

MATERNAL

Preeclampsia, eclampsia

PROM

Posttermpreg

Abruptio placenta

Chorioamnionitis

Medical conditions-DM,Heartds, Renal ds,Chr. HT etc

contraindications
CONTRAINDICATIONS

Severe degree CPD

Major degree placenta praevia

Transverse lie

Previous classical CS,Myomectomy

Previous>= 2 LSCS

Grand multiparity

Active genital herpes

Hypersensitivity to inducing agent

risks of induction
RISKS OF INDUCTION

Failure leading to CS

Uterine hyperstimulation

Fetal distress,death

Rupture uterus

Intrauterine infection,sepsis

Iatrogenic delivery of preterm infant

Precipitate/dysfunctional labour

Inc. risk of operative vaginal delivery

Inc. risk of birth trauma

Inc. risk of PPH

adverse effects
Adverse Effects

Tachysystole

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%

slide7
Hyperstimulation

Criteria

Exaggerated uterine response (i.e. Tachysystole)

Concerning Fetal Heart Rate tracing

Late Decelerations

Fetal Tachycardia >160 beats per minute

DinoprostoneHyperstimulationIncidence: 17%

MisoprostolHyperstimulationIncidence

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

prerequisites
PREREQUISITES

Establish indication clearly

Informed consent

Conformation of gestational age

Assessment of fetal size & presentation

Pelvic assessment

Cervical assessment (BISHOPs score)

Availability of trained personnel

methods of induction
CHEMICAL

NONHORMONAL

Herbs,evening primrose oil

Homeopathic prep

Enemas

Castor oil

HORMONAL

Oxytocin

Prostaglandins –PGE2,Misoprostol

Relaxin

Nitric oxide donors

mifepristone

METHODS OF INDUCTION

NATURAL

Breast/nipple stimulation

Sexual intercourse

Membrane stripping

Amniotomy

Acupuncture/acupressure

MECHANICAL

Balloon catheters

Lamineria tents

Synthetic osmotic dilators

stripping of the membranes
Stripping of the Membranes

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]

contd
contd.

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]

amniotomy
Amniotomy.

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.

balloon catheters
Balloon catheters

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.

prostaglandins
Prostaglandins

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..

contd16
contd.

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 ).

technique for placement of dinoprostone gel
Technique for Placement of Dinoprostone Gel

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.

slide18
Initiate Fetal Heart Rate and tocometry

Start 15-30 minutes before gel inserted

Continue monitoring for 30-120 minutes after

Insertion Technique

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

slide19
Dosing

Repeat every 6 hours up to 3 doses in 24 hours

End points

Bishop Score of 8 or greater

Strong uterine contractions

Drug interactions

Wait 6-12 hours before starting Pitocin