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Induction and augmentation of labour

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Induction and augmentation of labour done in indicated cases.M.K.C.G MEDICAL COLLEGE, BERHAMPUR, ORISSA,
DR.S.N.BERA,& DR. M.DASH

Induction and augmentation of labour done in indicated cases.M.K.C.G MEDICAL COLLEGE, BERHAMPUR, ORISSA,
DR.S.N.BERA,& DR. M.DASH

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Induction and augmentation of labour

  1. 1. DR. S.N. BERA DR. MITALI DASH M.K.C.G MEDICAL COLLEGE, BERHAMPUR
  2. 2. Induction of labour Initiation of uterine contraction artificially after the period of viability before onset of labour for the purpose of secure vaginal delivery. Augmentation of labour The process of stimulation of uterine contraction (both in frequency and intensity) that are already present but found to be inadequate.
  3. 3. Normal labour
  4. 4. Induction of labour  Incidence 10%  The over all incidence increased globally.  According to National Center for Health Statistics 90/1000 live birth in 1989 to 184/1000 live birth in 1997.
  5. 5. Indication of induction obstetrics medical  Abruptio placentae  IUGR  Post maturity  Rh isoimmunisation  PROMS  Congenital anomaly  IUD  Oligohydramnios,polyhydra mnios  Hypertensive disorders of pregnancy  Diabetes mellitus  Chronic renal disease.  Cholestasis of pregnancy
  6. 6. CONTRAINDICATIONS OF INDUCTION OF LABOUR  Contracted pelvis and CPD  Malpresentation (breech,tansverse lie or oblique lie)  Previous classical caesarean section or hysterotomy  Uteroplacental factors: Unexplained vaginal bleeding,vasa previa,placenta previa  Active genital herpes infection
  7. 7. Contd…  High risk pregnancy with fetal compromise  Heart disease  Pelvic tumor  Elderly primigravida with obstetric or medical complications.  Umbilical cord prolapse  Cervical carcinoma
  8. 8. PARAMETERS TO ASSESS PRIOR TO INDUCTION OF LABOUR MATERNAL FETAL  To confirm the indication for IOL.  Exclude the contraindication of IOL.  Asses BISHOP SCORE (Score >6 favourable)  Perform clinical pelvimetry to assess pelvic adequacy  Adequate counselling about the risks,benefits and alternatives of IOL with the woman and the family members  To ensure fetal gestatonal age.  To estimate fetal weight.  Ensure fetal lung maturation status.  Ensure fetal presentation and lie  Confirm fetal well being.
  9. 9. FACTORS FOR SUCCESSFUL INDUCTION OF LABOUR  Parity  Period of gestation  Preinduction score  Sensitivity of uterus :positive oxytocin sensitivity test is favourable for IOL.  Cervical ripening  Presence of fetal fibronectinin vaginal swab ( >50ng/ml)
  10. 10.  Induction of labour two componant Induction of labour Cervical ripening Dilatation of cervix and delivery Uterine contraction
  11. 11. Bishop’s score 1964 parameters score 0≥ 1 2 3 Cervical dilatation closed 1-2 3-4 5+ Effecement(%) 0-30 40-50 60-70 ≥80 consistancy firm median soft position posterior midline anterior station -3 -2 -1,0 +1, +2 Score 0-5 is unfavourable and 6-13 is favourable Calder modification 1974 is effecement of cervix with length of cervix Cervical length(cm) ≥4 2-4 1-2 <1
  12. 12. METHODS OF INDUCTION  HISTORY :  Massage of breasts and uterus.  Stretching of the cervix digitally.  Rubber tubing pushed into the uterus.  Castor oil  Warm bath  Enema
  13. 13.  Hot carbolic acid douche in 1856 by Scanzoni.  Kraus’ bougies  Rubber bags filled with water-Barnes(1861)  Artificial rupture of forewater-1st used by DENMAN in 1756.  Hind water rupture by Drew-Smythe catheter(1931)
  14. 14. METHODS OF INDUCTION  Medical induction : o Prostaglandins PGE2,PGE1 o Oxytocin o Other :Mifepristone,oestrogen,corticosteroids,relaxin,Hyaluronid ase under investigation.  Surgical induction : o ARM o Sweeping of the membranes. o Balloon catheterization
  15. 15. Oxytocin
  16. 16. OXYTOCIN  Occtapeptide, extracted from post. Pituitary 1906.  Blair Bell describe it application in pregnancy1909.  1910 used for augmentation of labour.  Used for induction of labour reported by Theobold 1952  chemical formula by Vincent de vigneaud (1953).  1968 Turnbull and Anderson introduced the tritration methode for oxytocin administration
  17. 17.  Routes of administration: Intravenous, intramuscular, Buccal, Transnasal  T (1/2) – 3-5mins.  Degraded by oxytocinase  Excreted by liver and kidneys.  Synthetic preparations: Syntocinon, Pitocin.
  18. 18. Oxytocin  Commonly used drugs for induction of labour inform of dilute solution.  Steady plasma con. Reaches15-20 min of infusion but recent studies shows it takes about 40 min (seitchik et al.1984).  According ACOG 1999 two regimen.  Low initial dose @0.5-2mIU/mi n and slow increment at every 15-40 min.  High dose start @3-6mIU/min with increment every 15-40 min.  RCOG 2001 recomends  Starting dose@1-2mIU/min & dose should be increased at interval of 30 min.
  19. 19.  Dose should be titrated against uterine contraction aiming of 3-4 contractions every 10 min. that usually develop with @12mIU/min  Max. licensed dose 20mIU/min  RCOG 2001 suggest max. dose 32mIU/min.
  20. 20. Oxytocin infusion for induction of labour using in infusion set(5U/500ml) Time since induction (min) Dose of oxytocin (mIU/min) Rate of infusion (ml/hr) Total vol. infused (ml) 00 1 6 0 30 2 12 3 60 4 24 9 90 8 48 21 120 12 72 45 150 16 96 81 180 20 120 129
  21. 21. Oxytocin infusion using a drip set for induction of labour Time since induction (min) Oxytocin driprate (drops/min) Dose of oxytocin (mIU/min) Total vol. infused (ml) 00 (2U/500ml) 10 2 0 30 20 4 15 60 30 6 45 90 40 8 90 120 50 10 150 150 60 12 225 180 (4U/500ml) 40 16 315 210 50 20 375
  22. 22.  Complication association…  Uterine hyperstimulation more with high dose regimen but increase chance of vaginal delivery  Uterine rupture.(to ↓risk, to be used carefully in grand multipara and pre.cs, should not be started for six hours following administration of vaginal prostaglandin)  water intoxication (can be reduced by infusion with electrolyte containing solution.)  Neonatal jaundice….. More study required.
  23. 23. PROSTAGLANDINS
  24. 24. PREPARATIONS AVAILABLE  Intra-cervical PGE2 Gel :  Dose : 0.5mg  Can be repeated every 6hrs and the max dose should not exceed 3 doses in24 hrs.  Intravaginal application (RCOG 2001)  Dose-2mg in nulliparous women with unfavourable cervix followed by a second dose 6-8 hrs later with a max dose of 4mg.  Multiparous women with favourable cx –Initial dose of 1mg followed by a second dose 6hrs later  Max dose of 3mg (RCOG 2001).
  25. 25. Controlled released vaginal insert 10mg insert which releases at the rate of 0.3mg/hr. No prewarming required. Patient should lie down for 2 hrs. Insert removed after 12 hrs or when active stage begins or in case of hyperstimulation.
  26. 26. Side effect: Uterine hyperstimulation Contraindication  Established uterine activity.  Glaucoma  Asthma  Known hypersensitivity to prostaglandins.  Severe hepatic or renal impairment.  Active vaginal bleeding.
  27. 27. MISOPROSTOL :  Methyl ester of PGE1.  Has been used for patient with peptic ulcer ds. since1988  Inexpensive.  Can be stored at room temperature.
  28. 28.  Complications :  Uterine hyperstimulation  Meconium stained liquor.  Precipitate delivery  Rupture of unscarre uterus.  Post partum bleeding.
  29. 29. SURGICAL METHODS  ARM/amniotomy  Sweeping of membranes  Ballon dilatation of cervix
  30. 30. ARM
  31. 31.  Mechanism of onset of labor :  Streching of cervix  Separation of membranes  Reduction of amniotic fluid volume.  Used alone amniotomy is associated with unpredictable and sometimes long intervals before delivery.  Amniotomy with oxyticin-shorter delivery intervals (ACOG 1999)
  32. 32.  Advantages :  High success rate Chance to observe the amniotic fluid for blood or meconium. Access to use fetal scalp electrode/intrauterine pressure catheter/fetal scalp blood sampling.
  33. 33.  Complications :  Prolapse of umbilical cord.  Chorioamnionitis.  APH Vasa previa.
  34. 34. IMMEDIATE BENEFICIAL EFFECTS OF ARM :  Lowering of BP in pre-eclampsia-eclampsia.  Relief of maternal distress in hydramnios.  Control of bleeding in APH.  Relief of tension in abruptio placentae and initiation of labor.
  35. 35. CONTRAINDICATIONS OF ARM  IUFD  Maternal AIDS  Genital active herpes infection
  36. 36. COMPLICATIONS OF ARM : Chance of umbilical cord prolapse Chorioamnionitis Accidental injury to the placenta,cervix or uterus,fetal parts or vasa previa. Liquor amnii embolism.
  37. 37. Sweeping of membranes  By inserting index finger through the internal OS as far as possible and roatating twice through 360 degree to separate the membrane from lower segment
  38. 38. SWEEPING OF MEMBRANES  When performed as a routine policy at 38-40 wks of gestation  Reduces the incidence of post-term pregnsncies one in eight casees  Reduces the incidence of other methods of induction of labour.  Not increases risk of maternal or fetal infection, chorioamnionitis ……….cochrane review
  39. 39. COMBINED METHOD The combined medical and surgical methods are commonly used to increase the efficacy of induction by reducing the induction-delivery interval.
  40. 40. Mechaniccal balloon dilatation
  41. 41. FACTORS FOR SUCCESSFUL INDUCTION OF LABOUR  Parity  Period of gestation  Preinduction score  Sensitivity of uterus :positive oxytocin sensitivity test is favourable for IOL.  Cervical ripening  Presence of fetal fibronectinin vaginal swab ( >50ng/ml)
  42. 42. INDUCTION OF LABOUR IN SPECIAL SITUATIONS
  43. 43. Failed induction  It is define when cervix failed to dilate 3-4 cm in 24 hours of induction. what to do now??????.... option to wait– if no PROM and postponement is not harmful for fetus as well as mother . review the case if there is urgency caesarean section to be done.
  44. 44. Risks of induction  Failure of induction  Prematurity  Abnormal uterine action  Fetal hypoxia  Amniotic fluid embolism
  45. 45. RESULTS OF INDUCTION  Proximity to term  Condition of the cervix  Method of induction  Station of presenting part  Amount of liquor drained
  46. 46. AUGMENTATION OF LABOUR  Introduced by O’Driscoll & his colleagues in 1968  Term ‘ACTIVE’ refers to the active involvement of the consultant-obstetrician in the management of primigravid labour.
  47. 47. When to augment ?  Dilatation does not increase @ 1cm/hr. HOW AUGMENTATION IS DONE? A standard concentration of 10u of oxytocin is used in all circumstances. Rate of infusion begins @ 10drps and increases by 10 drps at interval of 15 mins to a maximum of 60 drops.
  48. 48. Conditions to be fulfilled before augmentation  Mothers must be nulliparous.  Vertex presentation.  Fetus must be single.  Memranes must be ruptured.  No evidence of fetal distress must be seen.  The progress of labour charted on a partograph.  Every mother not close to an easy vaginal delivery after 12hrs to be delivered by cesarean section.
  49. 49.  AIM:To expedite delivery within 12hrs without increasing maternal morbidity and perinatal hazards.  Objectives:  Early detection of any delay in labour.  Diagnose its cause.  Initiate management.
  50. 50. COMPONENTS OF ACTIVE MANAGEMENT OF LABOUR  Prenatal education.  Admission to LR only after the diagnosis of labour.  Partographic monitoring of labour.  ARM with confirmation of labour.  Oxytocin augmentaion if cervical dilatation <1cm/hr.  Delivery completed within 12hrs of admission.  Fetal monitoring
  51. 51. Advantages :  Less chance of dysfunctional labour.  Shortens the duration of labour.  Fetal hypoxia can be detected early.  Low incidence of caesarean birth  Less analgesia.  Less maternal anxiety.
  52. 52. LIMITATION  Employed only in selected cases and in selected centres where intensive intrapartum monitoring by trained personnel is possible.

Notas

  • Calder modification 1974 is effecement of cervix with length of cervix
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