2. DefinitionsDefinitions
IOL: “Iatrogenic stimulation of uterineIOL: “Iatrogenic stimulation of uterine
contractions to accomplish delivery prior to thecontractions to accomplish delivery prior to the
spontaneous onset of labour”spontaneous onset of labour”
Cervical priming: Interventions designed toCervical priming: Interventions designed to
improve the Bishop score without necessarilyimprove the Bishop score without necessarily
inducing labourinducing labour
3. PrevalencePrevalence
USA: frequency has increased from 9.5%USA: frequency has increased from 9.5%
to 22.5% over 16 yearsto 22.5% over 16 years
Due to availability of better cervicalDue to availability of better cervical
ripening agents, more relaxed attitudesripening agents, more relaxed attitudes
towards marginal indications fortowards marginal indications for
inductioninduction
14. Significance of Bishop scoreSignificance of Bishop score
If Bishop score >5 chance of vaginalIf Bishop score >5 chance of vaginal
delivery after IOL same as afterdelivery after IOL same as after
spontaneous onset of labourspontaneous onset of labour
16. Other Predictors of Successful IOLOther Predictors of Successful IOL
MultiparityMultiparity
Tall stature ( > 5 ft 5” or 165 cm)Tall stature ( > 5 ft 5” or 165 cm)
Normal BMINormal BMI
Increasing GAIncreasing GA
EFW < 3500 gEFW < 3500 g
19. Membrane StrippingMembrane Stripping
Finger through cervical os, to detach membranesFinger through cervical os, to detach membranes
from LUSfrom LUS
Usually from 39 weeks onwardsUsually from 39 weeks onwards
Can be repeated safelyCan be repeated safely
Reduced risk of going beyond 41 (RR 0.59)Reduced risk of going beyond 41 (RR 0.59)
Reduced frequency of formal IOL (NNT =8)Reduced frequency of formal IOL (NNT =8)
May cause slight PV bleeding and crampsMay cause slight PV bleeding and cramps
20. Mechanical MethodsMechanical Methods
Required for low Bishop scoresRequired for low Bishop scores
Ideal when PG’s relatively contraindicatedIdeal when PG’s relatively contraindicated
Foley’s catheterFoley’s catheter
ATAD catheterATAD catheter
LaminariaLaminaria
21.
22.
23.
24.
25. AmniotomyAmniotomy
Usually when cx is partially dilatedUsually when cx is partially dilated
Usually combined with oxytocinUsually combined with oxytocin
Colour of amniotic fluid should beColour of amniotic fluid should be
notednoted
26.
27. Risks of AmniotomyRisks of Amniotomy
Fetal hemorrhage if vasa previaFetal hemorrhage if vasa previa
Cord prolapse, esp with high headCord prolapse, esp with high head
InfectionInfection
28.
29. OxytocinOxytocin
Almost always after amniotomyAlmost always after amniotomy
Given i.v. by infusion pump because of short half-lifeGiven i.v. by infusion pump because of short half-life
May take up to 40 mins to reach steady-stateMay take up to 40 mins to reach steady-state
concentrationsconcentrations
May be stopped once active phase of labour establishedMay be stopped once active phase of labour established
Continuous CTG monitoring requiredContinuous CTG monitoring required
30. Oxytocin regimesOxytocin regimes
Low-dose: less likely to cause hyperstimulationLow-dose: less likely to cause hyperstimulation
High dose: short incremental time intervals, noHigh dose: short incremental time intervals, no
more than 40 iu/minmore than 40 iu/min
Pulsatile regime: boluses at 8-10 min intervals,Pulsatile regime: boluses at 8-10 min intervals,
reduced total overall dose of of oxytocinreduced total overall dose of of oxytocin
31. Risks of OxytocinRisks of Oxytocin
Hyperstimulation / tachysystoleHyperstimulation / tachysystole
Uterine ruptureUterine rupture
High dose: water intoxicationHigh dose: water intoxication
Increased risk of PPHIncreased risk of PPH
32.
33.
34. ProstaglandinsProstaglandins
Required for low Bishop scoresRequired for low Bishop scores
PGE2 gel or pessariesPGE2 gel or pessaries
Slow-release systemsSlow-release systems
MisoprostolMisoprostol
35. Prostanoids in Clinical UseProstanoids in Clinical Use
Dinoprostone (PGE2)Dinoprostone (PGE2)
Dinoprost (PGF2-alpha)Dinoprost (PGF2-alpha)
Gemeprost: “cervagem”, analogue of PG E1,Gemeprost: “cervagem”, analogue of PG E1,
for TOPsfor TOPs
Carboprost (analogue of PGF2-alpha)Carboprost (analogue of PGF2-alpha)
Misoprostol (stable PGE2 analogue)Misoprostol (stable PGE2 analogue)
36.
37. Side Effects of ProstaglandinsSide Effects of Prostaglandins
38. SE’s of ProstaglandinsSE’s of Prostaglandins
HyperstimulationHyperstimulation
FeverFever
Allergic reactionsAllergic reactions
Exacerbation of asthmaExacerbation of asthma
42. Patient’s consent for IOLPatient’s consent for IOL
Indication to be explainedIndication to be explained
Failure rate and need for C/SFailure rate and need for C/S
Possible delay in starting IOLPossible delay in starting IOL
Risks to be explained: cord prolapse, fetalRisks to be explained: cord prolapse, fetal
distress, PPHdistress, PPH
Alternatives to inductionAlternatives to induction
Patient info. sheetPatient info. sheet