SlideShare una empresa de Scribd logo
1 de 76
Descargar para leer sin conexión
Dr. N. SRAVANTHI
      Dr. RENUKA
 Induction of labor – Implies stimulation of contractions
  before the spontaneous onset of labor, with or without
  membranes.

 Augmentation refers to stimulation of spontaneous that
  are considered to be inadequate because of failed cervical
  dilatation and fetal descent
Evaluation before induction of labour
           MATERNAL                                     FETAL
1.   Confirm indication for induction     1.   Confirm gestational age
2.   Review contraindications to labor    2.   Assess need to document fetal
     and/or vaginal delivery                   lung maturity status

3.   Perform clinical pelvimetry to       3.   Estimate fetal weight (either by
     assess pelvic shape and adequacy          clinical or ultrasound

     of bony pelvis
                                               examination)
                                          4.   Determine fetal presentation and
4.   Assess cervical condition (assign
                                               lie
     Bishop score)
                                          5.   Confirm fetal well-being
5.   Review risks, benefits and
     alternatives of induction of labor
     with patient
WHO RECOMMENDATIONS FOR INDUCTION OF
                  LABOUR

 Induction of labour should be performed only when there is a clear
    medical indication for it and the expected benefits outweigh its
    potential harms.


    In applying the recommendations, consideration must be given to
    the actual condition, wishes and preferences of each woman, with
    emphasis being placed on cervical status, the specific method of
    induction of labour and associated conditions such as parity and
    rupture of membranes.
 Induction of labour should be performed with caution since the
  procedure carries the risk of uterine hyperstimulation and
  rupture and fetal distress.



 Wherever induction of labour is carried out, facilities should be
  available for assessing maternal and fetal well-being
 Women receiving oxytocin, misoprostol or other prostaglandins
  should never be left unattended



 Failed induction of labour does not necessarily indicate
  caesarean section



 Wherever possible, induction of labour should be carried out in
  facilities where cesarean section can be performed
Indications

 Indicated when benefits to mother or fetus outweighs
  those of continuing the pregnancy
ACCEPTED ABSOLUTE INDICATIONS



 Hypertensive disorders             Fetal compromise
    Pre-eclampsia/eclampsia            Fetal growth restriction

 Maternal medical conditions           Isoimmunization

    Diabetes mellitus                  Non-reassuring antepartum

    Renal disease                       fetal testing

    Chronic pulmonary disease          Oligohydramnios

 Pre- labor rupture of membranes   • Fetal demise

 Chorioamnionitis                   Prolonged pregnancy(>42weeks)
RELATIVE INDICATIONS

 Hypertensive disorders             Fetal anomalies requiring
    Chronic hypertension             specialized neonatal care
 Maternal medical condition
                                     Logistic factors
    Systemic lupus erythematosus
                                         Risk of rapid labor
    Gestational diabetes
                                         Distance from hospital
    Hypercoagulable disorders
                                         Psychosocial indications
    Cholestasis of pregnancy
                                         Advanced cervical dilatation
 Polyhydramnios
                                     Previous still birth

                                     Post term pregnancy(>41weeks)
CONTRAINDICATIONS


 ABSOLUTE                               RELATIVE
   Prior classic uterine incision or      Cervical carcinoma

    transfundal uterine surgery            Funic presentation

   Active genital herpes infection        Malpresentation (breech)

   Placenta or vasa previa

   Umbilical cord prolapse

   Transverse or oblique fetal lie

   Absolute cephalopelvic
    disproportion (as in women with
    pelvic deformities)
RELATIVE INDICATIONS

 Hypertensive disorders             Fetal anomalies requiring
    Chronic hypertension             specialized neonatal care
 Maternal medical condition
                                     Logistic factors
    Systemic lupus erythematosus
                                         Risk of rapid labor
    Gestational diabetes
                                         Distance from hospital
    Hypercoagulable disorders
                                         Psychosocial indications
    Cholestasis of pregnancy
                                         Advanced cervical dilatation
 Polyhydramnios
                                     Previous still birth

                                     Post term pregnancy(>41weeks)
CONTRAINDICATIONS


 ABSOLUTE                               RELATIVE
   Prior classic uterine incision or      Cervical carcinoma

    transfundal uterine surgery            Funic presentation

   Active genital herpes infection        Malpresentation (breech)

   Placenta or vasa previa

   Umbilical cord prolapse

   Transverse or oblique fetal lie

   Absolute cephalopelvic
    disproportion (as in women with
    pelvic deformities)
Risks
       CESAREAN DELIVERY
         especially increased in nulliparas
         two- to threefold risks
         rates are inversely related with favorability of the cervix at induction,
          that is, the Bishop score.
       CHORIOAMNIONITIS
       UTERINE ATONY
         Postpartum atony and hemorrhage are more common in women
          undergoing induction or augmentation
         Intractable atony was the indication for a third of all cesarean
          hysterectomies
Cervical ripening and labour induction
   Cervical ripening : A prelude to the onset of labour whereby the cervix
    becomes soft and compliant.

      This allows its shape to change from being long and closed, to being

       thinned out (effaced) and starting to open (dilate).

      It either occurs naturally or as a result of physical or pharmacological

       interventions



                                                                     NICE 2008
Smooth muscle

           Cellular

                             Fibroblast


                          Collagen I (70%)
Cervix                      Collagen III
                               (30%)


                              Elastin

         Extra cellular

                           Proteoglycans



                              Decorin
MECHANISM INVOLVED IN CERVICAL RIPENING

 Cervix is a complex and heterogeneous organ, that undergoes
  extensive changes throughout gestation and parturition.
 Chronic process, which begins within the first trimester of pregnancy
  and progressively proceeds until term
 Softens, dilates and effaces the cervix

 This remodeling process is extremely complex and involves

    properly timed biochemical cascades,

    interaction between cellular and extra cellular components, and

    infiltration by inflammatory cells.
Hyperplasia of cellular components in early gestation




    physiologic cell death, in advanced pregnancy




Up gradation of                      -Invasion by neutrophils
                                     and macrophages
    Decorin
                                     -Nitric oxide – regulates
                                     MMPs and releases PGs.


              COLLAGEN REMODELLING
Enzymatic
            degradation




Increased   CERVICAL      Hormonal
 decorin    RIPENING      influences




             Increased
            Hyaluronic
               acid
Extra-cellular changes

Dispersion and Disorganization of Collagen

 Collagenases, Proteases and Elastases (produced by fibroblast and
  PMN)

 MMP 1 and 8 – source: stromal cells and neutrophils

 Proteoglycans e.g. Decorin

 Inflammatory cells--- increase in degradative enzymes

 Hyaluronic acid (GAG)- increase water content
Remodeling of cervix
      Degradative
                                   Inhibitors
       enzymes

-Collagenases, MMP 1 &
                             - Tissue inhibitors of
8, elastases
                             MMPs, alpha 2 macroglobulin
-Source – stromal cells,
neutrophils and
macrophages
-Activity enhanced by
cytokines like IL-1B, IL-8
AFFECTING ELEMENTS

 CYTOKINES –
 e.g. interleukin-1β            enhance the activity of collagenases
 and interleukin 8,
  Platelet activating factor,
  monocyte chemotactic factor-1


 HORMONAL INFLUENCES –
  Estrogens                      increases collagenases
  Progesterones                  inhibit collagenases, hyaluronic acid & IL-8


 NITRIC OXIDE                   stimulates leukocytes infiltration
                                 induce prostaglandin secretion
PREINDUCTION CERVICAL RIPENING

 The condition of the cervix influences the success of inducing labor.


 A cervical examination is essential before labor induction is initiated.


 In 1964, Bishop developed a scoring system to evaluate multiparous women
  for elective induction at term.


 The scoring system is based on properties of the cervix that may be assessed
  clinically at the time of pelvic examination such as
  dilatation, effacement, consistency, and position as well as the station of the
  fetal presenting part
“Bishop Scoring System” Used for Assessment of Inducibility


           DILATATION     EFFACEMENT    STATION       CERVICAL        CERVICAL
SCORE
                                                                      POSITION
           (cm)              (%)        (–3 to +2)   CONSISTENCY




  0          CLOSED         0 - 30         -3           FIRM       POSTERIOR




  1               1-2       40 - 50        -2         MEDIUM            MID

                                                                      POSITION


  2               3-4       60 - 70        -1           SOFT       ANTERIOR




  3               >/= 5     >/=80        +1, +2           -              -
 Bishop score is now widely used to predict the success of
  labor induction.

 The higher the Bishop score, the more “ripe” or
  “favorable” the cervix is for labor induction.

 A low Bishop score, usually considered less than or equal
  to 6, is “unripened” or “unfavorable” and will benefit from
  cervical ripening
Other predictors

                             Maternal
                              factors




           Height,                                      Fetal
Parity                 Age         Fetal factors
         weight, BMI                                 fibronectin     Insulin like
                                                                       growth
                                                                       Factor
                                Fetal weight                           binding
                                  >3.5kg.                              protein

                                Gestational
                                   age



                                                   fFN in cervical
                                                   secretions:
                                                   Not more
                                                   predictive than
                                                   Bishop’s score
Other scoring systems

 Field’s system

 Burnett modification of bishops score

 Weighted Bishop’s score by Friedman

 Pelvic score by Lange




        However, despite this none of the modifications have shown
                          improved predictability.
ULTRASOUND IMAGING

 Adv. Over digital examination: more objective and assesses the entire length of
  the cervix.



 Both bishop’s score and TVUS predicted successful induction.

 Bishop’s score predicted delivery within 24 hrs. and TVUS within 48 hrs.



 Cervical length related to latent phase of labor, funneling related to both latent
  and active phase of labor. (Am. J of Obs. Gynecol. 1994;171.)



 Some other studies have not found any USG parameter predictive, and consider
  bishop’s score to be superior.
METHODS OF CERVICAL RIPENING

 Unfortunately, women too frequently have an indication for induction but
  with an unfavorable cervix.



 As favorability or Bishop score decreases, there is an increasingly
  unsuccessful induction rate.



 Methods used for cervical ripening include pharmacological preparations
  and various forms of mechanical cervical distension.
Non pharmacologic means of cervical ripening
1.   Herbal supplements: evening primrose oil, blue and black cohosh,
     raspberry leaves.

2.   Breast stimulation: causes oxytocin release.

       Adv–non invasive, inexpensive, simple

       Disadv. – causes FHR abnormalities.

3.   Castor oil, hot baths, enemas

4.   Miscellaneous - acupuncture , sexual intercourse
4.       (HYGROSCOPIC DILATORS):
            Natural osmotic dilators –
               Laminaria japonicum
               Laminaria digitata
               Isapgol
            Synthetic osmotic dilators
               Lamicel
               Dilapan


            They absorb endocervical and local tissue fluids, causing the device to
             expand within the endocervix and provide mechanical pressure.
            cause mechanical dilation and release of prostaglandins.
            Swell up to 4 – 5 times.
            Most rapidly in first 4-6 hours but continue to swell up to 24 hours later.
ADVANTAGES                        DISADVANTAGES

                                  Skill needed for proper placement in
 Cheap
                                    internal os.
 Outpatient placement
                                  Delay in obtaining maximum effect.
 Easy for placement
                                  Patient discomfort.
 No need for fetal monitoring
                                  Inability of tents to be molded without
 Rapid improvement of              compromising mechanical integrity.
  cervical status                 Lack of manufacturer specifications for
                                    natural dilators.
                                  Potential for incomplete sterility. ETO
                                    gas does not eradicate spores in the
                                    interstices of the sea weed stem
5.        Membrane stripping:
           Release of endogenous PGs. and mechanical dilation.




           results in < labor inductions

               < post dated pregnancies

               > spontaneous onset of labor

     - inexpensive, safe, efficacious in promoting labor over several days
6.    Balloon devices :
 Single / Double balloon
 First described in 1967

 Safe
 Cheap


     ADVANTAGES:
     The combination of balloon catheter plus oxytocin is recommended as an
      alternative method when prostaglandins (including misoprostol) are not
      available or are contraindicated (previous caesarean)
     May be useful for outpatient ripening.
     Can be inserted in presence or absence of membranes.
     Associated with favorable Bishop scores and no additional side effects.
Single Balloon Devices

 A fluid filled balloon is inserted inside the cervix.

 A Foley catheter (26 Fr) or specifically designed balloon devices can be
  used
 Mechanism of action:

 The mechanism by which Foley' s catheter improves the cervical state is by
  its mechanical action.
 It strips the fetal membranes from the lower uterine segment, causing
  rupture of lysosomes , release of phospholipase A and formation of
  prostaglandins.
Technique of Balloon Placement
1.   After sterilization and draping, the catheter is introduced into the endocervix
     either by direct visualization or blindly by sliding it over fingers through the
     endocervix into the potential space between the amniotic membrane & the
     lower uterine segment.


2.   The balloon is inflated with 30 to 50 mL of normal saline and is retracted so
     that it rests on the internal os.


3.   Constant pressure may be applied over the catheter. e.g. a bag filled with 1 L
     of fluid may be attached to the catheter end / An intermittent pressure may
     also be exerted on the catheter end 2 -4 times per hour.
4.   Catheter is removed at the time of rupture of membranes or may

     be expelled spontaneously which indicate a cervical dilatation of

     3 - 4 Centimeters.
Cervical ripening and labour induction
PHARMACOLOGICAL TECHNIQUES

 Prostaglandins
    PGE2 : Dinoprostone

    PGE1 : Misoprostol

 Oxytocin
 Others
    Estrogen

    Relaxin

    Hyaluronic acid

    Progesterone receptor antagonist
PROSTAGLANDINS


       The chemical precursor is arachidonic acid

       PGs are endogenous compounds found in the
        myometrium, deciduas, and fetal membranes during pregnancy.

       Cervical production of PGE2, PGI2, PGF increases at term.

 Modulate fibroblast activity - Increase hyaluronic acid production

 Acting as chemotactic agents, Inflammatory cells further release
  degradative enzymes, causing cervical ripening.
 Prostaglandins administration results in dissolution of collagen bundles and
    an increase in sub mucosal water content of the cervix.

          These changes in cervical connective tissue at term are similar to

           those observed in early labor.




       Unlike oxytocin, response to prostaglandins does not change throughout

        gestation.
Preparations

      PGE2 : Dinoprostone                         PGE1 : Misoprostol

 Vaginal gel : Prepidil, CerviprimeTM     MisoprostTM

 Removable tampon : CervidilTM            CytotecTM

 Vaginal pessary : Prostin E2TM
Prostaglandin E2: (Dinoprostone)


                    Increase in elastase, glycosaminoglycan, dermatan
                      sulfate, and hyaluronic acid levels in the cervix.
                     A relaxation of cervical smooth muscle facilitates
                                           dilation.

Alter the extracellular ground substance
              of the cervix                      Increase in intracellular calcium levels,
increases the activity of collagenase in           ~ contraction of myometrial muscle
               the cervix.



                               Cervical Ripening
 PROSTAGLANDIN E2 (DINOPROSTONE):

   CERVIPRIME GEL -      is commonly used for cervical ripening .

   is available in a 2.5-mL syringe for an intracervical application of 0.5 mg of

    dinoprostone.



   With the woman supine, the tip of a pre-filled syringe is placed intracervically,

    and the gel is deposited just below the internal cervical os.



   After application she remains reclined for at least 30 minutes. Doses may be

    repeated every 6 hours, with a maximum of three doses recommended in 24
    hours.
Prepidil Intracervical placement
 Dinoprostone should only be administered at hospital.



 Continuous Uterine activity & FHR monitoring.



 If optimal response is not achieved by 6 hours, another dose can be
  administered. The maximum allowed dose is 3 doses be administered per
  24 hours.


 Oxytocin should not be initiated until 6 to12 hours after the last dose
  because of the potential for uterine hyperstimulation with concurrent
  oxytocin and prostaglandin administration.
Cervidil placed in posterior vaginal fornix
Cervical ripening and labour induction
 Vaginal insert containing 10 mg of dinoprostone in a timed-release
  formulation. The vaginal insert administers the medication at 0.3 mg/h

  and may be left in place for up to 12 hours.



 ADVANTAGE: the insert may be removed with the onset of active
  labor, rupture of membranes, or with the development of uterine

  hyperstimulation.
Vaginal pessary : Prostin E2TM
COCHRANE REVIEW
                 Vaginal Prostaglandin E2 versus placebo/no treatment
                                (37 trials, 6511 women)
                                                                           vaginal No Rx /   risk 95%
                                                                           PGE2    Placebo   ratio confidence
                                                                                             (RR) interval (CI)

risk of the cervix remaining unchanged/            5 trials, 467 women     21.6%   40.3%,    0.46   0.35 to 0.62
unfavourable after
12 to 24 hours

reduction in failure to achieve vaginal delivery   2 trials, 384 women     18.1%   98.9%,    0.19   0.14 to 0.25
within 24 hours


use of oxytocin augmentation                       12 trials, 1321 women   35.1%   43.8%     0.83   0.73 to 0.94



Uterine hyperstimulation with FHR changes          14 trials, 1259 women   4.4%    0.49%,    4.14   1.93 to 8.90


Hyperstimulation without FHR changes               13 trials, 3636 Women   1.4%    0.4%      2.48   1.17 to 5.26
COCHRANE REVIEW
Vehicle comparisons
 PGE2 gel is as efficacious as PGE2 tablets.
 PGE2 gel does reduce the need for oxytocin augmentation,
 Gel was associated with less uterine hyperstimulation.
 Sustained release pessaries in comparison with gel
     have not been shown to significantly reduce caesarean section rates

     have not been shown to improve adverse neonatal or maternal outcomes.

     There is reduction in the use of oxytocin augmentation and the reduction in
      instrumental delivery rates.
     The frequency of vaginal examinations is reduced when using sustained
      release pessaries.
 INTRACERVICAL PGE2: although this route of administration is
  effective, it offers no advantages when compared to other methods of
  administration, namely the vaginal route.



 Intracervical prostaglandins are effective compared to placebo, but
  appear inferior when compared to intravaginal prostaglandins.
PGE2 can cause
     Uterine hyperstimulation, Fetal distress and Cesarean section.


Uterine hyperstimulation :
- More common with intra vaginal application.

- 1-5%, similar to low dose oxytocin <=4mu/ml.

 - Begins within 1 hr
 - Removal, irrigation of Cervix, vagina : not helpful
 - Rapidly reversed with terbutaline or removal of insert.
 - Hence fetal heart rate monitoring is needed for 2 hours following single
  dose and longer if contractions persist after that.
 A retrospective study of case notes (n = 3099) investigated women who
  underwent induction with PGE2 (vaginal tablet, gel and intracervical gel).
 Uterine hyperstimulation (defined as contraction frequency being more
  than five in 10 minutes or contractions exceeding 2 minutes in duration)
  occurred in 5.8% patients, of which 31.5% were associated with FHR
  abnormalities.
 Administration of tocolytic treatment with β2-adrenergic drugs
    (hexoprenaline at 0.3 micrograms/minute
                                      OR
    single dose of terbutaline 250 micrograms intravenously or
     subcutaneously)

    successful in normalising uterine contractions and reversing any FHR
     abnormality in (98.3%).
 Improvement usually began within 5 minutes regardless of
  hyperstimulation patterns.
                                                                NICE 2008
Systemic effect
    Nausea
    Vomiting
    Diarrhea
    Caution in
      Glaucoma

      hepatic and renal disease

      Asthma
Safety in induction for VBAC


 Concern is with uterine rupture caused by uterotonic effects.

 In largest cohort study of 5022 patients willing for VBAC

    453 patients received intra vaginal gel

    The rates of rupture were, 1.3% with PGE2 and 0.7 without its

     use.

    ~ not statistically significant.

                                 Am J of Perinatol. 1997;14:157-160
Two studies have expanded on the differences in adverse outcomes between

   prostaglandin and non-prostaglandin (such as intracervical Foley catheter) based

   induction regimens. In the NICHD study, prostaglandin induction compared with

   non-prostaglandin induction incurred a non-significantly higher risk of uterine

   rupture (140/10,000 versus 89/10,000; P = 0.22).

In an analysis of nationally collected data from Scotland, prostaglandin induction

   compared with non-prostaglandin induction was associated with a statistically

   significantly higher uterine rupture risk (87/10,000 versus 29/10,000) and a higher

   risk of perinatal death from uterine rupture(11.2/10,000 versus 4.5/10,000).

This compares with 6/10,000 risk of perinatal death in women with an unscarred uterus

   induced by prostaglandin identified by a Cochrane review.

RCOG
 Given these risks and the absence of direct robust
 evidence, it is important not to exceed the safe
 recommended limit for prostaglandin priming in
 women with prior caesarean birth.

                                          RCOG 2007
Use with Premature Rupture of Membranes at term.

 It has not been shown to decrease neonatal infections when compared with
  expectant management.

 It could decrease time to delivery, but this can be achieved equally with
  optimum oxytocin dosing.

 More important intervention to decrease maternal infectious morbidity is
  decreasing number of PV examinations.
Misoprostol
 Dosing

    25 mcg

    50 mcg



 Very cheap

 Easy to store
Pharmacokinetics
 Route of administration: Oral, vaginal and sublingual route for induction.

 Bioavailability: Extensively absorbed from the GIT

 Metabolism: De-esterified to prostaglandin F analogs

 Half life: 20–40 minutes

 Excretion: Mainly renal 80%, remainder is fecal: 15%

 maximum plasma conc. with 400µg miso.
    - 34 mins. after oral , 80 mins. After vaginal
     - rapid onset and greater peak action with oral miso.
     - longer action with vaginal miso.
 Clinical trials indicate that the safe optimal dose and dosing

  interval is 25 mcg intravaginally every 4-6 hours.

                                                       ACOG 1999

 A maximum of 6 doses was suggested.
VAGINAL MISOPROSTOL (comparison)

Vaginal misoprostol versus    Trials/ No. of women                     Outcomes



    Placebo/ Expectant                 5 trials/                  Reduced risk of not
       management                 769 participants              achieving vaginal birth
                                                              within 24 hrs of induction

   Intravenous oxytocin      •9 trials/1200 participants        •Reduced risk of not
                                                               achieving vaginal birth
                             •25trials/3074 participants      •Fewer cesarean sections
                             •13 trials/1906 participants    •Fewer infants with apgars
                                                                  below 7 at 5mins

   Other prostaglandins                    -                •a reduced risk of vaginal birth not
                                                            achieved within 24 hours
                                                            •fewer caesarean sections
                                                            •increased risk of uterine
                                                            hyperstimulation with fetal heart rate
                                                            changes
 Compared with higher doses of vaginal misoprostol, lower doses (25 μg, 6-
  hourly) were associated with a reduced risk of uterine hyperstimulation
  with fetal heart rate changes (16 trials, 2540 participants, RR 0.51, 95% CI
  0.37–0.69).



 The risk of vaginal birth not being achieved within 24 hours was similar
  with both higher and lower doses
ORAL MISOPROSTOL
 Oral misoprostol versus       Trials/ No. of women                 Outcomes


    Placebo/ Expectant          •1 trials/96 participants      •Reduced risk of not
                                                              achieving vaginal birth
       management                                            within 24 hrs of induction
                               •6 trials/629 participants
                                                             •Reduced cesarean births
   Intravenous oxytocin        •8 trials/1026 participants   •Similar w. r, t. the risk of
                                                                 priority outcomes


Intracervical prostaglandins                                    •More effective in
                                                              achieving vaginal birth
                                                                   within 24 hrs



  Vaginal prostaglandins                                      •Reduction in cesarean
                                                                      rates
 Lower doses of oral misoprostol (up to 50 μg) were
  associated with similar outcomes compared with higher
  doses (100 μg)
Oral misoprostol versus vaginal misoprostol


 Similar with regard to priority outcomes except

 Oral misoprostol was associated with a lower risk of Apgar score being

  less than seven at 5 minutes of life (14 trials, 3270 participants, 94

  events, RR 0.65, 95% CI 0.44–0.97).
 Vaginal misoprostol versus sublingual/ buccal misoprostol :
  similar with regard to all the priority outcomes



 Oral versus sublingual/buccal misoprostol: Data are limited
Recommendations
1.   Oral misoprostol (25 μg, 2-hourly) is recommended for induction of
     labour.

     (Moderate-quality evidence. Strong recommendation.)

2.   Vaginal low-dose misoprostol (25 μg, 6-hourly) is recommended for
     induction of labour.

     (Moderate-quality evidence. Weak recommendation.)

3.   Misoprostol is not recommended for women with previous caesarean
     section.

     (Low-quality evidence. Strong recommendation.)
Misoprostol vs Dinoprostone
 The mean time to vaginal delivery was significantly shorter in the
  misoprostol group (925.8 versus 1577.6 minutes), and
    the mean duration of the active length of labour was significantly shorter in
  the misoprostol group (353.7 versus 496.8 minutes)


 Less likely to require a repeated dose of prostaglandin for cervical priming and
  oxytocin for augmentation of labour.
 no difference in the rate of Caesarean section


 More hyperstimulation during labour in the misoprostol group

                                     Aust N Z J Obstet Gynaecol. 2001 May;41(2):145-52
Oxytocin for cervical ripening : comparison
Intravenous Oxytocin     Trials /                    Outcome
       versus           No women

Expectant management 25 trials;     Intravenous oxytocin reduced the failure to
                     6660 women     achieve vaginal delivery within 24 hours
                                    when compared with expectant management
                                    (8.4% versus 54%)

Vaginal PGE2           27 trials;   compared with vaginal PGE2, oxytocin was
                       4564 women   associated with more failures to achieve
                                    vaginal delivery within 24 hours
                                    (70% versus 21%)

Intracervical PGE2     14 trials;   Oxytocin was associated with increased
                       1331 women   unsuccessful vaginal deliveries
                                    within 24 hours when compared with
                                    intracervical PGE2
                                    (50.4% versus 34.6%)
                                    Increase in cesarean sections (19% versus
                                    13.7%)
CONCLUSION
Comparison of oxytocin with either intravaginal or intracervical PGE2 reveals
  that the prostaglandin agents probably increase the chances of achieving
  vaginal birth within 24 hours.



Oxytocin induction may increase the rate of interventions in labour.


                                                                   NICE 2008
Cervical ripening and labour induction
Cervical ripening and labour induction
Risks
       CESAREAN DELIVERY
         especially increased in nulliparas
         two- to threefold risks
         rates are inversely related with favorability of the cervix at induction,
          that is, the Bishop score.
       CHORIOAMNIONITIS
       UTERINE ATONY
         Postpartum atony and hemorrhage are more common in women
          undergoing induction or augmentation
         Intractable atony was the indication for a third of all cesarean
          hysterectomies

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

BAD OBTETRIC HISTORY
BAD OBTETRIC HISTORYBAD OBTETRIC HISTORY
BAD OBTETRIC HISTORY
 
Iufd by dr shabnam
Iufd by dr shabnamIufd by dr shabnam
Iufd by dr shabnam
 
Cardiac disease in pregnancy
Cardiac disease in pregnancyCardiac disease in pregnancy
Cardiac disease in pregnancy
 
Fetal distress
Fetal distressFetal distress
Fetal distress
 
Cervical ripening
Cervical ripeningCervical ripening
Cervical ripening
 
Cervical ripening and the bishop score
Cervical ripening and the bishop scoreCervical ripening and the bishop score
Cervical ripening and the bishop score
 
Molar pregnancy
Molar pregnancyMolar pregnancy
Molar pregnancy
 
Urinary tract infections during pregnancy
Urinary tract infections during pregnancyUrinary tract infections during pregnancy
Urinary tract infections during pregnancy
 
secondary postpartum hemorrhage
secondary postpartum hemorrhagesecondary postpartum hemorrhage
secondary postpartum hemorrhage
 
Intrauterine death
Intrauterine deathIntrauterine death
Intrauterine death
 
Heart disease in pregnancy
Heart disease in pregnancyHeart disease in pregnancy
Heart disease in pregnancy
 
Shoulder,face ,braw,,compound presention for undergraduate
Shoulder,face ,braw,,compound presention for undergraduateShoulder,face ,braw,,compound presention for undergraduate
Shoulder,face ,braw,,compound presention for undergraduate
 
Intrahepatic Cholestasis of Pregnancy (IHCP)
Intrahepatic Cholestasis of Pregnancy (IHCP)Intrahepatic Cholestasis of Pregnancy (IHCP)
Intrahepatic Cholestasis of Pregnancy (IHCP)
 
Abortion and post abortion care
Abortion and post abortion careAbortion and post abortion care
Abortion and post abortion care
 
Cervical incompetence
Cervical incompetenceCervical incompetence
Cervical incompetence
 
Molar pregnancy
Molar pregnancyMolar pregnancy
Molar pregnancy
 
Diabetes in Pregnancy
Diabetes in PregnancyDiabetes in Pregnancy
Diabetes in Pregnancy
 
Premature ovarian failure
Premature ovarian failurePremature ovarian failure
Premature ovarian failure
 
Prom
PromProm
Prom
 
management of placenta previa
management of placenta previamanagement of placenta previa
management of placenta previa
 

Similar a Cervical ripening and labour induction

Seminar induction of labour
Seminar   induction of labourSeminar   induction of labour
Seminar induction of laboureshna gupta
 
OBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptx
OBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptxOBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptx
OBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptxmagie12
 
Puerperium and lactation
Puerperium and lactationPuerperium and lactation
Puerperium and lactationAyesha Safi
 
OBG - 14.5.20 AN UNIT - 7 ABORTION.pptx
OBG - 14.5.20 AN UNIT - 7  ABORTION.pptxOBG - 14.5.20 AN UNIT - 7  ABORTION.pptx
OBG - 14.5.20 AN UNIT - 7 ABORTION.pptxBasitRamzan1
 
2. ECTOPIC & MOLAR PREGNANCY.pptx
2. ECTOPIC & MOLAR PREGNANCY.pptx2. ECTOPIC & MOLAR PREGNANCY.pptx
2. ECTOPIC & MOLAR PREGNANCY.pptxMaximilianTUNGARAZA
 
Pathophysiology of preterm labor
Pathophysiology of preterm laborPathophysiology of preterm labor
Pathophysiology of preterm laborDr Praman Kushwah
 
Haemorrhage in early pregnancy
Haemorrhage in early pregnancyHaemorrhage in early pregnancy
Haemorrhage in early pregnancydrmohitmathur
 
Post date and induction of labor
Post date and induction of laborPost date and induction of labor
Post date and induction of laborMohammad Ihmeidan
 
Obstetric hemorrhages of the 1st half of pregnancy.ppt
Obstetric hemorrhages of the 1st half of pregnancy.pptObstetric hemorrhages of the 1st half of pregnancy.ppt
Obstetric hemorrhages of the 1st half of pregnancy.pptTARUNKUMAR472866
 
Induction of labour
Induction of labourInduction of labour
Induction of labourPOOJA KUMAR
 
Induction, augmentation and trial of labor
Induction, augmentation and trial of laborInduction, augmentation and trial of labor
Induction, augmentation and trial of laborNisha Ghimire
 
Preterm delivery : Preterm labour and PPROM
Preterm delivery : Preterm labour and PPROM Preterm delivery : Preterm labour and PPROM
Preterm delivery : Preterm labour and PPROM Jwan AlSofi
 
Post term pregnancy
Post term pregnancyPost term pregnancy
Post term pregnancydrmcbansal
 
Preterm labour seminar
Preterm labour seminarPreterm labour seminar
Preterm labour seminarSneha Jadhav
 
Ectopic pregnancy.presentation slides pt
Ectopic pregnancy.presentation slides ptEctopic pregnancy.presentation slides pt
Ectopic pregnancy.presentation slides ptyakemichael
 
GYNAE bleeding in a early pregnancy.docx
GYNAE  bleeding in a early pregnancy.docxGYNAE  bleeding in a early pregnancy.docx
GYNAE bleeding in a early pregnancy.docxchristinetoywa
 

Similar a Cervical ripening and labour induction (20)

Seminar induction of labour
Seminar   induction of labourSeminar   induction of labour
Seminar induction of labour
 
OBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptx
OBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptxOBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptx
OBSTETRICS AND GYNAECOLOGICAL NURSING- HIGH RISK PREGNANCY ABORTION.pptx
 
Puerperium and lactation
Puerperium and lactationPuerperium and lactation
Puerperium and lactation
 
OBG - 14.5.20 AN UNIT - 7 ABORTION.pptx
OBG - 14.5.20 AN UNIT - 7  ABORTION.pptxOBG - 14.5.20 AN UNIT - 7  ABORTION.pptx
OBG - 14.5.20 AN UNIT - 7 ABORTION.pptx
 
2. ECTOPIC & MOLAR PREGNANCY.pptx
2. ECTOPIC & MOLAR PREGNANCY.pptx2. ECTOPIC & MOLAR PREGNANCY.pptx
2. ECTOPIC & MOLAR PREGNANCY.pptx
 
Pathophysiology of preterm labor
Pathophysiology of preterm laborPathophysiology of preterm labor
Pathophysiology of preterm labor
 
Lecture 22 Preterm Labor.pptx
Lecture 22 Preterm Labor.pptxLecture 22 Preterm Labor.pptx
Lecture 22 Preterm Labor.pptx
 
Haemorrhage in early pregnancy
Haemorrhage in early pregnancyHaemorrhage in early pregnancy
Haemorrhage in early pregnancy
 
Induction Lecture Fmdrl
Induction Lecture FmdrlInduction Lecture Fmdrl
Induction Lecture Fmdrl
 
Post date and induction of labor
Post date and induction of laborPost date and induction of labor
Post date and induction of labor
 
Preterm labor & PROM
Preterm labor & PROMPreterm labor & PROM
Preterm labor & PROM
 
Obstetric hemorrhages of the 1st half of pregnancy.ppt
Obstetric hemorrhages of the 1st half of pregnancy.pptObstetric hemorrhages of the 1st half of pregnancy.ppt
Obstetric hemorrhages of the 1st half of pregnancy.ppt
 
Induction of labour
Induction of labourInduction of labour
Induction of labour
 
Induction, augmentation and trial of labor
Induction, augmentation and trial of laborInduction, augmentation and trial of labor
Induction, augmentation and trial of labor
 
Induction OF labor
Induction OF laborInduction OF labor
Induction OF labor
 
Preterm delivery : Preterm labour and PPROM
Preterm delivery : Preterm labour and PPROM Preterm delivery : Preterm labour and PPROM
Preterm delivery : Preterm labour and PPROM
 
Post term pregnancy
Post term pregnancyPost term pregnancy
Post term pregnancy
 
Preterm labour seminar
Preterm labour seminarPreterm labour seminar
Preterm labour seminar
 
Ectopic pregnancy.presentation slides pt
Ectopic pregnancy.presentation slides ptEctopic pregnancy.presentation slides pt
Ectopic pregnancy.presentation slides pt
 
GYNAE bleeding in a early pregnancy.docx
GYNAE  bleeding in a early pregnancy.docxGYNAE  bleeding in a early pregnancy.docx
GYNAE bleeding in a early pregnancy.docx
 

Más de Sravanthi Nuthalapati

Más de Sravanthi Nuthalapati (9)

Chemotherapy drugs in gynecological oncology
Chemotherapy drugs in gynecological oncologyChemotherapy drugs in gynecological oncology
Chemotherapy drugs in gynecological oncology
 
Epidemiology and molecular pathogenesis of gtn
Epidemiology and molecular pathogenesis of gtnEpidemiology and molecular pathogenesis of gtn
Epidemiology and molecular pathogenesis of gtn
 
Vulvar and vaginal cancer epidemiology and molecular pathogenesis
Vulvar and vaginal cancer epidemiology and molecular pathogenesisVulvar and vaginal cancer epidemiology and molecular pathogenesis
Vulvar and vaginal cancer epidemiology and molecular pathogenesis
 
Epidemiology of uterine cancer
Epidemiology of uterine cancerEpidemiology of uterine cancer
Epidemiology of uterine cancer
 
Management of vulvar carcinoma
Management of vulvar carcinomaManagement of vulvar carcinoma
Management of vulvar carcinoma
 
Benign ovarian tumours
Benign ovarian tumoursBenign ovarian tumours
Benign ovarian tumours
 
Leiomyomata uteri
Leiomyomata uteriLeiomyomata uteri
Leiomyomata uteri
 
tumor clinic
tumor clinictumor clinic
tumor clinic
 
Antepartum hemorrhage
Antepartum hemorrhageAntepartum hemorrhage
Antepartum hemorrhage
 

Último

Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 

Último (20)

Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 

Cervical ripening and labour induction

  • 1. Dr. N. SRAVANTHI Dr. RENUKA
  • 2.  Induction of labor – Implies stimulation of contractions before the spontaneous onset of labor, with or without membranes.  Augmentation refers to stimulation of spontaneous that are considered to be inadequate because of failed cervical dilatation and fetal descent
  • 3. Evaluation before induction of labour MATERNAL FETAL 1. Confirm indication for induction 1. Confirm gestational age 2. Review contraindications to labor 2. Assess need to document fetal and/or vaginal delivery lung maturity status 3. Perform clinical pelvimetry to 3. Estimate fetal weight (either by assess pelvic shape and adequacy clinical or ultrasound of bony pelvis examination) 4. Determine fetal presentation and 4. Assess cervical condition (assign lie Bishop score) 5. Confirm fetal well-being 5. Review risks, benefits and alternatives of induction of labor with patient
  • 4. WHO RECOMMENDATIONS FOR INDUCTION OF LABOUR  Induction of labour should be performed only when there is a clear medical indication for it and the expected benefits outweigh its potential harms.  In applying the recommendations, consideration must be given to the actual condition, wishes and preferences of each woman, with emphasis being placed on cervical status, the specific method of induction of labour and associated conditions such as parity and rupture of membranes.
  • 5.  Induction of labour should be performed with caution since the procedure carries the risk of uterine hyperstimulation and rupture and fetal distress.  Wherever induction of labour is carried out, facilities should be available for assessing maternal and fetal well-being
  • 6.  Women receiving oxytocin, misoprostol or other prostaglandins should never be left unattended  Failed induction of labour does not necessarily indicate caesarean section  Wherever possible, induction of labour should be carried out in facilities where cesarean section can be performed
  • 7. Indications  Indicated when benefits to mother or fetus outweighs those of continuing the pregnancy
  • 8. ACCEPTED ABSOLUTE INDICATIONS  Hypertensive disorders  Fetal compromise  Pre-eclampsia/eclampsia  Fetal growth restriction  Maternal medical conditions  Isoimmunization  Diabetes mellitus  Non-reassuring antepartum  Renal disease fetal testing  Chronic pulmonary disease  Oligohydramnios  Pre- labor rupture of membranes • Fetal demise  Chorioamnionitis  Prolonged pregnancy(>42weeks)
  • 9. RELATIVE INDICATIONS  Hypertensive disorders  Fetal anomalies requiring  Chronic hypertension specialized neonatal care  Maternal medical condition  Logistic factors  Systemic lupus erythematosus  Risk of rapid labor  Gestational diabetes  Distance from hospital  Hypercoagulable disorders  Psychosocial indications  Cholestasis of pregnancy  Advanced cervical dilatation  Polyhydramnios  Previous still birth  Post term pregnancy(>41weeks)
  • 10. CONTRAINDICATIONS  ABSOLUTE  RELATIVE  Prior classic uterine incision or  Cervical carcinoma transfundal uterine surgery  Funic presentation  Active genital herpes infection  Malpresentation (breech)  Placenta or vasa previa  Umbilical cord prolapse  Transverse or oblique fetal lie  Absolute cephalopelvic disproportion (as in women with pelvic deformities)
  • 11. RELATIVE INDICATIONS  Hypertensive disorders  Fetal anomalies requiring  Chronic hypertension specialized neonatal care  Maternal medical condition  Logistic factors  Systemic lupus erythematosus  Risk of rapid labor  Gestational diabetes  Distance from hospital  Hypercoagulable disorders  Psychosocial indications  Cholestasis of pregnancy  Advanced cervical dilatation  Polyhydramnios  Previous still birth  Post term pregnancy(>41weeks)
  • 12. CONTRAINDICATIONS  ABSOLUTE  RELATIVE  Prior classic uterine incision or  Cervical carcinoma transfundal uterine surgery  Funic presentation  Active genital herpes infection  Malpresentation (breech)  Placenta or vasa previa  Umbilical cord prolapse  Transverse or oblique fetal lie  Absolute cephalopelvic disproportion (as in women with pelvic deformities)
  • 13. Risks  CESAREAN DELIVERY  especially increased in nulliparas  two- to threefold risks  rates are inversely related with favorability of the cervix at induction, that is, the Bishop score.  CHORIOAMNIONITIS  UTERINE ATONY  Postpartum atony and hemorrhage are more common in women undergoing induction or augmentation  Intractable atony was the indication for a third of all cesarean hysterectomies
  • 15. Cervical ripening : A prelude to the onset of labour whereby the cervix becomes soft and compliant.  This allows its shape to change from being long and closed, to being thinned out (effaced) and starting to open (dilate).  It either occurs naturally or as a result of physical or pharmacological interventions NICE 2008
  • 16. Smooth muscle Cellular Fibroblast Collagen I (70%) Cervix Collagen III (30%) Elastin Extra cellular Proteoglycans Decorin
  • 17. MECHANISM INVOLVED IN CERVICAL RIPENING  Cervix is a complex and heterogeneous organ, that undergoes extensive changes throughout gestation and parturition.  Chronic process, which begins within the first trimester of pregnancy and progressively proceeds until term  Softens, dilates and effaces the cervix  This remodeling process is extremely complex and involves  properly timed biochemical cascades,  interaction between cellular and extra cellular components, and  infiltration by inflammatory cells.
  • 18. Hyperplasia of cellular components in early gestation physiologic cell death, in advanced pregnancy Up gradation of -Invasion by neutrophils and macrophages Decorin -Nitric oxide – regulates MMPs and releases PGs. COLLAGEN REMODELLING
  • 19. Enzymatic degradation Increased CERVICAL Hormonal decorin RIPENING influences Increased Hyaluronic acid
  • 20. Extra-cellular changes Dispersion and Disorganization of Collagen  Collagenases, Proteases and Elastases (produced by fibroblast and PMN)  MMP 1 and 8 – source: stromal cells and neutrophils  Proteoglycans e.g. Decorin  Inflammatory cells--- increase in degradative enzymes  Hyaluronic acid (GAG)- increase water content
  • 21. Remodeling of cervix Degradative Inhibitors enzymes -Collagenases, MMP 1 & - Tissue inhibitors of 8, elastases MMPs, alpha 2 macroglobulin -Source – stromal cells, neutrophils and macrophages -Activity enhanced by cytokines like IL-1B, IL-8
  • 22. AFFECTING ELEMENTS  CYTOKINES – e.g. interleukin-1β enhance the activity of collagenases and interleukin 8, Platelet activating factor, monocyte chemotactic factor-1  HORMONAL INFLUENCES – Estrogens increases collagenases Progesterones inhibit collagenases, hyaluronic acid & IL-8  NITRIC OXIDE stimulates leukocytes infiltration induce prostaglandin secretion
  • 23. PREINDUCTION CERVICAL RIPENING  The condition of the cervix influences the success of inducing labor.  A cervical examination is essential before labor induction is initiated.  In 1964, Bishop developed a scoring system to evaluate multiparous women for elective induction at term.  The scoring system is based on properties of the cervix that may be assessed clinically at the time of pelvic examination such as dilatation, effacement, consistency, and position as well as the station of the fetal presenting part
  • 24. “Bishop Scoring System” Used for Assessment of Inducibility DILATATION EFFACEMENT STATION CERVICAL CERVICAL SCORE POSITION (cm) (%) (–3 to +2) CONSISTENCY 0 CLOSED 0 - 30 -3 FIRM POSTERIOR 1 1-2 40 - 50 -2 MEDIUM MID POSITION 2 3-4 60 - 70 -1 SOFT ANTERIOR 3 >/= 5 >/=80 +1, +2 - -
  • 25.  Bishop score is now widely used to predict the success of labor induction.  The higher the Bishop score, the more “ripe” or “favorable” the cervix is for labor induction.  A low Bishop score, usually considered less than or equal to 6, is “unripened” or “unfavorable” and will benefit from cervical ripening
  • 26. Other predictors Maternal factors Height, Fetal Parity Age Fetal factors weight, BMI fibronectin Insulin like growth Factor Fetal weight binding >3.5kg. protein Gestational age fFN in cervical secretions: Not more predictive than Bishop’s score
  • 27. Other scoring systems  Field’s system  Burnett modification of bishops score  Weighted Bishop’s score by Friedman  Pelvic score by Lange However, despite this none of the modifications have shown improved predictability.
  • 28. ULTRASOUND IMAGING  Adv. Over digital examination: more objective and assesses the entire length of the cervix.  Both bishop’s score and TVUS predicted successful induction.  Bishop’s score predicted delivery within 24 hrs. and TVUS within 48 hrs.  Cervical length related to latent phase of labor, funneling related to both latent and active phase of labor. (Am. J of Obs. Gynecol. 1994;171.)  Some other studies have not found any USG parameter predictive, and consider bishop’s score to be superior.
  • 29. METHODS OF CERVICAL RIPENING  Unfortunately, women too frequently have an indication for induction but with an unfavorable cervix.  As favorability or Bishop score decreases, there is an increasingly unsuccessful induction rate.  Methods used for cervical ripening include pharmacological preparations and various forms of mechanical cervical distension.
  • 30. Non pharmacologic means of cervical ripening 1. Herbal supplements: evening primrose oil, blue and black cohosh, raspberry leaves. 2. Breast stimulation: causes oxytocin release. Adv–non invasive, inexpensive, simple Disadv. – causes FHR abnormalities. 3. Castor oil, hot baths, enemas 4. Miscellaneous - acupuncture , sexual intercourse
  • 31. 4. (HYGROSCOPIC DILATORS):  Natural osmotic dilators –  Laminaria japonicum  Laminaria digitata  Isapgol  Synthetic osmotic dilators  Lamicel  Dilapan  They absorb endocervical and local tissue fluids, causing the device to expand within the endocervix and provide mechanical pressure.  cause mechanical dilation and release of prostaglandins.  Swell up to 4 – 5 times.  Most rapidly in first 4-6 hours but continue to swell up to 24 hours later.
  • 32. ADVANTAGES DISADVANTAGES  Skill needed for proper placement in  Cheap internal os.  Outpatient placement  Delay in obtaining maximum effect.  Easy for placement  Patient discomfort.  No need for fetal monitoring  Inability of tents to be molded without  Rapid improvement of compromising mechanical integrity. cervical status  Lack of manufacturer specifications for natural dilators.  Potential for incomplete sterility. ETO gas does not eradicate spores in the interstices of the sea weed stem
  • 33. 5. Membrane stripping:  Release of endogenous PGs. and mechanical dilation.  results in < labor inductions < post dated pregnancies > spontaneous onset of labor - inexpensive, safe, efficacious in promoting labor over several days
  • 34. 6. Balloon devices :  Single / Double balloon  First described in 1967  Safe  Cheap ADVANTAGES:  The combination of balloon catheter plus oxytocin is recommended as an alternative method when prostaglandins (including misoprostol) are not available or are contraindicated (previous caesarean)  May be useful for outpatient ripening.  Can be inserted in presence or absence of membranes.  Associated with favorable Bishop scores and no additional side effects.
  • 35. Single Balloon Devices  A fluid filled balloon is inserted inside the cervix.  A Foley catheter (26 Fr) or specifically designed balloon devices can be used  Mechanism of action:  The mechanism by which Foley' s catheter improves the cervical state is by its mechanical action.  It strips the fetal membranes from the lower uterine segment, causing rupture of lysosomes , release of phospholipase A and formation of prostaglandins.
  • 36. Technique of Balloon Placement 1. After sterilization and draping, the catheter is introduced into the endocervix either by direct visualization or blindly by sliding it over fingers through the endocervix into the potential space between the amniotic membrane & the lower uterine segment. 2. The balloon is inflated with 30 to 50 mL of normal saline and is retracted so that it rests on the internal os. 3. Constant pressure may be applied over the catheter. e.g. a bag filled with 1 L of fluid may be attached to the catheter end / An intermittent pressure may also be exerted on the catheter end 2 -4 times per hour.
  • 37. 4. Catheter is removed at the time of rupture of membranes or may be expelled spontaneously which indicate a cervical dilatation of 3 - 4 Centimeters.
  • 39. PHARMACOLOGICAL TECHNIQUES  Prostaglandins  PGE2 : Dinoprostone  PGE1 : Misoprostol  Oxytocin  Others  Estrogen  Relaxin  Hyaluronic acid  Progesterone receptor antagonist
  • 40. PROSTAGLANDINS  The chemical precursor is arachidonic acid  PGs are endogenous compounds found in the myometrium, deciduas, and fetal membranes during pregnancy.  Cervical production of PGE2, PGI2, PGF increases at term.  Modulate fibroblast activity - Increase hyaluronic acid production  Acting as chemotactic agents, Inflammatory cells further release degradative enzymes, causing cervical ripening.
  • 41.  Prostaglandins administration results in dissolution of collagen bundles and an increase in sub mucosal water content of the cervix.  These changes in cervical connective tissue at term are similar to those observed in early labor.  Unlike oxytocin, response to prostaglandins does not change throughout gestation.
  • 42. Preparations PGE2 : Dinoprostone PGE1 : Misoprostol  Vaginal gel : Prepidil, CerviprimeTM  MisoprostTM  Removable tampon : CervidilTM  CytotecTM  Vaginal pessary : Prostin E2TM
  • 43. Prostaglandin E2: (Dinoprostone) Increase in elastase, glycosaminoglycan, dermatan sulfate, and hyaluronic acid levels in the cervix. A relaxation of cervical smooth muscle facilitates dilation. Alter the extracellular ground substance of the cervix Increase in intracellular calcium levels, increases the activity of collagenase in ~ contraction of myometrial muscle the cervix. Cervical Ripening
  • 44.  PROSTAGLANDIN E2 (DINOPROSTONE):  CERVIPRIME GEL - is commonly used for cervical ripening .  is available in a 2.5-mL syringe for an intracervical application of 0.5 mg of dinoprostone.  With the woman supine, the tip of a pre-filled syringe is placed intracervically, and the gel is deposited just below the internal cervical os.  After application she remains reclined for at least 30 minutes. Doses may be repeated every 6 hours, with a maximum of three doses recommended in 24 hours.
  • 46.  Dinoprostone should only be administered at hospital.  Continuous Uterine activity & FHR monitoring.  If optimal response is not achieved by 6 hours, another dose can be administered. The maximum allowed dose is 3 doses be administered per 24 hours.  Oxytocin should not be initiated until 6 to12 hours after the last dose because of the potential for uterine hyperstimulation with concurrent oxytocin and prostaglandin administration.
  • 47. Cervidil placed in posterior vaginal fornix
  • 49.  Vaginal insert containing 10 mg of dinoprostone in a timed-release formulation. The vaginal insert administers the medication at 0.3 mg/h and may be left in place for up to 12 hours.  ADVANTAGE: the insert may be removed with the onset of active labor, rupture of membranes, or with the development of uterine hyperstimulation.
  • 50. Vaginal pessary : Prostin E2TM
  • 51. COCHRANE REVIEW Vaginal Prostaglandin E2 versus placebo/no treatment (37 trials, 6511 women) vaginal No Rx / risk 95% PGE2 Placebo ratio confidence (RR) interval (CI) risk of the cervix remaining unchanged/ 5 trials, 467 women 21.6% 40.3%, 0.46 0.35 to 0.62 unfavourable after 12 to 24 hours reduction in failure to achieve vaginal delivery 2 trials, 384 women 18.1% 98.9%, 0.19 0.14 to 0.25 within 24 hours use of oxytocin augmentation 12 trials, 1321 women 35.1% 43.8% 0.83 0.73 to 0.94 Uterine hyperstimulation with FHR changes 14 trials, 1259 women 4.4% 0.49%, 4.14 1.93 to 8.90 Hyperstimulation without FHR changes 13 trials, 3636 Women 1.4% 0.4% 2.48 1.17 to 5.26
  • 52. COCHRANE REVIEW Vehicle comparisons  PGE2 gel is as efficacious as PGE2 tablets.  PGE2 gel does reduce the need for oxytocin augmentation,  Gel was associated with less uterine hyperstimulation.  Sustained release pessaries in comparison with gel  have not been shown to significantly reduce caesarean section rates  have not been shown to improve adverse neonatal or maternal outcomes.  There is reduction in the use of oxytocin augmentation and the reduction in instrumental delivery rates.  The frequency of vaginal examinations is reduced when using sustained release pessaries.
  • 53.  INTRACERVICAL PGE2: although this route of administration is effective, it offers no advantages when compared to other methods of administration, namely the vaginal route.  Intracervical prostaglandins are effective compared to placebo, but appear inferior when compared to intravaginal prostaglandins.
  • 54. PGE2 can cause Uterine hyperstimulation, Fetal distress and Cesarean section. Uterine hyperstimulation : - More common with intra vaginal application. - 1-5%, similar to low dose oxytocin <=4mu/ml. - Begins within 1 hr - Removal, irrigation of Cervix, vagina : not helpful - Rapidly reversed with terbutaline or removal of insert. - Hence fetal heart rate monitoring is needed for 2 hours following single dose and longer if contractions persist after that.
  • 55.  A retrospective study of case notes (n = 3099) investigated women who underwent induction with PGE2 (vaginal tablet, gel and intracervical gel).  Uterine hyperstimulation (defined as contraction frequency being more than five in 10 minutes or contractions exceeding 2 minutes in duration) occurred in 5.8% patients, of which 31.5% were associated with FHR abnormalities.  Administration of tocolytic treatment with β2-adrenergic drugs  (hexoprenaline at 0.3 micrograms/minute OR  single dose of terbutaline 250 micrograms intravenously or subcutaneously)  successful in normalising uterine contractions and reversing any FHR abnormality in (98.3%).  Improvement usually began within 5 minutes regardless of hyperstimulation patterns. NICE 2008
  • 56. Systemic effect  Nausea  Vomiting  Diarrhea  Caution in  Glaucoma  hepatic and renal disease  Asthma
  • 57. Safety in induction for VBAC  Concern is with uterine rupture caused by uterotonic effects.  In largest cohort study of 5022 patients willing for VBAC  453 patients received intra vaginal gel  The rates of rupture were, 1.3% with PGE2 and 0.7 without its use.  ~ not statistically significant. Am J of Perinatol. 1997;14:157-160
  • 58. Two studies have expanded on the differences in adverse outcomes between prostaglandin and non-prostaglandin (such as intracervical Foley catheter) based induction regimens. In the NICHD study, prostaglandin induction compared with non-prostaglandin induction incurred a non-significantly higher risk of uterine rupture (140/10,000 versus 89/10,000; P = 0.22). In an analysis of nationally collected data from Scotland, prostaglandin induction compared with non-prostaglandin induction was associated with a statistically significantly higher uterine rupture risk (87/10,000 versus 29/10,000) and a higher risk of perinatal death from uterine rupture(11.2/10,000 versus 4.5/10,000). This compares with 6/10,000 risk of perinatal death in women with an unscarred uterus induced by prostaglandin identified by a Cochrane review. RCOG
  • 59.  Given these risks and the absence of direct robust evidence, it is important not to exceed the safe recommended limit for prostaglandin priming in women with prior caesarean birth. RCOG 2007
  • 60. Use with Premature Rupture of Membranes at term.  It has not been shown to decrease neonatal infections when compared with expectant management.  It could decrease time to delivery, but this can be achieved equally with optimum oxytocin dosing.  More important intervention to decrease maternal infectious morbidity is decreasing number of PV examinations.
  • 61. Misoprostol  Dosing  25 mcg  50 mcg  Very cheap  Easy to store
  • 62. Pharmacokinetics  Route of administration: Oral, vaginal and sublingual route for induction.  Bioavailability: Extensively absorbed from the GIT  Metabolism: De-esterified to prostaglandin F analogs  Half life: 20–40 minutes  Excretion: Mainly renal 80%, remainder is fecal: 15%  maximum plasma conc. with 400µg miso. - 34 mins. after oral , 80 mins. After vaginal - rapid onset and greater peak action with oral miso. - longer action with vaginal miso.
  • 63.  Clinical trials indicate that the safe optimal dose and dosing interval is 25 mcg intravaginally every 4-6 hours. ACOG 1999  A maximum of 6 doses was suggested.
  • 64. VAGINAL MISOPROSTOL (comparison) Vaginal misoprostol versus Trials/ No. of women Outcomes Placebo/ Expectant 5 trials/ Reduced risk of not management 769 participants achieving vaginal birth within 24 hrs of induction Intravenous oxytocin •9 trials/1200 participants •Reduced risk of not achieving vaginal birth •25trials/3074 participants •Fewer cesarean sections •13 trials/1906 participants •Fewer infants with apgars below 7 at 5mins Other prostaglandins - •a reduced risk of vaginal birth not achieved within 24 hours •fewer caesarean sections •increased risk of uterine hyperstimulation with fetal heart rate changes
  • 65.  Compared with higher doses of vaginal misoprostol, lower doses (25 μg, 6- hourly) were associated with a reduced risk of uterine hyperstimulation with fetal heart rate changes (16 trials, 2540 participants, RR 0.51, 95% CI 0.37–0.69).  The risk of vaginal birth not being achieved within 24 hours was similar with both higher and lower doses
  • 66. ORAL MISOPROSTOL Oral misoprostol versus Trials/ No. of women Outcomes Placebo/ Expectant •1 trials/96 participants •Reduced risk of not achieving vaginal birth management within 24 hrs of induction •6 trials/629 participants •Reduced cesarean births Intravenous oxytocin •8 trials/1026 participants •Similar w. r, t. the risk of priority outcomes Intracervical prostaglandins •More effective in achieving vaginal birth within 24 hrs Vaginal prostaglandins •Reduction in cesarean rates
  • 67.  Lower doses of oral misoprostol (up to 50 μg) were associated with similar outcomes compared with higher doses (100 μg)
  • 68. Oral misoprostol versus vaginal misoprostol  Similar with regard to priority outcomes except  Oral misoprostol was associated with a lower risk of Apgar score being less than seven at 5 minutes of life (14 trials, 3270 participants, 94 events, RR 0.65, 95% CI 0.44–0.97).
  • 69.  Vaginal misoprostol versus sublingual/ buccal misoprostol : similar with regard to all the priority outcomes  Oral versus sublingual/buccal misoprostol: Data are limited
  • 70. Recommendations 1. Oral misoprostol (25 μg, 2-hourly) is recommended for induction of labour. (Moderate-quality evidence. Strong recommendation.) 2. Vaginal low-dose misoprostol (25 μg, 6-hourly) is recommended for induction of labour. (Moderate-quality evidence. Weak recommendation.) 3. Misoprostol is not recommended for women with previous caesarean section. (Low-quality evidence. Strong recommendation.)
  • 71. Misoprostol vs Dinoprostone  The mean time to vaginal delivery was significantly shorter in the misoprostol group (925.8 versus 1577.6 minutes), and the mean duration of the active length of labour was significantly shorter in the misoprostol group (353.7 versus 496.8 minutes)  Less likely to require a repeated dose of prostaglandin for cervical priming and oxytocin for augmentation of labour.  no difference in the rate of Caesarean section  More hyperstimulation during labour in the misoprostol group Aust N Z J Obstet Gynaecol. 2001 May;41(2):145-52
  • 72. Oxytocin for cervical ripening : comparison Intravenous Oxytocin Trials / Outcome versus No women Expectant management 25 trials; Intravenous oxytocin reduced the failure to 6660 women achieve vaginal delivery within 24 hours when compared with expectant management (8.4% versus 54%) Vaginal PGE2 27 trials; compared with vaginal PGE2, oxytocin was 4564 women associated with more failures to achieve vaginal delivery within 24 hours (70% versus 21%) Intracervical PGE2 14 trials; Oxytocin was associated with increased 1331 women unsuccessful vaginal deliveries within 24 hours when compared with intracervical PGE2 (50.4% versus 34.6%) Increase in cesarean sections (19% versus 13.7%)
  • 73. CONCLUSION Comparison of oxytocin with either intravaginal or intracervical PGE2 reveals that the prostaglandin agents probably increase the chances of achieving vaginal birth within 24 hours. Oxytocin induction may increase the rate of interventions in labour. NICE 2008
  • 76. Risks  CESAREAN DELIVERY  especially increased in nulliparas  two- to threefold risks  rates are inversely related with favorability of the cervix at induction, that is, the Bishop score.  CHORIOAMNIONITIS  UTERINE ATONY  Postpartum atony and hemorrhage are more common in women undergoing induction or augmentation  Intractable atony was the indication for a third of all cesarean hysterectomies