Induction of labour

1. Induction of labour
Mrs. U SREEVIDYA Msc.
NURSING,
Associate Professor,
Apollo college of nursing,
CHITTOOR

2. INDUCTION OF LABOUR
IOL means initiation of
uterine contraction
period of viability
method(medical
combined)for the
,surgical
purpose
(after the
)by any
or
of
vaginal delivery.
----D.C DUTTA
DEFINITION OF IOL

3. DEFINITIONOF
AUGMENTATION OF LABOUR
a process ofIt is
stimulation
contraction
of uterine
(both in
frequency and intensity) that
are already present but
found to be inadequate.
D.C.DUTTA

4. PURPOSES OF INDUCTION OF LABOUR
 Risk of
continuation of
pregnancy either
to the mother or
fetus is more.

5. GOALS
 The goal of induction of labour to eliminate
the potential risks to the fetus with prolonged
intrauterine existence while minimizing the
likelihood of operative delivery.

6. Indications for induction of labor:
Maternal indications
• Post-term (main indication]
• P.I.H (Timing depend )on the[ severity]
• Diabetes Mellitus (increase risk of baby loss
and mortality rate)
• Medical conditions (as renal, respiratory and
cardiac diseases)
• Placenta insufficiency (as moderate or severe
placenta abruption but commonly C.S)
• Prolonged pre-labor rupture of membranes.
• Rheuses isoimmunization.
• Maternal request.

7. Indications for Induction of Labor
cond..
• Fetal Indications:
• Suspected fetal compromise (I.U.G.R )
• Intrauterine death (I.U.F.D).

8. INDICATIONS OF INDUCTION LABOUR
1.
HYPERTENSIVE
DISORDER OF
PREGNANCY
2. DIABETES,
RENAL DISEASE
3.CHRONIC
PULMONARY
DISEASE
4.PREMATURE
RUPTUREOF
MEMBRANE
5. RH
ISOIMMUNIZA
TION
6.POSTDATED
PREGNANCY

9. CONTRAINDICATIONS OF IOL
• Contracted pelvis and CPD
• Malpresentation (breech , transverse or oblique
lie)
• Previous classical caesarean section or
hysterotomy
• Uteroplacental factors : unexplained ,
vaginal bleeding , vasa praevia, placenta
praevia.
• High risk pregnancy with fetal compromise
• Active genital herpes infection
• Heart disease
• Pelvic tumour
• Elderly primigravidae with obstetric or medical
complications
• Umbilical cord prolapsed
• Cervical carcinoma.

10. PARAMETERS TO ASSESS PRIOR TO IOL
MATERNAL
• To confirm the indication for IOL
• Exclude the contraindication of IOL
• Assess Bishop score (>6, favourable)
• Perform clinical Pelvimetry to assess pelvic
adequacy
• Adequate counselling about the risks,
benefits and alternatives of IOL with the
women and the family members

11. CONT..
FETAL
• To ensure fetal gestational age
• To estimate fetal weight(clinical
and USG )
• Ensure fetal lung maturation status
• Ensure fetal presentation and lie
• Confirm fetal well- being

12. FACTORS FOR SUCCESSFUL IOL
• Period of gestation- term or post term
• Pre- induction score- Bishop score >6 is favourable .
• Cervical ripening – favourable in parous women and in case
with PROM
• Sensitivity to uterus- positive oxytocin sensitivity test is
favourable to IOL.
• Presence of fibronectin in vaginal swab (> 50ng/ml) -
favourable for successful IOL
• Other positive factors –maternal height >5’inches,normal
BMI,EFW<3 kgs.

13. CERVICAL RIPENING
 Series of complex
biochemical changes in the
cervix which is mediated by
the hormones. Ultimately the
cervix become soft and
pliable.

14. METHODS OF CERVICAL RIPENING
PHARMACOLOGICAL METHODS
• Prostaglandins-Dinoprostone ,
Misoprostol
• Oxytocin
• Progesterone receptor antagonist-
Mifepristone
• Relaxin
• Hyaluronic acid
• Estrogen

15. Cont..
NON PHAMOCOLOGICAL
METHODS
• Stripping of membrane
• Amniotomy(ARM)
• Mechanical dilators, osmotic
dilators
• Transcervical balloon catheter
• Extra- aminotic saline
infusion

16. The Bishop score
Bishop score is producing a scoring system to
quantify the state of readiness of the cervix and
fetus. High scores (a favourable cervix) are
associated with an easier shorter induction.

17. BISHOP’S PREINDUCTION CERVICAL
SCORING SYTEM(MODIFIED)
PARAMETERS SCORE
0 1 2 3
CERVIX
DILATATION
CLOSED 1-2 3-4 5+
EFFACEMENT
%
0-30 40-50 60-70 ≥80
CONSISTENCY FIRM MEDIUM SOFT -
POSITION POSTERIOR MIDLINE ANTERIOR -
HEAD-STATION -3 -2 -1,0 +1,+2
CERVICAL
LENGTH
>4 2-4 1-2 <1

18. CONT..
TOTAL SCORE=13
Favorable score=6-13
Unfavorable score=0-5

19. METHODS OF IOL
 Natural non-medical methods
 Mechanical
 Medical
 Surgical
 Combined

20. Natural-Non Medical methods
1 Relaxation techniques: advise patient to relieve tension
and try to relax then use some visual aids to show how
labor starts.
2 Visualization: The patient is advised to imagine her
uterus contracting and she is laboring. Hypnosis/self-
hypnosis helps.
3 Walking: The force of gravity pulls the weight of the baby
towards the birth canal leading to dilatation and
effacement of the cervix.

21. Natural-Non Medical methods
(Cont.)
4. Cumin Tea: Used by midwives in Latino cultures.
Sugar or honey may be added to lessen its bitter
taste
5. Several herbs: Labor-enhancing herbs include
blue Cohosh, black Cohosh, Squawvine and Dong
Quai. Evening primrose oil also ripens the cervix. It
is given internally 5 gel caps up against the cervix
daily.

22. MECHANICAL INDUCTION
• Effective
• Low cost
• Low risk of tachysystole
• Disadvantage-infection

23. II-Mechanical methods
1-Hygroscopic dilators
They absorb endocervical and local tissue fluids, causing
the device to expand within the endocervix and provide
mechanical pressure. These dilators are either natural
osmotic dilators (e.g., Laminaria japonicum) or synthetic
osmotic dilators (e.g., Lamicel).
Advantages: 1- Outpatient placement
fetal monitoring
2- No need for
Risks: fetal and/or maternal infection

24. Hygroscopic dilators

25. II-Mechanical methods (Cont.)
1-Hygroscopic dilators:
Technique of insertion:
-The perineum and vagina are sterilized with antiseptic
sol & the patient is drapped.
-Using a sterile speculum, the dilator is introduced into
the endocervix.
-Dilators are progressively placed until the endocervix
is full.
-A sterile gauze pad is placed in the vagina to maintain
the position of the dilators.

26. II-Mechanical methods (Cont.)
2- Placement of Balloon Dilators after 42 weeks gestation:
A fluid filled balloon is inserted inside the cervix. The Balloon
provide mechanical pressure directly on the cervix which
respond by ripening and dilation. A Foley catheter (26 Fr) or
specifically designed balloon devices can be used.
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.

28. II-Mechanical methods (Cont.)
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 dilataion of 3-4
Centimeter.
(References 2-6 - Evidence level B, systematic review of non-RCTs)

31. DRUGS USED FOR MEDICAL
INDUCTION
• Prostaglandins(PGE2,PG E1)
• Oxytocin
• Mifepristone

32. PROSTOGLANDLINS(PGE2)
• It act locally on the contiguous cells and both
causes the myometrial contraction .
• Intracervical application of Dinoprostone ( PGE2-
0.5mg) gel is the gold standard for cervical ripening.
• It may be repeated after 6 hours for 3 – 4 doses if
required.
• The women should be in bed 30 min following
application and is monitored for uterine activity
and fetal heart rate .

33. MISOPROSTOL(PGE1)
• ROUTE- Transvaginally or orally
• DOSE- 25μg vaginally every 4 hours is found either
superior or similarly effective to that of PGE2 for
cervical ripening and labour induction. Maximum doses
is 6-8
• SIDE EFFECTS-tachysystole ,meconium passage ,fetal
heart rate irregularities and uterine rupture
• Contraindicated –previous LSCS

34. OXYTOCIN
• ACTION : Uterine activity
(CONTRACTION), Produce cervical
dilation and effect delivery (WHEN
RIPEN)
• Oxytocin is effective for IOL when
cervix is ripe.

35. Cont..
• DOSE- 0.5 -2.5 mu/min
• Initiated at the dosage of 1 mu/min,
with increases of 1 or 2 mU/minute
every 20–30 minutes until a
maximum administration rate of 16–
32 mU/minute is reached or
adequate uterine activity is present

36. MEFEPRISTONE
• It blocks both progesterone and
glucocorticoid receptor .
• RU 486,200mg vaginally daily for 2
days has been found to ripen the
cervix and to induce labour.
• Onapristone is a more selective
progesterone receptor antagonist.

37. SURGICAL INDUCTION OF
LABOUR

38. SURGICAL INDUCTION
METHODS
1. Artificial rupture of
membrane
 Low rupture of membrane
 High rupture of
membrane(rare)
2. Stripping of membrane

39. LOW RUPTUREOF MEMBRANES (LRM)
It is widely practiced nowadays with high degree of
success. The membranes below the presenting part
over lying the internal os are ruptured to drain some
amount of amniotic fluid.

41. ARTIFICIAL RUPTURE OF
MEMEBRANES
• INDICATION :
• Abruption placenta
• Chronic hydramnios
• Severe pre-eclampsia/eclampsia
• To place scalp electrode for
electronic fetal monitoring.

42. ARM
• CONTRAINDICATIONS:
• IUFD
• Maternal AIDS
• Genital active Herpes
Infection

43. PROCEDURE OF ARM
 Preliminaries : empty the bladder .
 The procedure can be done in labour
room or in OT if the risk of cord prolapse
is high
 Actual steps
1. Position the patient in lithotomy position
2. Full surgical asepsis to be maintained
3. Two fingers are introduced into
the vagina smeared with
antiseptic ointment
4. The index finger is passed through the
cervical canal beyond the internal os

44. AMNIOHOOK

45. KOCHER”S FORCEPS

46. Cont..
5.The membranes are swept free from the lower segment as far
as reached by the fingers
6.With one or two fingers still in the cervical canal with the
palmar surface upwards , a long kocher’s forceps with the
blades closed or an amnion hook is introduced along the
palmer aspect of the fingers up to the membranes
7.The blades are opened to seize the membranes and are torn
by twisting movements
8.Amnihook is used to scratch over the membranes . This is
followed by visible escape of amniotic fluid .

47. ARTIFICIAL RUPTUREOF MEMBRANE USING AMNI-
HOOK

48. TIMINGS

50. ARM

51. HAZARDS OF ARM

52.  Stripping of the membranes means
digital sepration of the chrioamniotic
membranes from the wall of the cervix
and lower uterine segment.
 It is the simple safe and beneficial for
induction of labor.

54. COMBINED METHOD

55.  The combined medical and surgical
methods are commonly used to
increase the efficacy of induction by
reducing the induction -delivery
interval.
 The oxytocin infusion is started either
prior to or following rupture of the
membranes depending mainly upon
the state of the cervix.

56. ADVANTAGES OF COMBINED METHOD
More effective than any single
procedure
Shortens the induction-
delivery interval thereby
minimizes the risk of infections
and lessens the period of
observation

57. MECHANISM OF ONSET OF LABOUR
May be related with
a)Stretching of the cervix
b)Separation of the membranes (liberation of
prostaglandins)
c)Reduction of amniotic fluid volume

58. SCHEME OF IOL

59. NURSING RESPONSIBILITY

60. NURSING RESPONSIBILITY OF MEDICAL INDUCTION
1. Nurse should know about the administration of drugs
2. Nurse should administer PGE2 gel 0.5mg before the cervical
ripening
3. Nurse should observe about the cervical ripening
4. Nurse should monitor for 30min after she should given
drugs 3or 4doses after 6hrs.
5. Nurse should know about the dose and route of
misoprostol drugs
6. Nurse should administer 25gvaginally every 4hours
7. Nurse should know about the preparation of Oxytocin
solution
8. Oxytocin should be started in low dose with interval of 20-
30minutes
9. Oxytocin should be administer 2units in 500ml ringer
solution with drop rate of 60/minutes

61. NURSING RESPONSIBILITYOF SURGICAL INDUCTION
OF LABOUR
1. Nurse should maintain aseptic techniques
2. She should provide proper position to the patient
3. She should do vaginal examination with the use of
proper aspetic techniques
4. She should known about how to assess in
procedure of low rupture of membrane
5. She should know about the instruments which is
used in the surgical induction of labour
6. She should know how to use Amni hook
7. She should observe by visible escape of amniotic
fluid

62. GENERAL NURSING
RESPONSIBILITY
1.AFETRTHEMEMBRANE RUPTURED
a. Check FHR
b. Check rate of infusion
c. Check uterine contractions and FHR 15min
2.GENERALCARE
2.Nurses provide care to women and their newborn during the
ante partum, post partum and neonatal stages of this
important life event.
3.They assess each mother and baby and develop an
individualized plan of care
4.They implement the plan of care by monitoring the mother
and baby and by teaching patients about their care and topics
related to women’s health and newborn care.

63. 5. Nurses evaluate the effectiveness of the care plan
and modify it is needed to meet the changing needs
of the mother, newborn and family
6. They also provide psychological and emotional
support to patients and families.

64. When an induction fails, the options include
 attempting induction again at some point in the
future,or performing a Caesarean section.
 Delaying delivery further is only acceptable if
there is no major threat to fetal or maternal
condition.This may be the case with a failed
social induction,for example.
 Failed induction in the setting of preeclampsia
or fetal growth restriction will usually
necessitate Caesarean delivery.