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Induction of Labor International Induction of Labor.

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Presentation on theme: "Induction of Labor International Induction of Labor."— Presentation transcript:

1 Induction of Labor International Induction of Labor

2 International Objectives Definitions Indications and contraindications Pregnancy dating Comparison of methods Management considerations

3 Induction of Labor International Induction initiation of uterine activity and cervical change with fetal descent by pharmacological or other means in a woman who is not in labor.

4 Induction of Labor International Cervical Ripening promotion of cervical change by pharmacological or other means not primarily intended to induce labor but to increase the success of subsequent induction

5 Induction of Labor International Contraindications to Induction Any contraindication to labor

6 Induction of Labor International Indications for Induction when continuation of the pregnancy is a greater risk to the mother or fetus than the risk of induction and delivery must be convincing, compelling, fully discussed and documented

7 Induction of Labor International Indications - Emergent severe gestational hypertension suspected acute fetal compromise severe IUGR significant maternal disease not responding to treatment significant APH chorioamnionitis

8 Induction of Labor International Indications - Urgent PROM at term or near term IUGR without evidence of acute compromise poorly controlled diabetes mellitus isoimmune disease at term or near term

9 Induction of Labor International Indications - Non-Urgent 'post-term' pregnancy well controlled diabetes mellitus intrauterine death in a prior pregnancy intrauterine fetal demise logistic problems (rapid labours, distance to hospital)

10 Induction of Labor International Indications - NOT elective induction -induction, in the absence of maternal or fetal indication, should not be undertaken

11 Induction of Labor International Risks of Induction failure to achieve labour uterine hyperstimulation with fetal compromise uterine hyperstimulation with uterine rupture increase risk of C/S

12 Induction of Labor International Labour Induction Methods Likelihood of Successful Vaginal Delivery LEAST MOST LEAST MOST favourable cervix unfavourable cervix multiparous nulliparous previous vaginal delivery previous C/S

13 Induction of Labor International If attempted induction does not achieve labor reevaluate the indication and method of induction

14 Induction of Labor International Methods of induction include mechanical and pharmacological means. The best choice depends on the cervical score (A cervix is unfavorable if the Bishop score is < 6)

15 Induction of Labor International Bishop Scoring System Score Factor0123 Dilatation (cm) > 5 Effacement (%) > 80 ConsistencyFirmMediumSoft PositionPosteriorMidAnterior Station Sp -3 or above Sp -2Sp -1 or 0 Sp +1 or lower

16 Induction of Labor International Effect of Cervical Status on C/S Rate >3Spontaneous Labour Cesarean Section (%) NulliparousParous Cervical dilatation at induction Xenakis Obstet Gynecol (1997) 90: 235

17 Induction of Labor International Labour Induction - Unfavourable Cervix Stripping of membranes Cervical ripening followed by oxytocin laminaria / artificial tents Foley catheter prostaglandins Prostaglandins (intracervical or vaginal) Amniotomy or oxytocin

18 Induction of Labor International Mechanical Methods catheters and tents cause cervical softening and effacement -this may facilitate an early amniotomy -these methods are effective by producing local prostaglandin along with direct dilatation less hypertonus and FH rate abnormalities than with pharmacologic agent

19 Induction of Labor International Prostaglandin Preparations Vaginal preparations are: -easier to administer -easier to remove -less likely to be placed extra-amniotically -less likely to cause patient discomfort

20 Induction of Labor International Prostaglandin E 2 myometrial contraction cervix -causes collagen breakdown and proteoglycan deposition vasodilator bronchodilator GI motility and secretory effects

21 Induction of Labor International Prostaglandin E 2 - Route and Dose intracervical (Prepidil ) -prostaglandin E mg into cervical canal vaginal (Prostin E 2 vaginal gel ) -prostaglandin E 2 1 or 2 mg into posterior fornix vaginal (Cervidil vaginal insert ) -prostaglandin E 2 10 mg into posterior fornix any formulation may be used for cervical ripening

22 Induction of Labor International Guidelines for PGE 2 Use insertion in hospital by experienced caregiver monitor appropriately for FHR and uterine activity if labour develops manage as appropriate if no labour, reassess, repeat as necessary or choose an alternative induction method

23 Induction of Labor International Prostaglandin E 2 - Advantages improved patient acceptance lower operative delivery rate less need for oxytocin induction may be used in PROM cost considerations

24 Induction of Labor International Prostaglandin E 2 - Disadvantages adverse reactions -hyperstimulation -CVS events -nausea, vomiting, diarrhea gel preparations are difficult to remove cost considerations

25 Induction of Labor International Precautions with Prostaglandins avoid placing PGs adjacent to myometrium use cautiously in patients with previous C/S do not repeat more frequently than every 6 hours wait 6 hours prior to oxytocin infusion following gels -may be started 30 minutes after Cervidil removal do not use for augmentation

26 Induction of Labor International Labour Induction - Favourable Cervix Stripping of membranes Amniotomy Oxytocin Vaginal prostaglandins

27 Induction of Labor International Amniotomy creates commitment to delivery effective with favourable cervix often used in conjunction with oxytocin caution in cases of high presenting part ( risk of cord prolapse)

28 Induction of Labor International Oxytocin Effects myometrial contraction cervix - no direct effect vasoactive -hypotension possible with bolus IV administration antidiuretic activity -water intoxication possible with high dose oxytocin

29 Induction of Labor International Oxytocin Guidelines cervix should be favourable experienced caregivers and access to caesarean delivery auscultation or EFM depending on indication administration -intravenous -concentrations vary but avoid large free water load

30 Induction of Labor International Uterine Hypertonus discontinue oxytocin if in use intravenous bolus prepare for emergency delivery consider tocolytic agents -ritodrine at mg/min IV until desired effect -nitroglycerin 50 mg IV push to maximum of 200 mg -nitroglycerin spray sublingual

31 Induction of Labor International Post partum consideration: if oxytocin was used in labor, PPH may occur for all induced patients, give oxytocin bolus post partum ( oxytocin 10 units I.M. 20 units 1L at 100 cc/hr for 2 hours or more

32 Induction of Labor International Conclusions reasons for induction must be compelling, convincing and documented risk and benefits must be discussed with patient patient preference must be considered ripen the cervix as much as possible match the method with the urgency and cervical status -do not use oxytocin if cervix unfavourable don't overestimate your ability to succeed

33 Induction of Labor International Goal of Induction avert anticipated adverse outcome associated with continuation of pregnancy to effect uterine activity sufficient for cervical change and fetal descent without causing uterine hyperstimulation or fetal compromise to allow as natural a birthing experience as safely possible and maximize maternal satisfaction happy baby + happy mom + vaginal delivery

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