Induction of LaborInduction of Labor

Dr Manal BeheryDr Manal Behery

20142014

InductionInduction

Induction of labor is the artificial initiation of Induction of labor is the artificial initiation of labor prior to its spontaneous onsetlabor prior to its spontaneous onset

AugmentationAugmentation

The artificial stimulation of labor that The artificial stimulation of labor that has been started spontaneouslyhas been started spontaneously to to increase the rate of progress of laborincrease the rate of progress of labor

TTime, place & preparationime, place & preparation

Time of inductionTime of induction: : Preferably early morningPreferably early morning

Place of inductionPlace of induction: where facility for : where facility for intervention and fetal monitoring is availableintervention and fetal monitoring is available

Preparation of Patient Preparation of Patient : : Enema may be given Enema may be given to patients prior to induction to patients prior to induction

Indication for InductionIndication for Induction

MaternalMaternal

FetalFetal

General conceptsGeneral conceptsElective inductionElective induction

induction, in the absence of maternal or fetal indication, induction, in the absence of maternal or fetal indication, should not be undertakenshould not be undertaken

-increase CS (especially, nulliparas)-increase CS (especially, nulliparas)

Emergent indicationEmergent indication

-ruptured membranes with chorioamnionitis-ruptured membranes with chorioamnionitis

severe preeclampsiasevere preeclampsia

MaternalMaternal

FetalFetal

Abpruptio placenta Abpruptio placenta IUGRIUGR Rh isoimmunizationRh isoimmunization Unexplained IUFD in prior pregnancyUnexplained IUFD in prior pregnancy ChorioamnionitisChorioamnionitis MalformationMalformation

Factors to assess prior to inductionFactors to assess prior to induction

ContraindicationsContraindications--Contracted pelvisContracted pelvis

Pregnancy following classical C.sectionPregnancy following classical C.section

Pregnancy following repair of a vesico-vaginal fistulaPregnancy following repair of a vesico-vaginal fistula

-Acute fetal distress-Acute fetal distress

-Abnormal presentation-Abnormal presentation

--Presence of active herpetic genital lesions Presence of active herpetic genital lesions

Cervical RipeningCervical Ripening

Cervical RipeningCervical Ripening

promotion of cervical change by promotion of cervical change by pharmacological or other meanspharmacological or other means

not primarily intended to induce labor but to not primarily intended to induce labor but to increase the success of subsequent inductionincrease the success of subsequent induction

Modified Bishop’s ScoreModified Bishop’s Score

Favourable score->6 Best score->8

 hygroscopic dilators, osmotic dilators (Laminaria japonicum), Foley catheters, double balloon devices, and extraamniotic saline infusion. 

Stripping of membraneStripping of membrane

performed by inserting the index finger through performed by inserting the index finger through the internal os as as far possible and rotating the internal os as as far possible and rotating twice through 360 degrees to separate the twice through 360 degrees to separate the membranes from the lower segmentmembranes from the lower segment

Intracervical foly catherIntracervical foly cather

Amniotomy (ARM)Amniotomy (ARM)

WidelyWidely used methodology used methodologyEasyEasyNo anaesthesia or analgesiaNo anaesthesia or analgesiaSafeSafeCord prolapseCord prolapseChorioamnionitisChorioamnionitis

OxytocinOxytocin

OctapeptideOctapeptide

Synthetic Oxytocin preparations, Syntocinon Synthetic Oxytocin preparations, Syntocinon and Pitocin are commonly used and Pitocin are commonly used

Syntocinon is avaiable in injections Syntocinon is avaiable in injections

EQUIPMENT REQUIREDEQUIPMENT REQUIRED::

Complications of SyntocinonComplications of Syntocinon

Incoordinate uterine action;Incoordinate uterine action;hyperstimulationhyperstimulationFetal Fetal hypoxiahypoxiaUterine Uterine ruptureruptureWater Water intoxicationintoxicationUterine Uterine fatiguefatigue;PPH;PPH

Routes of administrationRoutes of administration

OralOral Vaginal-Gel orVaginal-Gel or

PessaryPessaryLocal via catheterLocal via catheter

Mechanism of actionMechanism of actionChange the myometrial cell Change the myometrial cell memb permeablity and memb permeablity and alteration in the membrane alteration in the membrane bound calciumbound calcium

sensitises the mometrium to sensitises the mometrium to the oxytocinthe oxytocin

PGE2 has its collagenolytic PGE2 has its collagenolytic activityactivityalter the ground alter the ground substance of cervixsubstance of cervixcx cx ripeningripening

ContraindicationsContraindications

Bronchial asthmaBronchial asthmaEpilepsyEpilepsyHypersensitivityHypersensitivityRenal diseaseRenal diseaseHypertensionHypertensionPeptic ulcerPeptic ulcer

Risk of InductionRisk of Induction

FailureFailurePrematurityPrematurityAbnormal uterine actionAbnormal uterine action InfectionInfectionMaternal exhaustionMaternal exhaustionFetal hypoxiaFetal hypoxiaAmniotic fluid embolismAmniotic fluid embolism

ConclusionConclusion

reasons for induction must be convincing and documented

risk and benefits must be discussed with patient

patient preference must be considered

ripen the cervix as much as possible

do not use oxytocin if cervix unfavourable don't overestimate your ability to succeed

Pain relief in labourPain relief in labour

DOES LABOR PAIN NEED DOES LABOR PAIN NEED ANALGESIAANALGESIA??

Potential effects of maternal hyperventilation and subsequent Potential effects of maternal hyperventilation and subsequent hypocarbia on oxygen delivery to the fetushypocarbia on oxygen delivery to the fetus

Why is labour painfulWhy is labour painful??

Ischemia of uterine muscles.Ischemia of uterine muscles.

Dilatation and stretching of the cervix.Dilatation and stretching of the cervix.

Stretching of the perineum in the second Stretching of the perineum in the second stage of labour.stage of labour.

Pain Pathways of LaborPain Pathways of Labor

Panadol + NSAIDPanadol + NSAID

Simple analgesia is usually ineffective in controlling Simple analgesia is usually ineffective in controlling labour painlabour pain

X

The ideal analgesic in labourThe ideal analgesic in labour

Easy to administer.Easy to administer.

Safe to the mother and baby.Safe to the mother and baby.

Easily reversible if necessary.Easily reversible if necessary.

Does NOT interfere with uterine contractions.Does NOT interfere with uterine contractions.

Does NOT effect mobilityDoes NOT effect mobility..

Types of pain relief in labourTypes of pain relief in labour

Non-pharmacological:Non-pharmacological:

Relaxation.Relaxation.

TENS.TENS.

Hypnosis.Hypnosis.

AcupunctureAcupuncture

Hydrotherapy.Hydrotherapy.

Phar macologicalPhar macological

Opiates.Opiates.

Inhalational.Inhalational.

Epidural.Epidural.

::

Relaxation“psycoprophylaxisRelaxation“psycoprophylaxis””

Essential in all cases.Essential in all cases.

Antenatal classes to educate the mothers on Antenatal classes to educate the mothers on what to expect.what to expect.

Helps mothers to cope with pain and Helps mothers to cope with pain and satisfaction with pain relief.satisfaction with pain relief.

Transcutaneous nerve stimulation(TENS)Transcutaneous nerve stimulation(TENS)

Low grade electronic waves to nerves supplying Low grade electronic waves to nerves supplying the uterus via skin electrode.the uterus via skin electrode.

Provides good pain relief to 25% of patients.Provides good pain relief to 25% of patients.

Woman controls intensity and sensation patternsWoman controls intensity and sensation patterns

Drawback – interfers with FHR Drawback – interfers with FHR monitoringmonitoring

Contraindication – cardiac pacemakersContraindication – cardiac pacemakers

TENS

Transcutaneous electrical nerve stimulation equipment

general Birthday Trust's latest survey, only about 5.5% of women use TENS

Intradermal Water InjectionIntradermal Water Injection

HydrotherapyHydrotherapy

Hypnosis and acupunctureHypnosis and acupuncture

Reported to be successfulReported to be successful..

Needs special skill and preparationNeeds special skill and preparation..

Carries no risk to the mother or fetusCarries no risk to the mother or fetus..

??? ???Placebo effectPlacebo effect

Does this matterDoes this matter????????

OpiatesOpiatesPethidine and diamorphine are the Pethidine and diamorphine are the commonly used drugs.commonly used drugs.

Given inter-muscular or intravenousGiven inter-muscular or intravenous

repeated when necessary.repeated when necessary.

AdvantagesAdvantages::

Offers good pain relief for most patients.Offers good pain relief for most patients.

Short duration of action.Short duration of action.

DisadvantageDisadvantage::Nausea and vomiting. (antiemetic)Nausea and vomiting. (antiemetic)

Can cross BPB respiratory Can cross BPB respiratory depression in the new born.depression in the new born.

(Nalaxone)(Nalaxone)

Inhalational anesthesiaInhalational anesthesia

The commonest is nitrous oxide.The commonest is nitrous oxide.

Self administered to the patient via face mask.Self administered to the patient via face mask.

Given in a 50-50 mixture with oxygen (EntanoxGiven in a 50-50 mixture with oxygen (Entanox).).

AdvantagesAdvantages

Provides analgesia varying from good to Provides analgesia varying from good to ineffective.ineffective.

Under control of the patient.Under control of the patient.

Minimal adverse effects to mother and Minimal adverse effects to mother and fetus.fetus.

DisadvantageDisadvantage::

not adequate for second stage, instrumental delivery, not adequate for second stage, instrumental delivery, suturing of perineum or manual removal of placenta.suturing of perineum or manual removal of placenta.

Light headedness and nausea.Light headedness and nausea.

Not suitable for prolonged useNot suitable for prolonged use..

Epidural anesthesiaEpidural anesthesia

الوالدة بدون ألمالوالدة بدون ألم

Alternative Regional Anaesthetic Alternative Regional Anaesthetic TechniquesTechniques

Epidural blockEpidural block

Plastic catheter introduced into the epidural space.Plastic catheter introduced into the epidural space.

Catheter is left in and the analgesia is given Catheter is left in and the analgesia is given continuously.continuously.

Bupivican andBupivican and Fentanyl Fentanyl

AdvantagesAdvantages::

The most effective pain relief.The most effective pain relief.

The absence of pain allows enjoyment and The absence of pain allows enjoyment and control of labour.control of labour.

Reduces maternal fatigue and anxiety.Reduces maternal fatigue and anxiety.

Ideal in high risk pregnancies e.g. breech, MP, Ideal in high risk pregnancies e.g. breech, MP, and PET.and PET.

DisadvantageDisadvantage::

Restriction of movement during labour.Restriction of movement during labour.

Requires CTG.Requires CTG.

Requires resident anesthesia, cardio-Requires resident anesthesia, cardio-respiratory facilities and one to one care.respiratory facilities and one to one care.

?increase rate of instrumental delivery.?increase rate of instrumental delivery.

ComplicationsComplications::

Failure 3%.Failure 3%.

Hypotension.Hypotension.

Epidural tap (headache)Epidural tap (headache)

? Back pain.? Back pain.

Paralysis !!!!!!!!!.Paralysis !!!!!!!!!.

Analgesia used in second stage and Analgesia used in second stage and third stagethird stage..

Nerve blocks.Nerve blocks.

Spinal anesthesia.Spinal anesthesia.

General anesthesia.General anesthesia.

Paracervical blockParacervical block

Pudendal blockPudendal block

Performed by the obstetricianPerformed by the obstetrician..

Used for outlet forceps and vacuum Used for outlet forceps and vacuum deliverydelivery..

Spinal anesthesiaSpinal anesthesia

Can be used for …Can be used for …

Instrumental delivery.Instrumental delivery.

Manual removal of placenta.Manual removal of placenta.

Repair of third degree tear.Repair of third degree tear.

Contraindications to spinal or epidural Contraindications to spinal or epidural anesthesiaanesthesia

Maternal refusal.Maternal refusal.

Hypovolemia.Hypovolemia.

Sever back deformities,Sever back deformities,

Local infection.Local infection.

Coagulation disorders.Coagulation disorders.

Thank youThank you