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7_Induction of Labour 2

Induction Labour ppt

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7_Induction of Labour 2

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  1. INDUCTIONOF LABOUR DR. DAVID BREWEN CONTEH RefresherObstetrics-Masanga2023

  2. Whatistinductionoflabour? Triggeringlabourartificiallybeforeitbeginsnaturally • Twosteps: • cervicalripening(effacement,mid-position,early dilation) • inductionofcontractionsthatdilatethecervix

  3. WHOguidance:Indications(1/2) • Postterm≥41weeks(onlyconfirmed) • PROMatterm,within24hours • ChorioamnionitisatanyGA • APHatterm(orearlierifinstable) • Growthrestrictionatterm(onlyconfirmed) • IUFDorseverelyabnormalfetus

  4. WHOguidance:Indications(2/2) • HypertensivediseaseandPET • Preeclampsiaatterm • Poorlycontrolledhypertensivediseaseatterm • Unstableseverepreeclampsiaatanygestation • Preeclampsiawithdeadfetus • Eclampsia(afterstabilization)

  5. WHOguidance–NOindication • Lowriskpregnancy<41weeks • Gestationaldiabetes<41weeks(without polyhydramniosorfetalmacrosomia) • Suspectedmacrosomiaatterm • Twins(nostudiesavailable!)

  6. OtherIndicationsforIOL? • PPROM? • Onlyifsignsofinfection • Reducedgrowthpreterm? • Onlyifoligohydramnios/growtharrest • Oligohydramniosatterm? • Earlysignofplacentalinsufficiency! • Reducedmovementsatterm? • Placentalinsufficiency

  7. WHOrecommendedmethods • Misoprostol25mcg4hourly • 200mcgin200mlH2O=25ml • Or25mcgPV6hourly(if25mcgtabs available) • AmniotomyandOxytocin(notARMalone) • Mechanical:Ballooncatheter • Membranesweep?

  8. Howdoyouchosethe methodofinduction? • Parity • Indication • Previousuterine surgery • Staffing • Resourcesavailable • Experienceofstaff • Favourabilityofcervix– Bishop’sscore • Preferenceofmother?

  9. Cervicalripening

  10. (Simplified)BishopScore Bishopscore>5-favourable’forOxytocinandAmniotomy Bishopscore≤5=unfavourable

  11. Examples

  12. Afternoonhandingover • Youareoncall! • Frommaternitytheyreport aboutawomanwith followingvitals: • BP>180/90 • 4+proteinindipstick

  13. Assessment Whatdoweneedtoknowto undertakeasafeandeffectiveIOL?

  14. CaseDetails • 18yroldG1/P0 • 32/40bySFH,FH142bpm • BPcontrolledfollowing treatment • 4+proteinuria,severefascial oedema • Cephalic3/5 • BS2,membraneintact

  15. Induction? How? Risks? Precautions?

  16. InductionwithMisoprostol • Oncegiven,there`snowayback • Takecautionin: • Multipara,especiallygrand-multipara • ROM • BS>4(especiallyifmultiparaorROM) • Unsure/unstablefetalcondition • Avoid • PreviousC/Sormyomectomy • Latentphase

  17. SecondcaseDetails • 25yearoldG4P3A2-allSVD • 35weeksbySFH • ROM>24hours-pink • VitalsandFHstable • Cephalic3/5palpable • BS5,1contractionmildin10minutes

  18. Induction? How? Risks? Precautions?

  19. Inductionin PROMandpPROM • Atterm–Within24hoursorimmediatelyif evidenceofinfection • Atanygestationifevidenceofinfection • InPre-viablePPROM

  20. WHOguidanceforOxytocintitration– IOL(andaugmentationoflabour) • 2.5IUOxytocinin500mlN/SorD5 • Startinfusionat10dpm(0.5mlor2.5mIU/min) • Increaseby10dpmevery30minutesuntil3-4moderateto strongcontractions/10minutesthenmaintainrate • Ifgoodcontractionpatternnotestablishedby60dpmsetupanewdrip(doubledose:5IUin500ml),halftheinfusion rate(30dpm)andthenincreaseby10dpmevery30min • Maximumrate60dpm(atdoubledose)

  21. Importantconsiderations • Highlevelofmonitoringrequiredwithproperlytrainedand supervisedstaff • Membranesmustberupturedforoxytocininfusiontobeeffective • -includesfore-waters • Doseneedstobetitratedcorrectlyinordertobesafeand effective-potentiallyverydangerousdrugevenwhenusedforIOL • Multiparaswilloftenrespondveryrapidlyandinfusionoften needstobestoppedentirely • Thepurposeoftheinfusionistoachievecontractions.Ifthereare inadequatecontractionstherewilllikelybeinadequateprogress- thereisnopointusinganOxytocininfusionunlessyouarewilling totrytomakeitwork

  22. Example • TheabovedescribedG4P3withPROMhasa2.5IUin 500mlinfusioncommenced.After2hoursthedrops areon40dpmandsheisnotedtohave6/10strong contractions • Whatdoyoudo?

  23. Hyperstimulation • StoptheOxytocindripifrunning(notetherate) • Maybeappropriatetocheckdilatation • Rotatewomentoleftlateralandstaywithher • CheckFHandvitals–FHabnormalmanageasfetaldistress • Ifcontractionsnotreducedby20minutesconsidertocolysis • Oncecontractions<5/10review30minutesandconsiderre- startingOxytocininfusion • (Ifreceivedmisoprostolconsidertocolysis)

  24. Tocolysis • Terbutaline250mcgs/c • Salbutamol10mgin1literat10dpm • quickacting • Betamimeticsarecontraindicatedincardiacdisease • Nifedipine20mgpoasalternative(chewit!) Note:PerformVEbeforeadministering!Ifdelivery imminent(fulldilation)tocolysiscancausePPH!

  25. ThirdCaseExample • YouareinducingamultiparawithseverePETat36 weeks. • HerstartingBSis7andyouperformanARMandstart anoxytocininfusionof2.5IUin500ml • After2hourssheishasstrongcontractions4/10and theFHisheardtofallto70bpm.YouperformVE:7cm • Whatdoyoudo?

  26. FetalDistress • VeryDifficulttodiagnoseaccurately • Ifsuspected: • StopOxytocindripifongoing • Leftlateral/uprightposition,O2ifavailable • VE–meconium/cord/presentation/progress/blood • Checkforcauseandtreatifpossiblee.g.ivfluids,tocolysis, antibiotics • Isdeliveryrequired–How?

  27. FourthcaseExample • YouareinducingaP0attermforPROM.HerstartingBSwas5 • After8hoursofanoxytocininfusionsheis3cmwitha<1cm longwhichissoftandanteriorandheadat2/5 • WhatisherBishopscore? • Howwillyouproceed?Whatotherinformationdoyouneed?

  28. Induction? How? Risks? Precautions?

  29. CaseDetails: • SFH37/40 • G3P2 • AdmittedwithheavyPVbleedof>1liter,Abdopain • Hypotensiononadmissionbutrespondedto1livfluid • Observationsnowstable • MinimalactivebleedingPV • FHstable • USS–placentanotlow,Cephalic35/40byBPD,FH+ • VE–3cmdilated,1cmlong,soft,mid,head4/5, membranesintact,bulging

  30. Whattodo?

  31. Antepartalbleeding • Absoluteindicationforexpediateddeliveryunless small,selflimitingandpreterm • PossibleDDx • Abruptioplacentae • Placentapraevia • Uterinerupture

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