how to induce augment and give trial of labor

1. Prepared by:
Nisha Ghimire
Isha Aryal
Aayushma Khadka

2.  Induction of labor (IOL) means initiation of
uterine contractions after the period of
viability by any method (medical, surgical or
combined) for the purpose of vaginal
delivery.
 This includes both women with intact
membrane and women with spontaneous
rupture of membranes but who are not in
labor.

3.  Pre-eclampsia and eclampsia
 Maternal medical complications like diabetes
mellitus, chronic renal disease, cholestasis of
pregnancy
 Post-maturity
 Abruptio placenta
 Intrauterine growth restriction

4.  Premature rupture of membrane
 Fetus with a major congenital anomaly
 Intrauterine death of fetus
 Oligohydramnios, polyhydramnios
 Unstable lie
 Lesser degree of placenta previa
 Rh-isoimmunization

5.  Contracted pelvis
 Cephalopelvic disproportion
 Malpresentation
 Previous caesarean section or hysterectomy
 High risk pregnancy with fetal compromise
 Heart disease
 Pelvic tumor

6.  Elderly primigravida with obstetric or
medical complications
 Cord prolapse
 Cervical carcinoma
 any contraindication for vaginal delivery
 Uteroplacental factors: unexplained vaginal
bleeding, vasaprevia, placenta previa

7. Maternal:
 emotional fear, anxiety
 uterine inertia: prolonged labor
 intrapartum infection
 violent labor: abruption placenta, uterine
rupture, cervical laceration
 amniotic fluid embolism

8. postpartum hemorrhage
Increased operative interference
Increased morbidity
Fetal:
Hypoxia
Iatrogenic prematurity (wrong dates)
Prolapsed cord
infection

9.  Induction of labor 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

10.  On cervical status, the specific method of
induction of labor and associated conditions
such as parity and rupture of membranes.
 Induction of labor should be performed with
caution since the procedure carries the risk of
uterine hyper stimulation and rupture and
fetal distress.
 Wherever induction of labor is carried out,
facilities should be available for assessing
maternal and fetal well-being.

11.  Women receiving oxytocin, misoprostol or
other prostaglandins should never be left
unattended.
 Failed induction of labor does not
necessarily indicate caesarean section.
 Wherever possible, induction of labor
should be carried out in facilities where
caesarean section can be performed.

12. Rating
Factor 0 1 2 3
Dilatation (cm) Closed 1-2 3-4 More than
5
Length of cervix (cm) More than 4 3-4 1-2 Less than 1
Consistency Firm Average Soft -
Position Posterior mid Anterior -
Descent by station of head
Descent by abdominal
palpation
-3
4/5
-2
3/5
-1, 0
2/5
+1, +2
1/5

13.  Medical: oxytocin, prostaglandin,
 Surgical:
 Artificial Rupture of Membrane (ARM)
 Low rupture of Membrane (LRM)
 High Rupture of Membrane (HRM)
 Stripping the membrane
 Combined method

14. Prostaglandin:
Prostaglandin act on the cervix to enable
ripening of cervix.
Prostaglandin E2 (PGE2) or cerviprime is
inserted in the posterior fornix of vagina,
usually in the form of 2-3 mg gel or 3mg
pessary, every 6 to 8 hours as one, two or
three doses as required.

15. Misoprostol (PGE1) is being used either
transvaginally or orally for IOL.
A dose of 25 mcg in the posterior fornix of
the vagina or orally 50mcg is found as
effective for cervical ripening and labor
induction. It is administered about 6 to 8
doses as necessary.

16. Oxytocin:
Oxytocin causes contraction.
2.5 units of oxytocin usually mixed with
500ml of dextrose or normal saline is given
intravenously.
Starting the infusion as 10 drops per minute,
infusion rate is increased by 10 dpm every 30
min until a good contraction pattern is
established, not exceeding 60 drops.

17. Medical
Surgical
Combined

18. MEDICAL INDUCTION
Drugs used:
Prostaglandins ( PGE2 , PGE1 )
Oxytocin
Mifepristone

19.  Prostaglandins:
Prostaglandin act on cervix
to enable ripening by a no. of different
mechanisms. PGE2 is primarily important for
cervical ripening and myometrial contraction.
PGE2 (dinoprostone - 0.5mg ;
6hrly 3-4 doses) increases the activity of
collagenase and also sensitizes myometrium to
oxytocin.

20. They cause increase in elastase,
glycosaminoglycan , dermatan sulfate and
hyaluronic acid levels in cervix causing
relaxation of cervical smooth muscle that
facilitates dilatation.
Misoprostol (PGE1 ) used tansvaginally
or orally (25µg ; 4hrly) is found to be either
superior or similarly effective to PGE2 for
cervical ripening and labor induction.

21. Advantages:
 Effective method in IUD or unfavourble
cervix.
 No anti-diuretic effect.
 Highly effective in ripening the cervix
during induction of labor.

22. Disadvantages :
 Requires fetal monitoring for 1-2hrs
 Risk for sustained contraction
 Sometimes causes vaginal soreness
 Nausea, vomiting or diarrhoea may be seen
 Very occasionally cause uterine
hyperstimulation affect FHR pattern
 Uterine rupture may occur with Misoprostol
thus is contraindicated in previous caeserian
section.

23.  Oxytocin :
Oxytocin is an endogenous uterotonic that
stimulates uterine contraction. Receptor
concentration increases during pregnancy and
labor. Oxytocin acts by :
a) Receptor mediation
b) Voltage-mediated calcium channels
c) Prostaglandin production
It is effective for induction of labor when
cervix is ripe as it is less effective as ripening
agent.

24. Advantages :
 Wider availability
 Less systemic effects
 Major catastrophe is rare
 Cheaper
Precautions:
 Never give oxytocin IM before delivery
 If FHR <100 bpm, stop the infusion
 Assess contraction 1/2hrly if hyperstimulation
occurs
 Water intocication with high or prolonged use
 Rupture may occur in multigravida and previous
c/s.

26.  Mifepristone :
( Progesterone receptor antagonists )
It blocks progesterone and corticosteroid
receptors. 200mg vaginally daily for 2days
has been found to ripen the cervix and to
induce labor.
Progesterone inhibits contraction of
the uterus, while mifepristone counteracts
its action.

27. SURGICAL INDUCTION
 Artificial rupture of membrane (ARM)
 Low rupture of membrane ( LRM)
 High rupture of membrane (HRM)
 Stripping of membranes

28. Artificial rupture of membrane
(ARM )
Low rupture of membrane ( LRM):
It is a procedure where the puncture or
rupture of the membrane below the
presenting part overlying the internal os to
drain some amount of amniotic fluid.

29. Indications:
 Abruptio placenta
 Chronic hydraminos
 Severe pre eclampsia/eclampsia
 In combination with medical induction
 To place electrode for fetal monitoring

30. Contraindications:
 Intra uterine fetal death
 Cephalo pelvic disproportion
 Prematurity
 Maternal AIDS or active genital herpes infection
 Oblique or transverse lie
 Contracted pelvis
 Pelvic tumor

31.  High rupture of membrane (HRM) :
It is the procedure in which puncture of
the hind waters above the presenting part, is
made by a special instrument named “drew
smythe catheter”.

32. Indications :
obselete these days. However used in
chronic hydraminos where regulated escape
of liquor amnii facilitates settling down of
presenting part.
Contraindications:
 Antepartum hemorrhage
 Severe preeclampsia/eclampsia

33. Mechanism of onset of labor by ARM:
 Stretching of cervix
 Separation of the membranes
 Reduction of amniotic fluid volume
Advantages of amniotomy:
a) High success rate
b) Chance to observe the amniotic fluid
c) Access to fetal scalp for electrode or
scalp blood sampling.

34. Immediate beneficial effects of ARM:
 Lowering of b.p in eclapsia; pre-eclampsia
 Relief of maternal distress in hydraminos
 Control of bleeding in APH
 Relief of tension in abruptio placenta and
initiation of labor

35. Hazards of ARM:
 Chance of cord prolapse
 Amnionitis
 Accidental injury
 Amniotic fluid embolism

36.  Stripping the membranes:
Stripping of the membrane means digital
seperation of the chorion and amnion from the
wall of cervix and lower uterine segment.
Effective method in uncomplicated pregnancy.
Prostaglandins are rapidly produced in the
procedure thus is used in cervical ripening as
well. It is safe simple and beneficial

37. Criteria for membrane stripping:
a) The fetal head must be well applied to the
cervix
b) The cervix should be dilated so as to allow
the introduction of examiner’s fingers
[ It is done prior to rupture of membrane as
well ]

39. COMBINED METHOD
The combined medical and surgical methods
are used to increase the efficacy of induction by
reducing the induction-delivery interval.
The oxytocin infusion is given either prior to
or following rupture of membranes depending
mainly upon the state of the cervix and head
brim relation.
With non-engaged head, induction with
prostaglandin or oxytocin followed by ARM is
preferable.

40. Advantage of combined methods:
 More effective than any single procedure
 Shortens the induction delivery interval
 Minimizes the risk of infection
 Lessens the period of observation

42.  Stimulate the uterus during labour to increase
the frequency, duration and strength of
contractions.
 It involves stimulation of uterine contraction
to produce delivery after the onset of
spontaneous labor.
 It is officially indicated when SBA diagnoses
“hypotonic uterine dysfunction” i.e.
contractions ineffective at producing cervix
dilatation.

43. Aims:
To expedite delivery within 12 hours without
increasing maternal mortality and pernatal
hazards.
Indications of augmentation:
 Labor is prolonged without any evident cause.
 Uterine contraction is ineffective and inefficient
 To prevent risk of hypoxia from prolonged labor.

44. Contraindications of augmentation:
 When labor is progressing normally
 Woman isn't in true labor
 Cephalopelvic disproportion
 Mechanical obstruction (complete placenta
previa)
 Abnormal presentation

45.  Grand multipara
 Previous uterine operation scar
 Fetal distress
 Cord prolapse and fetus is alive
 Multiple gestation

46.  Advantages of AMOL:
Less chance of dysfunctional labour
Shortens the duration of labor
Fetal hypoxia can be detected early
Low incidence of caeserian section.
Less analgesia
Less maternal anxiety.

47. Essential components of AMOL:
 Antenatal education about purpose and
procedure of AMOL.
 Woman is in true labor
 Partographic monitoring of labor
 Amniotomy with confirmation of labor
 Oxytocin augmentation if cervical dilatation
(1cm/hr)

48.  Delivery is completed within 12hrs of
admission .
 Epidural anaesthesia is needed.
 Fetal monitoring by intermittent auscultation
or by continous electronic monitoring
 Active involvement of the consultation
obstetrician.

49.  Definition :
It is a conduction of spontaneous labor in
a moderate degree of cephalo -pelvic
disproportion , in an institution under
supervision with watchful expectancy
,hoping for vaginal delivery .

50.  Aims:
Trial labor aims at avoiding an unnecessary
cesarean section and delivering a healthy
baby.

51.  Associated mid pelvic and outlet contraction.
 Presence of complicating factors like elderly
primigravida , malpresentation , postmaturity
, post cesarean section pregnancy ,pre –
eclamsia , medical disorders like heart disease
,diabetes , tuberculosis , etc.
 Where facilities of cesarean section are not
available round the clock .

52.  The management of trial labor requires
careful supervision and consideration . The
following guidelines are prescribed :
- the labor should ideally be spontaneous in
onset . But in cases where labor fails to start
even on due date , induction of labor may be
done .

53.  Oral feeding remains suspended and
hydration is maintained by intravenous drip.
Adequate analgesics is administered
.pethidine 50 – 100 mg intramuscularly .
 The progress of labor is mapped with
partograph
 To monitor the maternal health routine
check up includes

54. (a)to record 2 hourly pulse , blood pressure
and temperature .
(b)to observe the tongue periodically for
hydration .
(c)To note the urine output , urine for acetone
, glucose and
(d)IV fluids , drugs.

55.  If there is failure to progress due to
inadequate uterine contraction ,
augmentation of labor maybe done by
amniotomy along with oxygen infusion . On
no account should the procedure be
employed before the cervix is at least 3cm .
 After the membranous rupture , pelvic
examination is to be done

56. (a) to exclude cord prolapse
(b) To note the color of liquor.
(c) To assess the pelvic once more
(d) To note the condition of cervix including
pressure of presenting part on the cervix .

57.  Degree of pelvic contraction
 Shape of pelvis : flat pelvis is better than
android or generally contracted pelvis
 Favorable vertex presentation – anterior
parietal presentation with less parietal
obliquity is favorable

58.  Intact membranes till full dilatations of
cervix
 Effective uterine contractions .
 Emotional stability of women .

59.  Appearance of abnormal uterine contraction
 Cervical dilatation <1cm per hour (protacted
active phase )inspite of regular uterine
contractions
 Arrest of cervical dilatation and non descent
of fetal head inspite of oxytocin therapy

60.  Early rupture of membranes
 Formation of caput and evidence of
excessive moulding
 Fetal distress.

61.  It is indeed difficult to set a arbitrary time
limit which is applicable to all cases . One
should be individualized the case .
 So long the progress is satisfactory (evidence
by descent of head and progressive cervical
dilatation ) and maternal and fetal
condition remain good ,trail may be
continued safely .

62.  However , if any ominous features appears
,trial is to be terminated forthwith .
 Nowadays there is tendency to shorten the
duration of trial .inspite of adequate uterine
contractions , if there is arrest of uterine
dilation of cervix for a reasonable period (3-
4hrs ) in the active phase, labor is
terminated by cesarean section

63.  The methods are anyone of the following :
- spontaneous delivery :with or without
episiotomy (30%)
- forceps or ventouse (30%) :difficult forceps
delivery is to be avoided .
-cesarean section : judicious and timely
decision foe cesarean delivery is to be taken
. However ,is significant cases , the section is
done even before full dilations of cervix ,
the indication being uterine inertia or fetal
distress

64.  A trial is successful ,if a healthy baby is born
vaginally , spontaneously or by forceps or
ventose with the mother in good condition .
Delivery by cesarean section or delivery if
dead baby ,spontaneously or by craniotomy
is called failure of trial labor .

65.  It eliminates unnecessary cesarean section
electively decided upon .
 It eliminates injudicious use of premature
induction of labor with its antecedents
hazards
 A successful trial ensures the woman a good
future obstetrics .

66.  Test of disproportion remains unproven
when cesarean delivery is done due to fetal
distress or uterine dysfunction
 Increased perinatal morbidity or mortality
due to asphyxia or intracranial
hemorraghage when the trial is prolonged
and / or ends in difficulty delivery

67.  increased maternal morbidity due to effects
of prolonged labor and / or operative
delivery.
 Increased psychological morbidity when
the trial ends with a traumatic vaginal
delivery or in cesarean delivery .

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