ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
induction of labor - A Clinical Case Discussion
1. CASE
A 24 year old Puan Nina was admitted to hospital on 8th August at
8.50 am for the induction of labour for post maturity, her
pregnancy gestation is 40 weeks and 1 day.
Previous Obstetric history:
Gravid 3, Para 2, two previous normal deliveries. No history of any
medical problems and no problems identified in this pregnancy.
At 8.50am admitted to the Labour ward, no signs of labour on
admission and the findings from the vaginal examination were
that the cervix was 2 cm dilated. Decision was made to do an ARM
(artificial rupture of membranes) and to commence Syntocinon.
2. CASE
The woman progressed well in labour and had a normal
delivery of a female infant at 1.19pm, The infant's
weight was 3.5kg, Apgar scores were 9 at 1 & 5 minutes.
4. DEFINITIONS
Induction of Labor (IOL) is defined as artificial initiation
of uterine contractions before the spontaneous onset
of labor.
Augmentation of labor refers to stimulation of
spontaneous contractions that are considered
inadequate because of failed cervical dilation and fetal
descent.
5. INDICATION
FOR INDUCTION
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1. pre-eclampsia, eclampsia,
chronic hypertension > 37wks
2. Diabetes, renal disease,
chronic pulmonary disease
3. Premature rupture of
membranes
4. Chorioamnionitis
5. Fetal growth restriction
6. Rh isoimmunization
7. Postdated pregnancy
8. Fetal demise
9. Abruptio placentae
10.Fetal malformations
incompatible with life
11.Logistic factors: Risk of rapid
labor, distance from hospital,
psychosocial indications
6. CONTRAINDICATION
OF INDUCTION
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1. Placenta praevia or Vasa praevia
2. Cord presentation
3. Abnormal fetal lie/ presentation
4. Cephalopelvic disproportion because of malpresentation or abnormal
pelvic bone structure
5. Active genital Herpes infection
6. Invasive cervical carcinoma
7. Hypersensitivity to cervical ripening agents
8. Previous uterine rupture
7. CONTRAINDICATION
OF INDUCTION
11
1. Multiple pregnancy
2. Polyhydramnios
3. Grand multiparity
4. Maternal heart disease.
5. Severe hypertension.
6. Breech presentation
7. One or more previous cesarean section
8. Abnormal fetal heart rate not requiring emergency cesarean section
CONDITIONS WHERE IOL IS NOT A TRUE CONTRAINDICATION BUT WHERE SPECIAL
CAUTION IS REQUIRED :
8. 1
RISK OF IOL
MATERNAL RISKS
I. Failure leading to Cesarean section
II. Uterine hyperstimulation
III. Rupture uterus
IV. Intrauterine infection, Chorioamnionitis
V. Amniotic Fluid Embolism
VI. Precipitate labor , Dysfunctional labor
VII.Increased risk of operative vaginal delivery
VIII.Increased risk of post partum hemorrhage
IX. Abruptio Placentae
X. APH from undiagnosed placenta praevia
XI. Water intoxication
9. 1
RISK OF IOL
FETAL RISKS
I. Fetal distress .
II. Fetal death
III. Neonatal sepsis
IV. Iatrogenic delivery of a preterm infant
V. Cord prolapse
VI. Neonatal jaundice
VII.Increased risk of birth trauma
10. PRE- REQUISITES
FOR IOLI. Evaluate the indication
II. Explain the indication to the patient + details of the method to
be used and take a written informed consent
III. Assess adequacy of the pelvis and fetal size
IV. Confirm the gestational age, fetal lie, and assess the fetal lung
maturity # where ever indicated
V. Uterine activity and FHR should be continuously monitored. In
case of clinical auscultation, FHR should be heard during and for
30 seconds after a contraction at least every 15 minutes during
the active phase of labor and after every contraction in the
second stage
VI. Partogram is to be maintained for active labour
VII.Trained personnel and well equipped center
11. PRE INDUCTION CERVICAL
ASSESSMENT:
Modified Bishop’s Preinduction cervical scoring system: to determine the
suitability of a patient for IOL in patients who were parous, at term , had an
uncomplicated pregnancy and the fetus was in cephalic presentation.
FACTOR 0 1 2 3
Dilatation (cm) 0
(closed)
1 – 2 3 – 4 5
Length (cm) >4 3 – 4 1 – 2 0
Position Posterior Midline Anterior -
Consistency Firm Medium Soft -
Head: station -3 -2 -1 , 0 +1 , +2
Score
Total Score =13
Favourable Score= 6-13
Unfavourable Score= 0-5
12. METHODS OF CERVICAL
RIPENING AND IOL
Methods for cervical ripening and labor induction can be broadly
classified as :
PHARMACEUTICAL
MECANICAL
SURGICAL
13. METHODS OF CERVICAL
RIPENING AND IOL
MECHANICAL
• Sweeping of membrane
Membrane stripping at term shortens the interval of time to onset of
spontaneous labor and reduces the need for formal induction.
• Foley's catheter
This uses the same mechanism as sweeping but the inflated bulb of Foley’s
results in release of endogenous prostaglandins and initiates labor.
14. METHODS OF CERVICAL
RIPENING AND IOL
• Exogenous Prostaglandins
Prostaglandins (E2) are effective for both cervical ripening and- labor
induction. Prostaglandin E2 are typically administered intravaginally for
cervical ripening as the first step in labor induction. They are administered
as gel, tablet or controlled release pessary.
The recommended regimens are:
One cycle of vaginal PGE2 tablets one dose 3mg in a nulliparous and 0.5
mg in a multipara, followed by second dose after 6 hours if labor is not
established . Maximum of 2 doses in a cycle.
One cycle of vaginal PGE2 controlled release pessary one dose over 24
hours.
PHARMACEUTICAL
15. METHODS OF CERVICAL
RIPENING AND IOL
intravaginal PGE2 are the preferred method of induction of labor,
unless there are any specific indications for not using it like the
risk of uterine hyperstimulation.
Prostaglandins PGEl – Misoprostol
Although studies have demonstrated that misoprostol is an
effective agent in induction of labor, there are concerns regarding
its safety and until the best dosage regimen is determined, its use
in labor induction is confined to clinical trials.
PHARMACEUTICAL
17. METHODS OF CERVICAL
RIPENING AND IOL
Oxytocin
Increase in responsiveness with advancing gestational age. Once spontaneous
labor begins the uterine sensitivity to endogenous oxytocin increases rapidly.
The dose is typically increased until there is normal progress of labor or strong
contractions occurring at 4 contractions per ten minutes and lasting for at
least 45 seconds. There is no benefit to increasing the dose after one of these
endpoints has been achieved. Continuous monitoring of uterine activity and
fetal heart rate are important once oxytocin is in use .
SURGICAL
18. METHODS OF CERVICAL
RIPENING AND IOL
Amniotomy
It is an effective method of labor induction but can only be performed in
patients with partially dilated and effaced cervices.
The obstetrician should ensure that the fetal vertex is well-applied to the
cervix and the umbilical cord or other fetal part is not the presenting part.
The fetal heart rate before and after the procedure has to be documented and
the color of the amniotic fluid should be noted.
SURGICAL
19. CERVICAL RIPENING &
SUCCESSFUL INDUCTION
Oxytocin is less effective for labor induction when used in
women with uneffaced and undilated cervices. Therefore, a
ripening process should be used prior to oxytocin induction
when the cervix is unfavorable.
The two major methods are as follow:
I. Mechanical (physical) interventions, such as disruption
of the fetal membranes or insertion of dilators or a
balloon catheter.
II. Application of cervical ripening agents, such as
prostaglandin compounds.