1. Induction of lobour By :- Hasanain Ghaleb Khudhair 4 th stage medical student College of Medicine/karbala university-Iraq E-mail:- hasanain.ghaleb@gmail.com Supervisor :- Dr. Mousa Mohsin Ali AL-Allak Consult gynecologist and obstetrician College of Medicine/karbala university-Iraq Department of gynecology and obstetric 29/ 3/ 2016

2. Questions welcome at any time

3. Scenario 1  Primigravida,,, 42w by first trimester US  Antinatal care normal  Fetus well growth, longitudinal lie, cephalic presentation  Mother wishes to have labour induced  Apart of some irregular uterine contraction she has not gone to spontaneous labour.  Opinion ??  Indication??

4. Scenario 2  Gravid 3, Para 2, two previous caesarian deliveries  Antinatal care normal  Fetus well growth, longitudinal lie, cephalic presentation  Mother wishes to have labour induced  Apart of some irregular uterine contraction she has not gone to spontaneous labour  Opinion??  Contraindication??

5. Scenario 3  Primigravida,,, 42w by second trimester US  Antinatal care normal  Fetus well growth, longitudinal lie, cephalic presentation  Mother wishes to have labour induced  Apart of some irregular uterine contraction she has not gone to spontaneous labour.  Induction of labour was performed _______ she came with C/S  Whats the explanation??  Complication??

6. Objuctives  Definition  Indications  Contraindications  The Bishop score  METHODS OF INDUCTION  Risk of induction of labour

7. Definition  planned initiation of uterine contractions prior to its spontaneous onset.  Vaginal  Fetal viable  when it is agreed that the mother or fetus will benefit from a higher probability of healthy outcome than if birth is delayed.  Approximately one in five deliveries in the United Kingdom occur following induction of labour.

8. Indications  Prolonged pregnancy  Fetal growth restriction  Prelabour rupture of membranes (term, infection)  Diabetes mellitus  Twin pregnancy continuing beyond 38 weeks  ‘Social’ reasons

9.  Pre-eclampsia and other maternal hypertensive disorders (earlier)  Deteriorating maternal illnesses  Unexplained antepartum hemorrhage  Intrahepatic cholestasis of pregnancy

10. Contraindications absolute contraindications  placenta praevia  severe fetal compromise.  Transverse lie  Cord presentation and prolapse  Pelvic structural deformity/CPD

11.  Breech presentation is a relative contraindication to IOL, and women with a previous history of caesarean birth need to be informed of the greater risk of uterine rupture.

12. Bishop score

15.  As the time of spontaneous labour approaches, the cervix becomes softer, shortened, moves forward and starts to dilate. This reflects the natural preparation for labour.  Bishop produced a scoring system to quantify how far this process had progressed prior to the IOL.  High scores are associated with an easier, shorter induction that is less likely to fail.  Low scores point to a longer IOL that is more likely to fail and result in Caesarean section.

16. “ ” METHODS OF INDUCTION

17. Natural-Non Medical methods 1-Relaxation techniques: relieve tension and visual aids to show how labor starts. 2-Visualization: imagine her uterus contracting. 3-Walking: The force of gravity 4-Nipple stimulation: 2 minutes alternating with 3 minutes of rest 5-Bath/Castor oil/Enemas:

18. Surgical Methods Sweeping/Stripping of Membranes  Finger inserted in internal os is moved circumferentially, when cervix is sufficiently dilated or try to open the cervix or cervical massage, when closed  Releases phospoholipase A2 and ↑ production of PGF2α

20. Concerns: Patient discomfort Bleeding Accidental rupture of membranes Initiation of irregular uterine contractions.

21.  Amniotomy  Artificial rupture of membranes  Alone is not recommended as a method of induction of labor  Complications: 1- cord prolapse 2- if sudden rupture of membranes in polyhydramnios there is risk of placental abruption 3-infection.

23. Pharmacological Methods Prostaglandins Oxytocin Mifepristone Relaxin.

24. Prostaglandins Prostaglandins used in induction are PGE2 (Dinoprostone) and PGE1 (Misoprostol). side effects Bronchospasm Shivering Contraindications??? (+glaucoma)

25.  How they act? (Uterus and cervix)  Different mechanisms of cervical ripening are involved: They alter the extracellular ground substance of cervix PGE2 increases activity of collagenase in cervix Relaxation of smooth muscle of cervix facilitates dilatation.

26.  Benefits of misoprostol Inexpensive Stored at room temperature No refrigeration required, therefore easily transported Shorter induction to delivery interval Lower cesarean section rates.

27. Risks and Side Effects of Prostaglandins  Uterine hyperstimulation Defined as either occurrence of uterine contractions each lasting > 60 seconds, or occurrence of> 4 contractions in 10 minutes, regardless of the state of the fetus Tocolytics should always be available

28.  Uterine rupture Risk – 5.6% with misoprostol – 0.2% with dinoprostone.  Uterine tachysystole after PGE2  Pain relief after induction of labor Simple analgesics by oral route Epidural analgesia can be offered.

29. Oxytocin IV oxytocin is used for induction of labor since 1950 Oxytocin activates the phospholipase C- inositol pathway and increases intracellular calcium levels, stimulating contractions in myometrial smooth muscle

30. Side effects 1.Are principally dose related 2.Uterine tachysystole or category II or III FHR tracings are the most common side effects 3.Hypotension may occur following a rapid IV injection of oxytocin, so is always diluted when used for induction.

31. Low dose Decreased uterine tachysystole High dose Shorter labor duration Less chances of chorioamnionitis Decreased number of cesarean sections for dystocia Increased chances of uterine tachysystole.

32. Risks of induction of labour 1. Greater pain in labour 2.Uterine hyperstimulation 3.Cord prolapse 4.Greater risk of uterine rupture during VBAC 5.Failure ? 6.Increased need for Caesarean or instrumental delivery 7.Fetal compromise

33. references 1.Clinics in Obstetrics (book) 2.Ten teacher (book) 3.Dr. mousa lecture 2015 (lecture) 4.Google image (website) 5.core-clinical-cases-in-og-signed (book) 6.Stewart RD, Bleich AT, Lo Jy, et al. Defining uterine tachysystole: how much is too much?. Am J Obstet Gynecol. 2012 Oct;207(4):290.e1-6. (article)

34. “ ” Any Questions????