1. INDUCTION OF LABOUR

2. DEFINITION
Artificial stimulation of uterine contractions before spontaneous onset of labour with the purpose of accomplishing successful vaginal delivery

3. INDICATIONS FETAL MATERNAL IUFD Fetal anomaly incompatible with life
Severe IUGR
Rh isoimmunisation
Macrosomia
MATERNAL
Preeclampsia, eclampsia
PROM
Postterm preg
Abruptio placenta
Chorioamnionitis
Medical conditions- DM,Heart ds, Renal ds,Chr. HT etc

4. CONTRAINDICATIONS Severe degree CPD Major degree placenta praevia
Transverse lie
Previous classical CS,Myomectomy
Previous>= 2 LSCS
Grand multiparity
Active genital herpes
Hypersensitivity to inducing agent

5. RISKS OF INDUCTION Failure leading to CS Uterine hyperstimulation
Fetal distress,death
Rupture uterus
Intrauterine infection,sepsis
Iatrogenic delivery of preterm infant
Precipitate/dysfunctional labour
Inc. risk of operative vaginal delivery
Inc. risk of birth trauma
Inc. risk of PPH

6. Adverse Effects Tachysystole
Criteria: >10 contractions in 20 minutes
Dinoprostone Tachysystole Incidence: 33%
Misoprostol Tachysystole Incidence
Intravaginal gel or tablet: 31 to 49%
Oral crushed form or tablet: 16 to 22%

7. Uterine Rupture in VBAC
Hyperstimulation
Criteria
Exaggerated uterine response (i.e. Tachysystole)
Concerning Fetal Heart Rate tracing
Late Decelerations
Fetal Tachycardia >160 beats per minute
Dinoprostone Hyperstimulation Incidence: 17%
Misoprostol Hyperstimulation Incidence
Intravaginal gel or tablet: 8%
Oral crushed form or tablet: 1 to 2%
Uterine Rupture in VBAC
Risk: 2.5% in Trial of Labor after Cesarean

8. PREREQUISITES Establish indication clearly Informed consent
Conformation of gestational age
Assessment of fetal size & presentation
Pelvic assessment
Cervical assessment (BISHOPs score)
Availability of trained personnel

9. MOD. BISHOPS SCORE SCORE 1 2 3 DILATATION 1-2 3-4 >4 EFFACEMENT1 2 3
DILATATION
1-2
3-4
>4
EFFACEMENT
0-30%
40-50%
60-70%
>80%
STATION -3 -2
-1/0
+1,+2,+3
CONSISTENCY
firm
medium
soft
POSITION
posterior
mid
anterior

10. METHODS OF INDUCTION CHEMICAL NATURAL Breast/nipple stimulation
Sexual intercourse
Membrane stripping
Amniotomy
Acupuncture/acupressure
MECHANICAL
Balloon catheters
Lamineria tents
Synthetic osmotic dilators
CHEMICAL
NONHORMONAL
Herbs,evening primrose oil
Homeopathic prep
Enemas
Castor oil
HORMONAL
Oxytocin
Prostaglandins –PGE2,Misoprostol
Relaxin
Nitric oxide donors
mifepristone

11. Stripping of the Membranes
Stripping of the membranes causes an increase in the activity of phospholipase and prostaglandin as well as causing mechanical dilation of the cervix, which releases prostaglandins. The membranes are stripped by inserting the examining finger through the internal cervical os and moving it in a circular direction to detach the inferior pole of the membranes from the lower uterine segment. [Evidence level C]

12. contd.
Risks of this technique include infection, bleeding, accidental rupture of the membranes, and patient discomfort. The Cochrane reviewers concluded that stripping of the membranes alone does not seem to produce clinically important benefits, but when used as an adjunct does seem to be associated with a lower mean dose of oxytocin needed and an increased rate of normal vaginal deliveries. [Evidence level A, RCT]

13. Amniotomy.
It is hypothesized that amniotomy increases the production of, or causes a release of, prostaglandins locally. Risks associated with this procedure include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding from placenta previa or low- lying placenta, and possible fetal injury.

14. Balloon catheters
The Atad Ripener Device in place with the two balloons inflated. The uterine balloon is at the internal os and the cervicovaginal balloon is at the external os.

15. Prostaglandins
M/A :Act on the cervix to enable ripening by a number of different mechanisms.
They alter the extracellular ground substance of the cervix, and PG increases the activity of collagenase in the cervix.
They cause an increase in elastase, glycosaminoglycan, dermatan sulfate, and hyaluronic acid levels in the cervix. A relaxation of cervical smooth muscle facilitates dilation.
prostaglandins allow for an increase in intracellular calcium levels, causing contraction of myometrial muscle..

16. contd.
Risks associated with the use of prostaglandins include uterine hyperstimulation and maternal side effects such as nausea, vomiting, diarrhea, and fever.
Currently, two prostaglandin analogs are available for the purpose of cervical ripening, dinoprostone gel (CERVIPRIME: 0.5 mg ) and dinoprostone inserts (PRIMIPROST :10 mg ).

17. Technique for Placement of Dinoprostone Gel
Patient selection: Patient is afebrile. No active vaginal bleeding is present. Fetal heart rate tracing is reassuring. Patient gives informed consent. Bishop score is < 4.
Bring gel to room temperature before application, per manufacturer's instructions.

18. Initiate Fetal Heart Rate and tocometry
Start minutes before gel inserted
Continue monitoring for minutes after
Insertion Technique
Use one syringe of gel (0.5 mg )
Introduce gel into cervix
Just below level of internal os
Intracervical is preferred over posterior fornix (if leaking p/v posterior Fx)
Patient remains supine for 30 minutes

19. Dosing End points Drug interactions
Repeat every 6 hours up to 3 doses in 24 hours
End points
Bishop Score of 8 or greater
Strong uterine contractions
Drug interactions
Wait 6-12 hours before starting Pitocin

20. PGE2 GEL