1. Dr. Yasir Katib MBBS, FRCSC, Perinatologest Dr. Yasir Katib MBBS, FRCSC, Perinatologest

2. Objectives Basic principles Indications and contraindications of induction of labour Methods of induction Prediction of success Induction after cesarean

3. Histology The fundus is composed of myometrium, predominantly smooth muscle cells and the endometrium The normal pregnant cervix is 3.5 cm or longer and is composed predominantly of connective tissue, mainly collagen. In contrast to the fundus, it has only 10-15% smooth muscle

4. Introduction Definition It is an iatrogenic stimulation of uterine contractions to accomplish delivery prior to the onset of spontaneous labor Induction of labour is done when the benefits of expeditious delivery outweigh the potential maternal or fetal risks of the procedure Rate 15-25%

5. Indications Either maternal or fetal indications with the following criteria : 1. Continuing the pregnancy is believed to be associated with greater maternal or fetal risk than intervention to deliver the pregnancy 2. There is no contraindication to vaginal birth

6. Indications Examples of common and Obstetrical conditions  postterm pregnancy  prelabor (premature) rupture of membranes  intrauterine fetal growth restriction  fetal demise Medical conditions  preeclampsia/eclampsia  GDM on insulin

7. Gestational Age at Induction

8. Gravidity

9. Parity

10. Concerns Major concerns Increase rates of cesarean delivery Iatrogenic prematurity Cost Neonatal safety Maternal safety Infection

11. Contra-indications Absolute Prior classical uterine incision Prior transmural uterine incision entering the uterine cavity Active genital herpes infection Placenta or vasa previa Umbilical cord prolapse Transverse fetal lie Relative (with caution) previous low transverse cesarean delivery multifetal pregnancy

12. Methods of induction Mechanical 1. Membrane sweep 2. Artificial rupture of membrane 3. Balloon catheter 4. Laminaria Hormonal 1. Prostaglandin 2. Oxytocin Natural methods 1. Caster oil

13. Induction of labour

14. Methods of Induction

15. Cervical ripening Associated with cervical ripening is an increase in the enzyme cyclooxygenase-2, which leads to a local increase of prostaglandin E2 (PGE2) in the cervix that led to: 1. Dilatation of small vessels in the cervix 2. Increase in collagen degradation 3. Increase in hyaluronic acid 4. Increase in chemotaxis for leukocytes, which causes increased collagen degradation 5. Increase in stimulation of interleukin (IL)–8 release

16. Bishop score

17. PREDICTING A SUCCESSFUL INDUCTION Using Bishop score Score < 5 suggests further ripening is needed Score 5-7 is equivocal score >7 suggests that ripening is completed

18. Type of Delivery

19. Induction after cesarean Induced labor after cesarean delivery have a 2- to 3- fold increased risk of cesarean delivery compared with those who present with spontaneous labor Associated risks: 1. Rupture of uterus 2. Emergency cesarean