13 . Induction of labor. Active management of labor.

Question 1

what is induction of labour ?

what are the indications for induction of labour ?

Answer 1

initiation of uterine contractions for the purpose of vaginal delivery

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ruptured membranes with chorioamnionitis

severe preeclampsia

membrane rupture without labour

non reassuring fetal status ,

posterm pregnancy

or elective in term - for comfort

maternal diabetes

Question 2

contraindications to induce pregnancy ?

Answer 2

appreciable macrosomia ,

malpresentation

cephalopelvic disproportion

multifetal gestation

severe hydrocephalus,

non reassuring fetal status

maternal related -prior classical c section or hysterectomy

active genital herpes

placenta previa

cervical cancer or pelvic tumor

Question 3

factors increase the success of labor induction

Answer 3

multiparty

gestation - term or post term

positive oxytocin sensitivity test

body mass index less than 30

cervical ripening

presence of fetal fibronectin in vaginal swab >50ng/ml

birth weight less than 3500g

bishop score >6 = favourable

Question 4

there needs to be two things to take place when inducing labour ?

Answer 4

cervical ripening - softening and

dilation of the cervix

Question 5

what is a quantifiable method to predict good outcomes for labour induction ?

Answer 5

scoring system by Bishop through manual vaginal examination

Question 6

what are is measured in scoring system by bishop ?

Answer 6

cervical dilation

cervical positioning

cervical effacement

cervical consistency

fetal occiput station

Question 7

bishop score system ?

Answer 7

bishop score 6-13 favourable

0 points 
no dilation
<40 percent effacement 
firm consistency 
posterior position 
station = -3 

1pts 
1-2cm 
<60 
medium 
midline 
-2 

2 pts 
3-4 cm 
<80 percent 
soft 
anterior 
-1 

3pts 
5 or more cm 
80 or more percent 
""
""
\+1

Question 8

a bishop score less than 6 needs what ?

Answer 8

needs cervical ripening

Question 9

what are the techniques for cervical ripening

Answer 9

prostaglandin E2 - dinoporstone
local gel application
tablet = GOLD STANDARD
intravaginal application -cervidil - string tampon -

pge1 -misoprostol cytotec / misoprost
only vaginal tablets

oxytocin

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non pharmacological

STRIPPING THE MEMBRANES

transcervical balloon catheter-

extra amniotic saline infusion

very controversial - but artificial rupture of the membranes (AMNIOTOMY) maybe used to increase uterine activity and perhaps speed cervical change , when performed in conjunction with administration of oxytocin

Question 10

why is misprostol preferred for cervical ripening ?

Answer 10

has shown to decrease the rate of oxytocin induction for labou

Question 11

what should the clinical management be when giving medication for cervical ripening ?

Answer 11

uterine activity and fetal heart rate should be monitored in all cases - these guidelines stem from that prostaglandin may cause uterine tachysystole.-
it is more commonly associated with vaginal administration

Question 12

what is the definition of uterine tachysystole ?

Answer 12

uterine tachysystole is defined as more than 6-10 contractions per minute

Question 13

what are other rare complication of using prostaglandin ?

Answer 13

other side effects uterine hypertonic - which is a single uterine contraction lasting more than 2 minutes

uterine hyperstimulation leads to unfavourable fetal heart conditions

misoportsol -meconium passage and possibly uterine rupture

Question 14

what are the contraindications for the use of prostaglandins ?

Answer 14

MISOPROSTOL - previous cesarean birth

asthma ,

glaucoma ,

increased intraocular pressure,

and caution with women predisposed to or had ruptured membrane

Question 15

describe the process of transcervical balloon catheter ?

Answer 15

Placement of a transcervical balloon catheter induces cervical ripening without causing significant uterine contractions

inserted either digitally during a vaginal examination or using direct visualization by sterile speculum exam with aseptic setting

transcervical Foley catheter balloon is advanced to or past the internal cervical os

then the balloon is filled with 30 mL–80 mL of sterile water.

The catheter is then placed on gentle traction by taping the distal tip to the medial thigh

maintain gentle traction, periodic repositioning of the distal tip on the thigh is necessary

Question 16

what is the procedure of extramniotic saline infusion ?

Answer 16

• saline infusion through transcervical catheter into the space between the internal cervical os and placental membranes

Question 17

what are osmotic mechanical / dilators ?

Answer 17

used to dilate the uterine cervix by swelling as they absorb fluid from surrounding tissue

act by release of endogenous prostaglandins from the membranes and maternal decidua to induce labor

dilators, = laminaria stick (desiccated seaweed),
lamicel (magnesium sulfate in polyvinyl alcohol) act by absorption of water

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hegar dilators - which are metal rods of different sizes (used treat vaginismus aswell)

Question 18

what are the techniques for induction of uterine contractions ?

Answer 18

medical -
PGE2 is primarily important for cervical ripening

whereas PGF2α carboprost myometrial contraction -IM

Misoprostol (PGE1) is currently being used either transvaginally or orally for induction of labor

vaginal more effective

intravenous oxytocin

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surgical :
membrane stripping

amniotomy- or artificial rupture of membranes

Question 19

what are the contraindication for oxytocin ?

Answer 19

contracted pelvis ,

preterm fetus with incomplete lung development

acute fetal distress

Question 20

what is a complication of oxytocin ?

Answer 20

tachysystole of uterine -fetal distress from ischemia

titanic contraction can occur leading to rupture of uterus

oxytocin has similar effect to antidiuretic - water reabsorption - severe water intoxication with convulsions and coma can occur rarely with infusion done 24 hours

prolonged infusion lead two uterine fatigue and post delivery uterus atony - increase the risk for post part haemorrhage

Question 21

what is the advantage of oxytocin over other medication to induce uterine contraction

Answer 21

advanatage of oxytocin is that discontinuation causes immediate effect of stopping contractions because its half like if approx 5 minutes
and its physiological effect will diminish quickly in 15 minutes

Question 22

the dose of oxytocin administration ?

Answer 22

oxytocin at 2mU/min - increases it as needed every 15 minutes -4,8,12

Question 23

what are the immediate beneficial effect of ARM ?

Answer 23

Lowering of the blood pressure in pre-eclampsia-eclampsia.

Relief of maternal distress in hydramnios.

Control of bleeding in APH.

Relief of tension in abruptio placentae and initiation of labor

Question 24

artificial rupture of the membrane always implies ?

Answer 24

Once the procedure is adopted, there is no scope of retreating from the decision of delivery

Question 25

complications for artificial rupture of membranes/ amniotomy ?

Answer 25

umbilical cord prolapse

Amnionitis

Accidental injury to the placenta, cervix or uterus, fetal parts or vasa previa

amniotic fluid embolism

Question 26

how do you prevent cord prolapse in in aminiotomy?

Answer 26

Fundal and suprabpubic pressure reduce the risk for cord prolapse

Question 27

what should immediately be done after amniotomy ?

Answer 27

fetal heart rate should always be assessed before and immediately

Question 28

contraindication of amniotomy ?

Answer 28

chronic hydramnios=sudden massive liquor drainage = Sudden uterine decompression = early placental separation

Question 29

procedure of amniotomy ?

Answer 29

Two fingers are introduced into the vagina smeared
with antiseptic ointment.

The index finger is passed the internal os.

The membranes are swept free from the lower segment as far as the finger and be reached.

With one or two fingers still in the cervical canal with the palmar surface upwards, a long Kocher’s forceps with its blades closed inserted up to the membranes

blades are opened to seize the membranes and are torn by twisting

If the head is not engaged, an assistant should push the head to fix it to the brim of the pelvis to prevent cord prolapse.

If the head is deeply engaged and the drainage of liquor is insignificant, gentle pushing of the head up

Question 30

what does stripping the membrane entail?

Answer 30

digital separation of the chorioamniotic membranes from the wall of the cervix and lower uterine segment

significant increase of serum levels of endogenous prostaglandins with stripping from the membranes and decidua

Manual exploration of the cervix triggers Ferguson reflex which promotes oxytocin release from maternal pituitary

used as a preliminary step prior to rupture of the membranes

Question 31

criteria fulfilled for membrane stripping?

Answer 31

fetal head must be well applied to the cervix;

The cervix should be dilated so as to allow the introduction of the examiner’s finger.

Question 32

what is the difference between induction vs augmentation

Answer 32

induction of labor is the process whereby labor is initiated by artificial means
and augmentation is the stimulation of labour that has already begun spontaneously but is insufficient

Question 33

who is active management of labour for ?

Answer 33

exclusively to primigravidas with singleton pregnancy and cephalic presentation who are in spontaneous labor and with clear liquor.

Partograph is maintained to record the progress of labor

Question 34

what re th essential components in active management of labour ?

Answer 34

Antenatal classes to explain the purpose and the procedure of AMOL

admitted in the labor ward only after the diagnosis of labor

One to one nursing care with partographic monitoring of labor

Amniotomy (ARM) with confirmation of labor

Oxytocin augmentation (escalating dose) if cervical dilatation is <1 cm/hr. (p. 576)

Delivery is completed within 12 hours of admission!

Epidural if needed

Fetal monitoring by intermittent auscultation or by continuous electronic monitoring

Question 35

what is the objective of active management labour ?

Answer 35

early detection of delay in labor

diagnose its cause and initiate management.

Question 36

what is the advantages of active management of labour ?

Answer 36

Correct use of the partograph =
>prevent and manage prolonged or obstructed labour and other serious complications such as a ruptured uterus, obstetric fistula and stillbirth.

> Shortens the duration of labor (< 12 hours)

> Fetal hypoxia can be detected early

> Low incidence of cesarean birth

> Less analgesia

> Less maternal anxiety due to support of the
caregiver and prenatal education.

Question 37

what is the components of partograph

Answer 37

> Fetal heart rate: recorded at an interval of thirty minutes.

> State of membranes and colour of liquor: “I” designates intact membranes, “C” designates clear and “M” designates meconium stained liquor.

> Cervical dilatation

> descent of head

> how many Uterine contractions per min : Squares are shaded according to duration and intensity.

> Drugs and fluids

> Blood pressure:

> Pulse rate:

> Oxytocin: Concentration and

> Urine analysis

> Temperature record