13 . Induction of labor. Active management of labor. Flashcards
what is induction of labour ?
what are the indications for induction of labour ?
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
contraindications to induce pregnancy ?
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
factors increase the success of labor induction
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
there needs to be two things to take place when inducing labour ?
cervical ripening - softening and
dilation of the cervix
what is a quantifiable method to predict good outcomes for labour induction ?
scoring system by Bishop through manual vaginal examination
what are is measured in scoring system by bishop ?
cervical dilation
cervical positioning
cervical effacement
cervical consistency
fetal occiput station
bishop score system ?
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
a bishop score less than 6 needs what ?
needs cervical ripening
what are the techniques for cervical ripening
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
why is misprostol preferred for cervical ripening ?
has shown to decrease the rate of oxytocin induction for labou
what should the clinical management be when giving medication for cervical ripening ?
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
what is the definition of uterine tachysystole ?
uterine tachysystole is defined as more than 6-10 contractions per minute
what are other rare complication of using prostaglandin ?
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
what are the contraindications for the use of prostaglandins ?
MISOPROSTOL - previous cesarean birth
asthma ,
glaucoma ,
increased intraocular pressure,
and caution with women predisposed to or had ruptured membrane
describe the process of transcervical balloon catheter ?
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
what is the procedure of extramniotic saline infusion ?
- saline infusion through transcervical catheter into the space between the internal cervical os and placental membranes
what are osmotic mechanical / dilators ?
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)
what are the techniques for induction of uterine contractions ?
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
what are the contraindication for oxytocin ?
contracted pelvis ,
preterm fetus with incomplete lung development
acute fetal distress
what is a complication of oxytocin ?
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
what is the advantage of oxytocin over other medication to induce uterine contraction
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
the dose of oxytocin administration ?
oxytocin at 2mU/min - increases it as needed every 15 minutes -4,8,12
what are the immediate beneficial effect of ARM ?
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
artificial rupture of the membrane always implies ?
Once the procedure is adopted, there is no scope of retreating from the decision of delivery
complications for artificial rupture of membranes/ amniotomy ?
umbilical cord prolapse
Amnionitis
Accidental injury to the placenta, cervix or uterus, fetal parts or vasa previa
amniotic fluid embolism
how do you prevent cord prolapse in in aminiotomy?
Fundal and suprabpubic pressure reduce the risk for cord prolapse
what should immediately be done after amniotomy ?
fetal heart rate should always be assessed before and immediately
contraindication of amniotomy ?
chronic hydramnios=sudden massive liquor drainage = Sudden uterine decompression = early placental separation
procedure of amniotomy ?
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
what does stripping the membrane entail?
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
criteria fulfilled for membrane stripping?
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.
what is the difference between induction vs augmentation
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
who is active management of labour for ?
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
what re th essential components in active management of labour ?
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
what is the objective of active management labour ?
early detection of delay in labor
diagnose its cause and initiate management.
what is the advantages of active management of labour ?
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.
what is the components of partograph
> 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
