Induction of labour

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• Induction of Labour- Complications

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• Dr. Sulsa M. Jain
• (MBBS,MD,DNB,MRCOG)
• Senior Specialist HOD, OBGYN, Ibra Hospital,
  Oman

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Topics Covered

• Introduction about IOL
• General complications of IOL
• IOL lscs
• How can we avoid complications during IOL
• Oxytocin and IOL
• Care of various high risk pregnancies during IOL
  to avoid complications
• Prostaglandins and IOL
• Sweeping stretching
• Artificial rupture of membranes
• Intracervical Foleys catheter balloon

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Introduction

• Labor induction appears to be becoming more and
  more popular. In fact, between 15 and 30 of
  pregnant women choose to have labor induced in
  one or more of their pregnancies.

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• An intervention designed to artificially initiate
  uterine contractions leading to progressive
  dilatation and effacement of the cervix and birth
  of the baby.
• This includes both women with intact membranes
  and women with spontaneous rupture of the
  membranes but who are not in labour.
• The term is usually restricted to pregnancies at
  gestations greater than the legal definition of
  fetal viability(26wk)

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Complications of Induction

• May fail and require caesarean section.
• All the complications of a normal vaginal
  delivery, plus
• Uterine hyperstimulation fetal distress and
  hypoxic damage to the baby
• Uterine rupture, especially in multiparous women
• Intrauterine infection with prolonged membrane
  rupture without delivery (less likely if labour
  occurs within 12 hours)
• Prolapsed cord can occur with first rush of
  amniotic fluid, if presenting part not well
  engaged
• Amniotic fluid embolism

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• Induced labour has an impact on the birth
  experience of women. 
• It is less efficient
• and more painful than spontaneous labour, often
  leading to the increased use of analgesics and
  other pain-relieving pharmaceuticals
• and is also more likely to require epidural
  anaesthesia and assisted delivery. 
• 1.5x increased risk of operative vaginal delivery
  and 1.8x increased risk of caesarean

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When to induce

• Until recently, the most common practice has been
  to induce labor by the end of the 42nd week of
  gestation. This practice is still very common.
  Recent studies have shown an increasing risk of
  infant mortality for births in 41st and
  particularly 42nd week of gestation, as well as a
  higher risk of injury to the mother and child .
• The recomended date for induction of labor has
  therefore been moved to the end of the 41 week of
  gestation in many countries including Sweden and
  Canada.

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IOL LSCS

• It has been said that IOL has lead to an
  increased likelihood of caesarean section
  delivery for the baby. (Roberts 2000). However,
  studies into this matter indicates that induction
  has no effect on the rates of caesarean section.
  Two more recent studies have shown that induction
  may increase the risk of caesarean section if
  performed before the 40th week of gestation, but
  has no effect or actually lowers the risk if
  performed after the 40th week.

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How to avoid complications

• It should be used when it is thought that the
  baby will be safer delivered than it is in utero.
• The process of induction of labour should only be
  considered when vaginal delivery is felt to be
  the appropriate route of delivery
• Verbal advice should be supported by accurate
  printed information, in a format that women can
  understand and which they may take away with them
  and read before the procedure.

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• Check prior to induction
• Lie
• position
• amniotic fluid
• cervix this is best predictor of readiness for
  induction and can be scored using Bishop's
  system If score gt8, probability of successful
  delivery with induction as same as spontaneous
  onset of labour.
• tone of uterus

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• When undertaking induction of labour in women,
  with recognized risk factors (e.g. Including
  suspected fetal growth compromise, previous
  caesarean section and high parity) the clinical
  discussion regarding the timing and method of
  induction of labour should be undertaken at
  consultant level.
• The induction process should not occur on an
  antenatal ward. C

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• Wherever induction of labour occurs, facilities
  should be available for continuous uterine and
  FHR monitoring. (C)
• And also the facilities for performing vaginal
  instrumental delivery and lscs should be there.

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Oxytocin IOL

• Where oxytocin is being used for
• induction or augmentation of labour,
• continuous electronic fetal monitoring should
• be used. (C)

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A comparison of different regimens of oxytocin
administration

• To reduce error, a standard dilution should
  always be used. Suggested standardised dilutions
  and dose regimens include C
• 30 iu in 500 ml of normal saline hence 1ml/hr
  1milliunits oxytocin per minute
• 10 iu oxytocin in 500 ml of normal saline hence
  3 ml/hr 1milliunits oxytocin per minute

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• In cases of uterine hypercontractility with a
  suspicious or pathological CTG secondary to
  oxytocin infusions, the oxytocin infusion should
  be decreased or discontinued. (B)
• In the presence of abnormal FHR patterns and
  uterine hypercontractility (not secondary to
  oxytocin infusion), tocolysis should be
  considered. (A)

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oxytocin

• Increased contractions
• Fetal distress
• Rupture uterus
• Amniotic fluid embolism

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Uterine hypercontractility

• Tachysystole (more than five contractions per ten
  minutes for at least 20 minutes)
• uterine hypersystole/hypertonus
• (a contraction lasting at least two minutes).

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Combination of oxytocin and other methods

• Oxytocin should not be started for six hours
  following administration of vaginal
  prostaglandin.
• In women with intact membranes, amniotomy should
  be performed where feasible prior to commencement
  of an infusion of oxytocin. C
• When induction of labour is undertaken with
  oxytocin the recommended regimen is
• a starting dose of 1-2 milliunits per minute
• increased at intervals of 30 minutes or more.

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Comparison of oxytocin and prostaglandins for
induction of labour

• Prostaglandins should be used in preference to
  oxytocin when induction of labour is undertaken
  in either nulliparous or multiparous women with
  intact membranes, regardless of their cervical
  favourability. A
• Either prostaglandins or oxytocin may be used
  when induction of labour is undertaken in
  nulliparous or multiparous women who have
  ruptured membranes, regardless of cervical
  status, as they are equally effective. A

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• Care of
• higher-risk
• pregnancies

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with suspected fetal growth compromise

• Fetus with compromised growth enter labour in an
  increased state of vulnerability and are more
  likely to become acidotic
• No studies that considered induction of labour
  specifically in babies with suspected fetal
  growth compromise.

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women with a previous caesarean section

• Careful consideration of the risks of an
  induction of labour versus the risks of an
  elective caesarean section should be made in
  light of the woman's wishes and views.
• Induction of women with previous caesarean
  section should follow the working algorithm with
  careful consideration of cervical status and
  membrane status.

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Women with Breech

• The perinatal mortality was lower for planned
  caesarean section compared with planned vaginal
  breech delivery .Hence, no conclusions can be
  reached from these data regarding induction of
  labour with a breech presentation.(1b)

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women of high parity

• Induction of labour in women of high parity with
  standard oxytocin regimens may be associated with
  an increase in uterine rupture.

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Diabetic Mothers

• Women who have pregnancies complicated by
  diabetes should be offered induction of labour
  prior to their estimated date for delivery. (c)
  However, the potential benefits of induction need
  to be balanced against the potential to increase
  the risk of pulmonary complications in the fetus.
• The risk of macrosomia (birth weight over 4000 g)
  was reduced in those women who were actively
  induced (1a)

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Multifetal pregnancy

• The perinatal mortality rate in twin pregnancies
  is increased in comparison with singleton
  pregnancies at term.
• No conclusions can be drawn from the available
  trial evidence relating to the merits of an
  active policy of induction of labour in
  uncomplicated multifetal pregnancies.

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Prelabour Rupture of the Membranes

• most women go into spontaneous labour within 24
  hours of rupturing their membranes.
• 86 of women will labour within 12-23 hours.
• 91 will labour within 24-47 hours.
• 94 will labour within 48-95 hours.
• 6 of women will not be in spontaneous labour
  within 96 hours of PROM. IIa

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• There is no difference in operative delivery
  rates between induction versus a conservative
  approach in women with prelabour rupture of the
  membranes.
• A policy of induction of labour is associated
  with a reduction in infective sequelae for mother
  and baby.

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• Women with prelabour rupture of the membranes
  at term (over 37 weeks) should be offered a
  choice of immediate induction of labour or
  expectant management. A
• Expectant management of women with prelabour
  rupture of the membranes at term should not
  exceed 96 hours following membrane rupture A

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Macrosomic fetus

• all methods currently used to estimate fetal size
  especially for large fetuses are poorly
  predictive.
• the evidence is inconclusive that a policy of
  induction of labour for suspected fetal
  macrosomia in women who are not diabetic can
  reduce maternal or neonatal morbidity.

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Maternal Request

• Where resources allow, maternal request for
  induction of labour should be considered when
  there are compelling psychological or social
  reasons and the woman has a favourable cervix .

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IOL with prostaglandin

• For women who are healthy and have had assessment
  of fetal wellbeing following the administration
  of vaginal prostaglandins in an otherwise
  uncomplicated pregnancy, an initial assessment
  should be with continuous electronic fetal
  monitoring and, once normality is confirmed,
  intermittent monitoring can be used.

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A comparison of intracervical and intravaginal
prostaglandins (PGE2 )

• When induction of labour is undertaken with
  prostaglandins, intravaginal PGE 2 should be used
  in preference to intracervical preparations, as
  they are equally effective and administration of
  vaginal PGE 2 is less invasive. A

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Prostaglandin gels

• These gels have been associated with nausea,
  fever, diarrhea.

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A comparison of different preparations of vaginal
prostaglandin (PGE2

• Given that they are clinically equivalent, when
  induction of labour is undertaken with vaginal
  PGE 2 preparations, vaginal tablets should be
  considered in preference to gel formulations. A

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Vaginal or oral misoprostol (PGE1)

• The caesarean-section rate was not different
  between oral and vaginal preparations. Ia
• Vaginal misoprostol appears to be a more
  effective induction agent than either
  intravaginal or intracervical PGE 2 or oxytocin.
• Misoprostol is significantly cheaper than
  currently recommended PGE 2 preparations.

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Misoprostol

• The safety issues concerning the use of vaginal
  misoprostol are unclear.
• Further clinical trials are warranted in order to
  evaluate further the issues of safety regarding
  the use of vaginal and oral misoprostol for
  induction of labour using commercially produced
  low-dose tablets

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Membrane sweeping for induction of labour

• Sweeping the membranes during a cervical
  examination is done to bring on labour in women
  at term.
• Prior to formal induction of labour, women should
  be offered sweeping of the membranes. A
• it is typically performed at your local clinic,
  and you can go home afterwards and wait for the
  results.
• Sweeping the membranes is effective in bringing
  on labour

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Membrane sweeping

• The review of trials found that sweeping brings
  on labour and is generally safe where there are
  no other complications.
• Sweeping reduces the need for other methods of
  labour induction such as oxytocin or
  prostaglandins
• It is not associated with an increase in maternal
  or neonatal infection
• but can cause discomfort, some bleeding and
  accidental rupture of the amniotic sac, irregular
  contractions.
• However, these complications are quite rare.

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Artificial Rupture of Membranes

• Cochrane Review showed that amniotomy reduced
  labour by 60-120 minutes, but did not improve
  outcome. There was also a perception of increased
  pain associated with the procedure and
  potentially more variable decelerations on
  cardiotocograph.

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• There are some risks associated with this
  technique, though. If too much time elapses
  between the procedure and labor, there is a
  possibility of infection. The technique can also
  increase your risk of experiencing intense
  contractions during labor.

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trans-cervical Foley catheter for labor induction

• The balloon had to be removed due to
  complications in 95 (8.8). The main
  complications were
• acute transient febrile reaction in 32 (3),
• non-reassuring fetal heart rate tracing in 22
  (2),
• vaginal bleeding in 20 (1.8),
• unbearable pain that necessitated removal of the
  catheter in 19 women (1.7) and
• altered presentation from vertex to breech in 14
  (1.3).

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• there is some evidence that the use of a foley
  catheter is linked with an increase in risk of
  having a subsequent preterm birth.

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• THANK YOU