1. INDUCTION OF LABOUR2. AUGMENTATION OF LABOUR3. PROLONGED LABOUR4. DELAYED SECOND STAGE5. INSTRUMENTATION:

FORCEPS/VENTOUSE

SPECIAL CIRCUMSTANCES DURING LABOUR

INDUCTION•Process whereby labor is

initiated by artificial means

AUGMENTATION•Artificial stimulation of

labor that has begun spontaneously

DEFINITION

INDICATIONS for inductions

Pre-eclampsiaDiabetes mellitus

Heart diseaseProlonged pregnancy

IUGRUnexplained antepartum

haemorrhage

Abnormal fetal testingRh incompatibility

Fetal abnormality ie anencephaly

PROMChorioamnionitis

Intra-uterine death

PROLONGED PREGNANCY

Or post-term pregnancy is one that persists beyond 42 weeks from onset of last normal menstrual period

Incidence 6% - 12% of all pregnancies2-3 times perinatal mortalityEtiology:

Unknown mostly Anencephalic fetus (lack of fetal labor-initiating factor

from hypoplastic fetal adrenals) Placental sulfatase deficiency & extra-uterine

pregnancy

POSTMATURITY SYNDROME

Occurs when growth-restricted fetus remains in utero beyond term

Features: loss of subcutaneous fat long fingernails dry & peeling skin abundant hair

Aging & infarction of placenta in post-term pregnancy

Placental insufficiency- impaired oxygen and nutrients delivery

Some have intra-uterine growth restriction (IUGR)

But if fetus not affected by placental insufficiency, can continue to grow to the point of macrosomia

Abnormal labor, shoulder dystocia, birth trauma, increase risk for cesarean

PATHOPHYSIOLOGY

http://www.nice.org.uk

Recommendations on prolonged pregnancyWomen with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour.

Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy. The exact timing should take into account the woman’s preferences and local circumstances.

If a woman chooses not to have induction of labour, her decision should be respected.

Healthcare professionals should discuss the woman’s care with her from then on. From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth.

INDICATIONS for augmentation

Abnormal labor (in the presence of inadequate

uterine activity)

Prolonged latent phase

Prolonged active phase

CONTRAINDICATIONS

MATERNAL•ABSOLUTE- contracted pelvis,previous classic C-

sec,placenta previa•RELATIVE- prior uterine surgery, complete transection of

uterus (myomectomy, reconstruction), overdistended uterus, pelvic structural deformities, cephalopelvic disproportion, invasive cervical carcinoma

FETOPLACENTAL •Preterm fetus without lung maturity

•Acute fetal distress•Abnormal presentation

PHARMACOLOGICAL

• PGE2 (vaginal,oral,IV,extra-amniotic,intra-cervical)

• IV oxytocin• amniotomy + IV

oxytocin• Misoprostol• Mifepristone• Hyaluronidase• Corticosteroids• Oestrogens• Vaginal nitric oxide

donors

NON-PHARMACOLOGICA

L• Membrane

sweeping• Herbal

supplements• Acupuncture• Homeopathy• Castor oil, hot

baths and enemas• Sexual intercourse• Breast stimulation

SURGICAL

• Amniotomy• Mechanical

methods

METHODS of induction

ASSESSMENT of cervix

Modified Bishop Criteria >6 = favourable for induction <6 = high risk for induction failure & risk for cesarean

Score 0 1 2 3

Cervical dilatation (cm)

0 1-2 3-4 5-6

Cervical length (cm)

>4 3-4 1-2 <1

Consistency Firm Medium Soft -

Position posterior Central Anterior -

Level of fetal head (cm)

-3 abovespines

-2 above -1 above 0 Below spines

CERVICAL RIPENING

A) Intravaginal Prostaglandin E2 One cycle of tablets/gel:

one dose followed by 2nd dose if labor is not established (max two doses)

One cycle of controlled release pessary: one dose over 24 hour

Can be removed quickly if hyperstimulation

B) Intrauterine catheters May stimulate local production of PG

C) Osmotic dilators (laminaria tents)Gradually dilate uterine cervix by absorbing

body fluid

AMNIOTOMY

Hollister amnihook

To rupture membranes overlying the presenting part Not to damage the fetal tissue Passing instrument along fingers/direct vision using speculum

AIMS1) To initiate labour or to accelarate the

process during labour2) To allow a fetal scalp electrode to be

applied3) To permit estimation of fetal pH4) To release local secretion of

endogenous PG

COMPLICATIONS

Failure of inductionPlacental separation

BleedingProlapse of cords

InfectionsPulmonary embolism of amniotic

fluid

IV OXYTOCIN

To initiate effective uterine contractionsIs identical to natural pituitary peptide, and

is the only approved drug for induction and augmentation of labor

PRINCIPLES of using

Must be given intravenouslyUse dilute infusion and “piggybacked” into

main IV lineBest infused with a calibrated infusion pumpIOL for specific indications generally should

not exceed 72 hoursIf adequate labor is established, the infusion

rate and concentration may be reduced

COMPLICATIONS

Hyperstimulation

•Fetal distress from ischemia

•Uterine rupture

Anti-diuretic effect

•Water intoxication•Convulsion •Coma

Uterine muscle fatigue

•Post-delivery uterine atony (hypotonus)

•Post-partum hemorrhage

DELAYED SECOND STAGE

>1hour considered to be delayed in primigravida

>30min considered to be delayed in multigravida

CAUSES

The second stage of labour may be delayed due to:

Uterine inertia: Uterine inertia is a type of incoordinate uterine action. It is usually secondary to a prolonged first stage causing the uterine muscles to become tired. The intensity of uterine contraction is diminished, duration of contraction is diminished and the gap between two contractions increases. The woman in labor feels a lessening of the labor pains.

Malpresentation of the foetus: If malpresentations like face presentation or occipito-posterior positions are present, the progress of labor is delayed. Compound presentations in which two parts of the foetus present at the mouth of the uterus at the same time, (e.g. the head and one arm), can also cause delayed second stage of labor.

Undiagnosed contracted pelvis: A pelvis which is mildly contracted near the outlet (Cephalo-pelvic Disproportion)may often go undiagnosed until the second stage of labor. Sometimes, even if the contraction is diagnosed, a 'trial of labor' is allowed to see if the woman can deliver vaginally. The second stage may, however, get delayed and delivery by forceps or vacuum aspiration required.

Obstruction in the vagina: An obstruction in the vagina like a vaginal septum or a tumor can cause delayed second stage.

Improper use of anesthesia: Heavy use of anesthesia and other sedatives can leave the woman in labor unable to push in the second stage.

HOW to MANAGE?

If the head is high up:

If the cervix is fully dilated, as is the case in the second stage of labour, but the presenting part of the foetus is very high up, an attempt is made to increase labour pains with the help of medicines like oxytocin.

If, after 1 hour, there is no progress and the presenting part is still high up, caesarian section is done.

If presenting part is high up and there are signs of foetal distress, an immediate caesarian section is done.

If the head is at the vaginal outlet:

If the greatest diameter of the presenting part is below the narrowest part of the pelvic canal (at the level of the ischial spine), then labour pains are augmented by medicines like oxytocin and a normal delivery expected.

If there are signs of fetal distress, and the head is low down, Forceps Delivery or Vacuum Extraction of the foetus is done.

Forceps Delivery or Vacuum Extraction of the foetus is also done where there is maternal distress due to prolonged labour.

INSTRUMENTATION

Forcep

Naville Barne's forceps Wrigley's forceps

FORCEPS

Can only be done if fetal head is in a direct occipito-anterior position

Neville Barnes Forceps:Outlet/mid cavity forceps

Wringleys Forceps:Used mainly outlet forceps

When fetal head not in a occipito-anterior position eg occipito-transverse

Killands forceps (rotational forceps)

VENTOUSE

Suction cup applied on occipital region of vertex of the fetal head

Steel cup is bell shape with smooth turned in lip diameter of 50 or 60 mm

Dome attach to rubber suction tube and ten attach to vacuum gauge and air pump.

CHIGNON is created within the cup and ensures fetal scalp a fixed firmly to it.

Traction is applied to the handle of the cup to assit delivery

INDICATIONS

Prolonged 2nd stage of labor.

Shorten 2nd stage of labor for maternal benefit.

Fetal Compromise.

Stabilize head during breech.

Kielland Forceps

Simpson Forceps

Vacuum Extraction

PRE-REQUISITES1. Fully dilated cervix, ruptured

membrane and engaged head into pelvis.

2. No doubt regarding position of fetal head.

3. Adequate anesthesia.4. Empty bladder.

Two Extra for vacuum:5. Preterm labor is contraindication.6. Face or breech presentation is

contraindication.

Complications Forceps1. Traumatic vaginal and

uterine injuries.2. Trauma to maternal anal

sphincter.3. Facial Palsy. 4. Fetal Skull fracture

Complications Ventose1. Cephalohematomas.2. Subgaleal hematoma3. Scalp bruising and

lacerations4. Maternal perineal

lacerations

VENTOUSE

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