Risks:
Care During: Continuous electronic fetal monitoring during oxytocin infusion, and after prostaglandin contraction. Uterine hyper-contractility, single contraction lasting < 2 minutes or contraction frequency of 5 or more in 10 minutes. Oxytocin should be decreased or discontinued Uterine tocolysis should be considered especially in the presence of abnormal fetal heart rate (FHR) Suggested regime is subcutaneous Terbutaline 0.25 mg or Nitroglycerin resoriblet 0,25 mg or 0,4 mg sublingual or as nasal spray as required. Possible soon delivery, eventually by cesarean section. Methods of Induction: Prior to formal induction of labour, women should be offered sweeping of the membranes which reduce duration of pregnancy with 3 days. (increase level of discomfort, no increase of infection risk, and may facilitate the induction). Prostaglandin should be used in preference to Oxytocin when induction is undertaken with intact membrane regardless of the cervical favorability. Either Oxytocin or Prostaglandin (PG) may be used when induction of is undertaken in women who have rupture of membranes, as they are equally effective. Intravaginal Prostaglin E2 seems to be as effective as intracervical Prostaglandin but less invasive. Uterine hyper-contractility with a fetal heart rate is reduced with the use of vaginal gel formulation in comparison with suppositories but they are equal effective. Prostaglin E2 in sustained released form, should be removed at the onset of hyper stimulation. Vaginal Prostaglandin 3 mg PGE2, 6-8 hourly, maximum doses 2 tablets for all women. PGE2 gels, 2 mg PGE2 for nulliparous with Bishop <4,(see later) all other patients 1 mg dose to be repeated 6 hours later. Maximum dose 4 mg PGE2. For nulliparous women with an unfavorable cervix and 3 mg for all other women. Misoprostol (PGE1) 25 mg repeated after 6 hours has been reported superior or as effective as PGE2 gel. Doses up to 25 mg 4 hours up to 6 times has been reported. Because of lack of experience many do not use it in case of previous Cesarean section. Comparing misoprostol 50 µg and 25 µg there seems to be more hyperstimulation and Cesarean section (C/S) caused by fetal distress but less C/S because of dystocia, less intrusmental vaginal delivery and sphicterupture than in the low dose regime. A recently study has shown that titrated oral misoprostol was associated with a lower incidence of uterine hyperstimulation and lower Caesarian delivery rate than vaginal misoprostol 25 mg every 4 hour for induction in women with unfavourable cervix. Misoprostol was given as 20 mg per hour in the first 4 hours. After 4 hours the dose was increased to 40 mg and after further 4 hours the dose was increased to 60 mg. Oxytocin (in the presence Oxytocin should not be started before 4-6 hours following PGE2 administration or 30-60 minutes after removal of Prostaglandin in sustained-release form. Induction with Oxytocin:
30 iu in 500 ml normal saline; hence 1 ml/hr = 1 milliunits oxytocin per minut. 10 iu oxytocin in 500 ml of normal saline; hence 3 ml/hr = 1 miliunits oxytocin per minute Oxytocin is delivered through an infusion pump via a syringe driver with a non-return valve. Oxytocin performance is optimized with ruptured membranes
Doses up to 32 milliunits per minute should not be exceeded. Maximum licensed dose is 20 milliunits per minute. If regular contraction not established after TOTAL of 5 iu (five hours on suggested Regimen) then induction should be stopped. Ballon catheter: Foley catheter No. 16 with the tip removed and 30 to 80 ml ballon through the internal os into the extraamniotic apace. The ballon installed with Saline and retracted to it rest against the internal os. A double ballon 80 ml x 2 are also developed. In a smal study it was more succesfull than prostaglandin and oxytocin.
References (1) Andresen DM, Jensen JS, Ulbjerg N. Misoprostol-a safe preparation for induction of labour. Ugeskr Laeger, 206 Oct 23;168(43): 3711-4. (2) Cheng SY, Ming H, Lee JC. Titrated oral compared with vaginal misoprostol for induction: a randomized controlled trial.. Obstet Gynecol, 2008 Jan;111(1):119-25 (3) Induction of labour. RCOG Evidence-based Clinical Guideline No. 9, June 2001. (4) MacLean A., et al. Infection and Pregnancy, RCOG Press 2001. (5) Savas M. Menticoglou, Philip F. Hall. Routine induction of labour at 41 weeks gestation: nonsensus consensus. British Journal of Obstetrics and Gynecology 2002; 109:485-491. (6) Tan BP, et al. Prostaglandins versus oxytocin for prerupture of membranes at or near term. Cochrane Database Syut Rev 2001;Issue 2 Andre Cochrane reviews: Smith CA, Crowther CA Acupuncture for induction of labour (Cochrane Review) Bricker L, Luckas M Amniotomy alone for induction of labour Alfirevic Z, Weeks A Oral misoprostol for induction of labour. Kavanagh J, Kelly AJ, Thomas J Breast stimulation for cervical ripening and induction of labour Muzonzini G, Hofmeyr GJ Buccal or sublingual misoprostol for cervical ripening and induction of labour, French L Oral prostaglandin E2 for induction of labour , Hutton E, Mozurkewich E Extra-amniotic prostaglandin for induction of labour , Irion O, Boulvain M Induction of labour for suspected fetal macrosomia, Mechanical methods for induction of labour , Boulvain M, Kelly A, Lohse C, Stan C, Irion O Membrane sweeping for induction of labour, Boulvain M, Stan C, Irion O Mifepristone for induction of labour, Neilson JP Alfirevic Z, Weeks A Oral misoprostol for induction of labour , Kavanagh J, Kelly AJ, Thomas J Sexual intercourse for cervical ripening and induction of labour, Hofmeyr GJ, Gülmezoglu AM Vaginal misoprostol for cervical ripening and induction of labour , Kelly AJ, Kavanagh J, Thomas J Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term ,
Feel free to mail me |