awin_induction of labor delivery management in pee

8/2/2019 Awin_Induction of Labor Delivery Management in PEE

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INDUCTION OF LABOUR- RECOMMENDATIONS

Dr Narimah Awin

Regional Adviser (MRH)

SEARO

Asian Conference on Maternal and

Newborn Health, Dhaka, 4th-6th2012


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INDUCTION OF LABOUR

WHAT? HOW? WHY? WHY NOT?

WHAT TO RECOMMEND?

WHO Recommendations for IOL


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WHAT IS IOL ?

The process of artificially

stimulating the uterus to start labour

HOW is IOL done?

Oxytocin or prostaglandin

Manual rupture of amnioticmembrane (ARM)


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WHY ?

post-mature , 41 weeks gestation or more

prelabour rupture of membranes

fetal death

ecclampsia and severe pre ecclampsia(separaterecommendations)

maternal medical conditions (GDM)


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WHY?

vaginal bleeding

chorioamnionities

twin pregnancy

request - not willing to wait

- convenience, choice of date


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WHY NOT ?

- not risk free

- discomfort, reduced mobility

- close monitoring required,implication on resources, LSCS

- complications can occur

- bleeding

- hyperstimulation of uterus --- rupture


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Recommendations


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Recommendations

General principles

IOL in specific circumstances

Methods of cervical ripening & IOL

Management of complications

Setting for IOL


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General principles

Only when indicated, benefits vs risks

Consider wishes of woman, status of

cervix, methods and associated conds Caution risk and complications

Monitor; if oxytocin/prostaglandin never

to leave unattended Failed IOL not always indicate Cs, but if

possible only in facilities with CS


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Recommendations

(1) Specific circumstances- post-term - prelabour rupture of mebrane

- GDM - macrosomia

- uncomplicated twin(2) Methods

-oxytocin -misoprostol - other prostaglandin

- balloon catheter

(3) Managing uterine hyperstimulation

(4) IOL in outpatient setting


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GRADE

Grading of

Recommendations

Assessment and

Development of

Evidence


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GRADE

1) Quality of evidence

- evaluate quality

- prepare GRADE tables

2) Strength of recommendation

- strong (desirable effect of the recommendationoutweighs the undesirable effects)

- weak (desirable effects probably outweighsundesirable effects but expert panel is not confidentabout these trade-offs)


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(1) Specific

CircumstancesRecommendation Quality Strength

1. Post-term, 41 weeks (YES) Low Weak

2. GDM beofre 41 week (NO) Low Weak

3. Fetal macrosomia (NO) Very Low Weak

4. Pre Labour membranerupture (YES)

High Strong

5. Un complicated twin (NONE) - -

6. Dead fetus (YES) Low Strong


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HDP ECCLAMPSIA

&PRE-ECCLAMPSIA

- The only definitive treatment ofecclampsia and pre-ecclampsia isdelivery of the baby and placenta

- Separate guidelines developed

- Timing of delivery depends on severity ofdisease, term or preterm


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Expectant management

or IOL for mild PET?

IOL is associated with improved

maternal outcome and should be

advised for women with mildhypertensive disease beyond 37weeks of gestation

Koopmans et al, Lancet 2009, 374:979-988


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HDP-TIMING BASED ON SEVERITY

OF DISEASE

"Severe pre-eclampsia andeclampsia are managedsimilarly with the exceptionthat delivery must occurwithin 12 hours of onset ofconvulsions in eclampsia.ALL cases of severe pre-eclampsia should bemanaged actively"

Managing Complications inPregnancy and Childbirth, 2000


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HDP -TIMING BASED ON SEVERITY

OF DISEASE

"In severe pre-eclampsia,delivery should occurwithin 24 hours of the onsetof symptoms"

Managing Complications inPregnancy and Childbirth, 2000


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HDP - CURRENT RECOMMENDATIONS

Deliver within 24 h for severe pre-eclampsia

Expectant management withmonitoring for mild pre-

eclampsia until 36 wk; inducelabour after 37 wk

Induction methods includeamniotomy, oxytocin,prostaglandins including

misoprostol and balloon catheter

Managing Complications in Pregnancyand Childbirth, 2000


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Recommendation Quality Strength

1. Oxytocin alone, prosta not available(YES)

Mod Weak

2. Oral misoprostal 2ug, 2hrly (YES) Moderate Strong

3. Vaginal misoprostal 2ug, 6hrly (YES) Moderate Strong

4. Previous caesarian (NO) Low Strong

5. Balloon Catheter with oxytocin

prostaglandin not available (YES)

Low Weak

6. Sweeping membrane (YES) Moderate Strong

(2) Methods of iOL


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(3) Management of uterinehyperstimulation betamimetics are

recommended (low quality, weak rec)

(4) IOL in outpatient setting is NOT

recommended (low quality, weak rec)


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THANK YOU

awin_induction of labor delivery management in pee

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