1. SPECIAL CIRCUMSTANCES DURING LABOUR Induction of labour Augmentation of labour Prolonged labour Delayed second stage Instrumentation: forceps/ventouse

2. DEFINITION

3. INDICATIONS for inductions

4. 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 pregnancies 2-3 times perinatal mortality Etiology: Unknown mostly Anencephalic fetus (lack of fetal labor-initiating factor from hypoplastic fetal adrenals) Placental sulfatase deficiency & extra-uterine pregnancy

5. POSTMATURITY SYNDROME Occurs when growth-restricted fetus remains in utero beyond term Features: loss of subcutaneous fat long fingernails dry & peeling skin abundant hair

6. PATHOPHYSIOLOGY

7. http://www.nice.org.uk Recommendations on prolonged pregnancy Women 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.

8. INDICATIONS for augmentation

9. CONTRAINDICATIONS

10. METHODS of induction

11. ASSESSMENT of cervix Modified Bishop Criteria >6 = favourable for induction <6 = high risk for induction failure & risk for cesarean

14. Not to damage the fetal tissue

15. Passing instrument along fingers/direct vision using speculumAIMS To initiate labour or to accelarate the process during labour To allow a fetal scalp electrode to be applied To permit estimation of fetal pH To release local secretion of endogenous PG Hollister amnihook

16. COMPLICATIONS

17. IV OXYTOCIN To initiate effective uterine contractions Is identical to natural pituitary peptide, and is the only approved drug for induction and augmentation of labor

19. Use dilute infusion and “piggybacked” into main IV line

20. Best infused with a calibrated infusion pump

21. IOL for specific indications generally should not exceed 72 hours

25. 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.

26. 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.

27. 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.

28. INSTRUMENTATION Forcep NavilleBarne's forceps Wrigley's forceps

30. 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

32. Shorten 2nd stage of labor for maternal benefit.

33. Fetal Compromise.

34. Stabilize head during breech.Kielland Forceps Simpson Forceps PRE-REQUISITES Fully dilated cervix, ruptured membrane and engaged head into pelvis. No doubt regarding position of fetal head. Adequate anesthesia. Empty bladder. Two Extra for vacuum: 5. Preterm labor is contraindication. 6. Face or breech presentation is contraindication. Vacuum Extraction

35. Complications Forceps Complications Ventose Traumatic vaginal and uterine injuries. Trauma to maternal anal sphincter. Facial Palsy. Fetal Skull fracture Cephalohematomas. Subgaleal hematoma Scalp bruising and lacerations Maternal perineal lacerations

36. VENTOUSE

37. THANK YOU