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11.6 Stimulation of Labour and Myometrial Relaxation

Table of Contents

Myometrial stimulants should be used with great care before delivery especially in porous women. Use in obstructed labour should be avoided.

Oxytocics are indicated for:–

  • Augmentation of labour
  • Induction of labour
  • Active management of third stage of labour.
  • Uterine stimulation after delivery

Induction of Labour

Indications/Contraindications

  • The indication for induction must be documented, and discussion should include reason for induction, method of induction, and risks, including failure to achieve labour and possible increased risk of Caesarean section5
  • If induction of labour is unsuccessful, the indication and method of induction should be re-evaluated.

Pre-induction assessment

  • Health care providers should assess the cervix (using the Bishop score) to determine the likelihood of success and to select the appropriate method of induction.
  • The Bishop score should be documented.
  • Care providers need to consider that induction of women with an unfavorable cervix is associated with a higher failure rate in nulliparous patients and a higher Caesarean section rate in nulliparous and parous patients.

Post-dates induction

  • Women should be offered induction of labour between 41+0 and 42+0 weeks as this intervention may reduce perinatal mortality and meconium aspiration syndrome without increasing the Caesarean section rate
  • Women who chose to delay induction >41+0 weeks should undergo twiceweekly assessment for fetal wellbeing

Options for Cervical Ripening/Induction: Unfavorable Cervix

  • Intracervical Foley catheters are acceptable agents that are safe both in the setting of a vaginal birth after Caesarean section and in the outpatient setting
  • Double lumen catheters may be considered a second-line alternative

Pharmacological treatment

B: Misoprostol 25µg 8 hourly for 24 hours can be considered a safe and effective agent for labour induction with intact membranes and on an inpatient basis.

Note:
Misoprostol should not be used in the setting of vaginal birth after Caesarean section due to the increased risk of uterine rupture
Oxytocin should be started no earlier than 4 hours after the last dose of misoprostol

 

Options for induction with a favorable cervix

  • Amniotomy should be reserved for women with a favorable cervix. Particular care should be given in the case of unengaged presentation because there is a risk of cord prolapse.
  • After amniotomy, oxytocin should be commenced early in order to establish labour.
  • In the setting of ruptured membranes at term, oxytocin should be considered before expectant management.
  • Women positive for group B streptococcus (GBS) should be started on oxytocin as early as possible after ruptured membranes in order to establish labour within 24 hours.
  • Both high- and low-dose oxytocin may be considered within a hospital protocol.
  • Because of the various concentrations, oxytocin infusion rates should always be recorded in mU/min rather than mL/hr.
  • Oxytocin induction maybe considered in the hospital setting of vaginal birth after Caesarean section.
  • For induction of labour use: Oxytocin IV, the dose will depend on parity.

Primigravida

A: Oxytocin IV 5 IU in 500mls of fluid titrate at 15, 30, 60 drops per minute until desired uterine contractions are attained

Multiparous

A: Oxytocin IV starts with low dose e.g. 1.25 IU in 500mls of fluid titrate as above. Regulate the dose according to response.

If no progress of labour is achieved give:

A: Oxytocin (IV), initially 1U then 4U in 1 liter Normal Saline at 15, 30, 60 drops per minute until regular contractions lasting for more than 40 secondly are maintained. When 4U are not enough to cause maintained contractions, and it is first pregnancy, the dose can be increased to 16, 32 then 64U in liter of Normal Saline each time increasing the delivery rate through 15, 30 and 60 drops per minute.

Augmentation of labour

If labour progress is not optimum labour augmentation is necessary. Can be achieved by:

A: Oxytocin as above

OR

Artificial rupture of membranes (ARM) and oxytocin. If membranes are already ruptured and no labour progress the steps above should be followed; rule out obstruction before augmenting labour with oxytocin.

Myometrial stimulation after delivery

Drugs of choice:

A: Oxytocin (IM) 10 IU after delivery of the infant; when no response give oxytocin (IV infusion) 10–20 units in 1 liter of NS running at 10–20 drops per minute.

OR

C: Ergometrine (IM) 0.25–0.5 mg after delivery of the infant, in the absence of myometrium contraction and to prevent postpartum hemorrhage.

OR

A: Misoprostol 800–1000 microgram (µg) orally/rectally

Note: Use Ergometrine cautiously in hypertensive heart disease patients

Myometrium relaxation

It is done to relax the uterus in order to:

  • Relieve fetal distress immediately prior to Caesarian section
  • Stop contraction of uterine in premature labour
  • Prevent uterine rupture
  • Perform external cephalic version

Pharmacological treatment

A: Nefedipine 20 mg start, followed by 10–20 mg three–four times daily

OR

B: Salbutamol IV 2.5mg in 500mls of Ringers lactate and run 20–30 drops per minute and monitor contractions and maternal heart rate

Note:
β -stimulants should never be used if the patient had an antepartum hemorrhage
β -stimulants are contra-indicated for cardiac disease and severe anemia in pregnancy

 

11.6.2 Rhesus Incompatibility

Incompatibility between an infant’s blood type and that of its mother, resulting in destruction of the infant’s red blood cells (hemolytic anemia) during pregnancy and after birth by antibodies from its mother’s blood.

Investigation

Test to detect antibody

Treatment

If the mother is Rhesus negative give

C: Anti D immunoglobin 300microgram (IM) within 72 hours of delivery

Abortion in Rhesus negative mother give

C: Anti D immunoglobin 100microgram (IM) within 72 hours of abortion

The codes will be shown below

Seconds
First: 170598
Seconds
Second: 180198

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