INDUCTION OF LABOR

&
MANUAL REMOVAL OF
PLACENTA
Presented by: VANSHIKA PATEL
Roll no : 58
DEFINITION

PURPOSE

INDICATION &
CONTRAINDICATION

PARAMETERS

FACTORS

METHODS
DEFINATION:
IOL means initiation of uterine contraction (after a period of
viability ) by any method for the purpose of the vaginal delivery.
AUGMENTATION OF LABOR is the process
of stimulating the uterus to increase the frequency, duration and
intensity of contraction after the onset of spontaneous labor.
 PURPOSE OF INDUCTION OF LABOR
• Risk of continuation of pregnancy either to the
mother or fetus is more.
• Eliminate the potential risk to the fetus
INDICATION
 Cont…
Medical condition like:
Diabetes mellitus
Chronic renal failure
Rh isoimmunization
Post maturity
 CONTRAINDICATION
 Cephalo pelvic disproportion(CPD)
 Previous LSCS
 Infection
 Heart disease
 Pelvic tumor
 Umbilical cord prolapsed
 Placenta previa
 PARAMETERS TO ASSESS PRIOR TO IOL
MATERNAL:
• confirm the indication for IOL
• Exclude the contraindication of IOL
• Assess Bishop score >6
• Perform clinical Pelvimetry to assess pelvic adequacy
• Adequate counselling about the risks, benefits and alternatives
of IOL with the women and the family members
 BISHOP’S PREINDUCTION CERVICAL
SCOREING SYSTEM
PARAMETERS 0 1 2 3

CERVIX
CLOSED 1-2 3-4 5+
DILATATION

EFFACEMENT 0-30 40-50 60-70 >=80

CONSISTENCY FIRM MEDIUM SOFT -

POSITION POSTERIOR MIDDLNE ANTERIOR -

HEAD STATION -3 -2 -1 ,0 +1 , +2

CERVICAL
>4 2-4 1-2 <1
LENGTH
 FETAL
• To ensure fetal gestational age
• To estimate fetal weight(EFW) and Maternal height >5inches
• Ensure fetal lung maturation status & heart beat
• Ensure fetal presentation and lie
• Confirm fetal well- being
METHODS OF IOL
1. MEDICAL
2. SURGICAL
3. COMBINE
MEDICAL MANAGEMENT
PHARMACOLOGICA NON PHARMACO
L LOGICAL

PROSTAGLANDI MECHANICAL
N DILATOR

OXYTOCIN AMNIOTOMY

STRIPPING OF
PROGESTERONE
MEMBRANE
 PROSTAGLANDIN
MISOPROSTOL(PGE1):
• 25 µg vaginally or orally every 4 hours
DIANOPROSTONE (PGE2)
• 0.5 mg gel, , intracervical Repeated after 6 hours for 3-4 doses.
• Women should be in bed for 30minutes
 Contraindicated for previous cs.
 OXYTOCIN
Used for cervical dilatation and uterine activity
Doses : 0.5-1mUnit/min IV ,
Titrate: 1-2mUnit/min for 15to 60 min
 MIFEPRISTONE
• PROGESTERONE RECEPTOR ANTAGONISTS
• RU 486 , 200mg vaginally daily for 2 days
• Used for ripen the cervix and induced labor
MECHANICAL DILATORS
TRANSCERVICAL BALLON CATHETER

• Its foley catheter

• Used for cervical ripening
EXTRA AMNIOTIC SALINE INFUSION
 SURGICAL INDUCTION
1.AMNIOTOMY -
ARTIFICIAL
RUPTURE OF
MEMBRANE(AR
M)
INDICATION: CONTRAINDICATION :
Abruptio placentae Intrauterine fetus death
Chronic hydramnios maternal AIDS
Severe pre-eclampsia /
Genital active herps infection
eclampsia
 PROCEDURE

1. Its INDOOR procedure in labor or O.T

2. FHR should be monitor after and before procedure.
3. Lithotomy position given.
4. Two finger introduce in vagina though the cervical canal beyond
internal os .
5. A long Kocher’s forceps with closed blades or an amnion hook is
introduce along with the fingers up to the membranes.
6. The blades are opened to seize the membrane , torn by twisting
movements.
AFTER THE MEMBRANE IS RUPTURED , ASSESS
a. Color of amniotic fluid
b. Status of the cervix
c. Station of the head
d. In high risk , scalp electrode for fetal monitoring is
applied.
 HAZARDS OF ARM
 There is no scope of re treating
 Chance of umbilical cord prolapse
 AMNIONITIS
 Accidental injury to the cervix and presenting part
 Placental abruption
 Amniotic fluid embolism (rare)
 STRIPPING OF THE MEMBRANE
 SWEEPING ( STRIPPING) OF THE MEMBRANES
means digital separation of the chorioamniotic
membranes from the wall of the cervix and lower uterine
segment.
 Its done prior to ARM.
 Its also used for cervix ripe.
MANUAL REMOVAL OF
PLACENTA
DEFINATION Manual removal of placenta
is a procedure to remove a
retained placenta from the
uterus after childbirth .
DEFINATION OF
RETAIN PLACENTA
Failure of placental delivery
within 30 minutes after
delivery of the fetus.
STEPS OF MANUAL REMOVAL OF PLACENTA
 step2
• Hold the umbilical cord with clamp.
• One hand is introduced into the
uterus after smearing with the
antiseptic solution in cone-shaped
manner following the cord, until the
placenta is located.
• While introducing the hand, the
labia are separated by the fingers of
the other hand.
stap3
• Counter pressure on the uterine fundus is
applied by the other hand placed over the
abdomen.
• The abdominal hand should steady the
fundus and guide the movements of the
fingers inside the uterine cavity.
• To support the fundus & provide counter
traction to prevent uterine inversion.
stap4

As soon as the placental margin is reached, the

fingers are insinuated between the placenta and the
uterine wall with the back of the hand in contact
with the uterine wall.
The placenta is gradually separated with a sideways
slicing movement of the fingers.
stap5

• When the placenta is completely separated, it is

extracted by traction of the cord by the other
hand.
• The uterine hand is still inside the uterus for
exploration of the cavity to be sure that nothing
is left behind.
stap6
• Intravenous methergine 0.2 mg is given .
• the uterine hand is gradually removed while massaging the
uterus by the external hand to make it hard.
• After the completion of manual removal, inspection of the
cervicovaginal canal is to be made to exclude any injury.
stap7
• The placenta and membranes are inspected for completeness
and be sure that the uterus remains hard and contracted.
 DIFFICULTIES
1. Hour-glass contraction leading to difficulty in introducing
hand.
2. Morbid adherent placenta , cause difficulty in getting to
the plane of cleavage of placental separation.
 In such cases , placenta is removed using ovum forceps ;
or flushing curette.
 Complications
(1)Hemorrhage
(2) Shock
(3)Injury to the uterus
(4)Infection
(5)Inversion. (rare)
(6)Subinvolution
(7)Thrombophlebitis; 8) Embolism
Thank
you