DELIVERY (3)
ARTIFICIAL INDUCTION OF LABOR, HOW DOES IT HAPPEN IN PRACTICE?
DELIVERANCE: WHAT IS IT? MAZE?
WHAT ARE INSTRUMENTAL AIDS?
Dr Claude Allouche, gynecologist
Ahuza Clinic, Raanana
058 726 02 64
ARTIFICIAL INDUCTION OF LABOR, HOW DOES IT HAPPEN IN PRACTICE?
Artificial induction of labor (in Hebrew “zirouz” זירוז) consists of anticipating childbirth without waiting for labor to begin naturally and spontaneously.
In general it is suggested by the obstetrician for various medical reasons dictated by the state of health of the mother or the baby.
But it can also be considered at the patient's request (convenience triggering) and discussed with the obstetrician depending on the local conditions of the cervix.
Note that when induction is decided, hospitalization is essential until delivery in order to ensure fetal monitoring.
And depending on the initial condition of the cervix and the methods used, this can take a while, up to 48 hours or even 72 hours.
You should also know that the time to go to the delivery room will be decided by the medical team depending on the degree of emergency and the places available in the labor room.
So sometimes you have to be patient, savlanout in Hebrew (סבלנות)...
The choice of induction method will directly depend on the obstetric history (Cesarean section) and the local conditions of the cervix which will be assessed by vaginal examination.
The latter will make it possible to evaluate different parameters which will determine the choice of the method to use depending on the degree of maturation of the cervix:
- The length of the cervix: long, mid-length, short or clear (in France) or expressed as a percentage of clearing in Israel
- Cervical dilation: expressed in centimeters or fingers, depending on the length of the cervix
- The position of the cervix: posterior centered or anterior
- The consistency of the cervix: tonic, soft or intermediate
- The level of presentation: expressed as mobile, applied, initiated or fixed (in France), or expressed in numbers from -3 to +3 depending on the position of the head in relation to the sciatic spines (in Israel)
A score can be calculated, thanks to these parameters, the Bishop score: this score, widely used in France (but apparently little in Israel) allows the doctor to choose the trigger method.
A] If local conditions are favorable (Bishop score >5), the patient can be admitted directly to the labor room where 2 options can be considered:
1/ oxytocin infusion (Pitocin in Israel)
Oxytocin is a hormone that promotes uterine contractions by increasing their frequency and intensity.
It is administered by an infusion whose flow rate is adjusted by the midwife according to the progress of labor:
We start with very low doses which we gradually increase every half hour depending on the response of the uterus, until the appearance of intense and regular uterine contractions every 3 to 4 minutes.
2/ Artificial rupture of the water bag:
it helps speed up labor by releasing natural prostanglandins
The midwife or obstetrician uses an amniotome to pierce it during a vaginal examination. It's not painful.
This method cannot be considered if the cervix is closed, or if the presentation is too high.
It also has the disadvantage of not allowing any reversal: once the water bag is broken, it is no longer possible to abandon the induction which must necessarily continue until delivery due to the risk of infection. potential.
B] If local conditions are unfavorable (Bishop score < 6), then maturation of the cervix will be necessary to prepare it for induction.
The patient is then hospitalized in the obstetrics department where prostaglandins are used in various forms to allow this cervical ripening:
- As a tampon: Propess, inserted into the posterior cul de sac of the vagina.
It comes in the form of a polymeric vaginal delivery system, thin, 0.8 mm thick, flat, semi-transparent, rectangular in shape (29 mm by 9.5 mm) with rounded corners contained in a woven polyester removal system.
It will be left in place for 24 hours during which prostaglandin E2 (dinoprostone) will gradually be diffused vaginally.
It has the advantage of being able to be easily removed in the event of an excessive reaction from the body, such as contractions that are too strong or too frequent.
- In gel: Prostine E2, this is a prostaglandin E2 gel (Dinoprostone) which is placed inside the vagina and renewed after a few hours depending on the condition of the cervix and uterine contractions.
- In oral tablets, Cytotec
Authorized only in Israel, Cytotec is a prostaglandin E1, very effective in maturing the cervix while triggering contractions.
We start with the smallest possible dose, 25 mg which will be renewed every 4 to 6 hours, depending on the intensity of the contractions and the condition of the cervix.
Often in the hours following the use of these prostaglandins, labor contractions become more intense and regularize, which allows the patient to be transferred to the delivery room (in Hebrew hadar leïda חדר לידה)
Otherwise, if labor has not started "spontaneously", we wait until the cervix is sufficiently mature to transfer the patient to the labor room and consider triggering either by artificial rupture of the membranes, or by a oxytocin infusion.
C] special case: In the event of a history of cesarean section, the use of prostaglandins is contraindicated due to the risk of uterine rupture.
If medical induction of labor is indicated in this case while local conditions are unfavorable, a Foley catheter will be inserted into the cervix, the balloon of which will then be inflated with physiological serum.
This balloon will be left in place for 12 to 24 hours to allow the cervix to dilate.
Its insertion will be carried out in the department by the doctor after placing a speculum on the gynecological table.
The procedure is not pleasant but is not meant to be painful
E] About membrane stripping
- This is a “natural” method of inducing labor in the sense that it does not use any medicinal substances.
- It consists of manually peeling off the membranes, without breaking them, during a vaginal examination.
- This separation will allow the release of natural prostaglandins which will mature the cervix.
- It requires minimal opening of the cervix and that the baby's head is not too high
- this practice can be uncomfortable and cause some blood loss.
- its advantage is that it does not require hospitalization as for drug induction: the patient can return home immediately afterwards since its effect is progressive, and will be felt within the 24 hours that follow
- Its disadvantage is that it does not work every time, and therefore it is not sufficient when triggering is decided for medical reasons.
DELIVERANCE: WHAT IS IT? MAZE?
Deliverance (in Hebrew hafradat shilia הפרדת שיליה) corresponds to the expulsion of the placenta once the baby is born.
- Indeed, the appendages of the fetus, made up of the placenta, the membranes and the cord do not come out immediately at the same time as the baby.
- Delivery is therefore the very last stage of childbirth which is only considered finished when it has taken place.
- It can be natural or artificial.
A] Natural deliverance
It takes place in 3 stages:
1/ Placenta abruption
* It occurs between 10 and 30 minutes after the birth of the baby, thanks to the resumption of uterine contractions.
* Slight bleeding may be a warning sign of placental abruption, but in all cases the Midwife or Doctor must diagnose the abruption by lightly pressing on the stomach.
2/ The expulsion of the placenta
* When the gynecologist or midwife is certain of the placental abruption, a final pushing effort is requested to cause the expulsion of the placenta.
* The latter, once taken out, will be carefully examined to verify that it is complete and that all the membranes have also been expelled.
* The umbilical cord measures between 50 and 70cm, it is made up of 3 blood vessels (2 arteries and 1 vein) and is surrounded by a transparent jelly, called Wharton's jelly.
* All fetal appendages weigh approximately 1/5th of the baby's weight
3/ Hemostasis
* This is the ability of the uterus to contract to prevent hemorrhage from occurring:
* Once the placenta has come out, the gynecologist or midwife will gently massage the uterus to encourage its contraction and ensure the formation of the safe uterine globe.
* This procedure can be uncomfortable in the absence of an epidural but is not painful;
* It is necessary because it reduces the risk of bleeding.
B] Artificial deliverance
(in Hebrew hafrada yadanit הפרדה ידנית)
- When the placenta has not separated within 30 to 45 minutes after the birth of the baby, it may be necessary to carry out a procedure to get it out in order to avoid the occurrence of a hemorrhage.
- We no longer speak of natural deliverance but of artificial deliverance.
- Under general or epidural anesthesia, the obstetrician inserts his hand inside the uterus to manually detach the placenta and extract it from the uterus so that it can contract properly, and thus prevent or stop hemorrhage.
- This procedure can also be carried out earlier, as an emergency in the event of a hemorrhage occurring after the birth of the baby.
- This procedure is unpleasant but not painful if it is carried out with sufficiently effective anesthesia (epidural reinjection, spinal anesthesia, or general anesthesia).
C] Uterine revision
(In Hebrew Revizia, רוויזיה)
- When after the expulsion of the placenta, the obstetrician has doubts about the integrity of it or of the membranes, he may decide to perform a procedure called uterine revision.
- This procedure consists of introducing the hand inside the uterus, still under anesthesia, in order to check that there is not a piece of placenta or membranes remaining inside the uterus.
- If this is the case, they will be extracted manually by the doctor until the uterus is empty,
- The goal being in the short term to obtain good contraction of the uterus and to avoid hemorrhage, and in the medium term to avoid superinfection of the material possibly left inside the uterus.
WHAT ARE INSTRUMENTAL AIDS?
What is instrumental aid?
- During the last phase of childbirth, once the head is already engaged in the upper strait of the pelvis, the gynecologist can use different means to help you give birth to your child.
- Thus, to carry out this aid, also called instrumental extraction, the obstetrician can use forceps, suction cups or spatulas.
- The choice of instrument will mainly depend on one's habits and experience.
A] The instruments
1/ The forceps (in Hebrew milkakhaïm מלקחיים)
- It is a metal instrument to facilitate the exit of the child's head.
- It is made up of 2 branches that articulate with each other.
- Each branch has a spoon and a handle.
- Depending on the needs, the gynecologist uses it as a simple release aid by providing traction on the handle or he uses it to orient the head in the right direction using a rotational movement.
- There are several different models of forceps throughout the world; in general, the obstetrician uses the one he knows best and is most familiar with.
2/ The suction cup (in Hebrew vacuum, ווקאום)
- The suction cup is used as a flexion and extraction instrument with limited traction.
- It is connected to a suction system whose power is controlled, which allows the suction cup to adhere to the baby's head.
- There are metal or silicone suction cups of different sizes, reusable after sterilization.
- there is also a sterile single-use suction cup model, made of plastic, called kiwi.
* The advantage of this suction cup is that it incorporates a hand pump which easily allows the vacuum to be obtained under the cup and therefore does not require any motor to do so.
* It is light, autonomous, easily transportable and can be used very quickly because it does not need an electrical connection.
* Obviously this costs more than reusable and sterilizable suction cups.
Most recent scientific studies find a reduction in the risk of serious perineal injuries when using the suction cup compared to the forceps.
3/ Thierry’s spatulas
- The principle of Thierry's spatulas is based on the separation of the walls of the vagina, thus making it easier for the baby to pass through.
- The baby's head is free to move.
- this technique is already used very little in France, and even less in Israel due to a greater risk of serious perineal lesions.
The use of forceps, a suction cup or a spatula is a decision made by your gynecologist based on the situation, their training, their experience and the nature of the emergency.
B] Indications
They can be fetal or maternal
1/ Fetal indications:
-Anomaly of the fetal heart rate at the end of dilation or expulsion,
- Duration of expulsion too long with a halt to the progression of the baby's head.
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2/ Maternal indications:
- insufficient expulsive efforts,
maternal fatigue, tonicity of the perineum.
- maternal contraindication to expulsive efforts:
* eye damage, retinal detachment
* history of spontaneous pneumothorax,
* respiratory failure,…
C] In general
- Instrumental extraction requires placement in a gynecological position with sufficient lighting to control the perineum.
- It cannot be done in water or in a bathtub
- In general, it is done under regional (epidural) or local anesthesia.
- It is more often accompanied by an episiotomy, especially if forceps or spatulas are used, in order to protect the perineum and reduce the risk of serious injuries.
- In well-trained hands, the risk of fetal or maternal complications nevertheless remains low.
- you should also know that the choice of instrumental extraction is not an alternative to cesarean section: in fact, the height of the fetal head in the maternal pelvis will be the only decision criterion for a cesarean section or a instrumental extraction:
* if the head is too high in the pelvis, and is not engaged in the upper strait, we will go directly to cesarean section without attempting an instrumental extraction which would be dangerous and ineffective.
* on the other hand, if the head is engaged in the pelvis, it is too low to require a cesarean section, and this is where instrumental extraction can be carried out.
Other publications on the same subject:
- Childbirth (1): at what term do we give birth?
- Childbirth (2): when should you go to the maternity ward?
- Childbirth (3): how is the fetus monitored during labor?
- Childbirth (4): what maternal supervision
- Childbirth (5): how does the expulsion phase of a normal childbirth work in practice?
- Childbirth (6): episiotomy is not systematic!
- Childbirth (7): artificial induction of labor, how does it happen in practice?
- Childbirth (8): instrumental aids, what are they?
- Childbirth (9): deliverance, what is it, mazé?