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Practice bulletins > #107 Induction of Labor > Flashcards

#107 Induction of Labor Flashcards

1
Q

How many gravid women undergo induction of labor in the United States?

A

More than 22%

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2
Q

What methods of induction of labor are there?

A

Membrane stripping, amniotomy, nipple stimulation, prostaglandin E analogues, and oxytocin

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3
Q

What is included in cervical remodeling (molecularly)?

A

Collagen breakdown and rearrangement, changes in glycosaminoglycans, increased production of cytokines, and white blood cell infiltration

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4
Q

What scoring system is used to determine the status of the cervix?

A

Bishop scoring system

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5
Q

An unfavorable cervix has a Bishop’s score of how much?

A

6 or less

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6
Q

What does a Bishop score of more than 8 mean?

A

Favorable. Probability of vaginal delivery after labor induction is similar to that after spontaneous labor

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7
Q

Bishop Score:

Points for closed cervix

A

0

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8
Q

Bishop Score:

Points for 1cm dilated

A

1

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9
Q

Bishop Score:

Points for 2cm dilated

A

1

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10
Q

Bishop Score:

Points for 3cm dilated

A

2

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11
Q

Bishop Score:

Points for 4cm dilated

A

2

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12
Q

Bishop Score:

Points for 5cm dilated

A

3

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13
Q

Bishop Score:

Points for 6cm dilated

A

3

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14
Q

Bishop Score:

Points for posterior cervix

A

0

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15
Q

Bishop Score:

Points for midposition cervix

A

1

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16
Q

Bishop Score:

Points for anterior cervix

A

2

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17
Q

Bishop Score:

Points for 0% effacement

A

0

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18
Q

Bishop Score:

Points for 10% effacement

A

0

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19
Q

Bishop Score:

Points for 20% effacement

A

0

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20
Q

Bishop Score:

Points for 30% effacement

A

0

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21
Q

Bishop Score:

Points for 40% effacement

A

1

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22
Q

Bishop Score:

Points for 50% effacement

A

1

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23
Q

Bishop Score:

Points for 60% effacement

A

2

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24
Q

Bishop Score:

Points for 70% effacement

A

2

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25
Q

Bishop Score:

Points for 80% effacement

A

3

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26
Q

Bishop Score:

Points for -3 station

A

0

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27
Q

Bishop Score:

Points for -2 station

A

1

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28
Q

Bishop Score:

Points for -1 station

A

2

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29
Q

Bishop Score:

Points for 0 station

A

2

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30
Q

Bishop Score:

Points for +1 station

A

3

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31
Q

Bishop Score:

Points for +2 station

A

3

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32
Q

Bishop Score:

Points for firm cervical consistency

A

0

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33
Q

Bishop Score:

Points for medium cervical consistency

A

1

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34
Q

Bishop Score:

Points for soft cervical consistency

A

2

35
Q

Bishop Score:

2/40/-3/soft/midposition

A

5

36
Q

Bishop Score:

1/20/-2/medium/posterior

A

3

37
Q

Bishop Score:

4/60/-2/soft/anterior

A

9

38
Q

Maximum Bishop score?

A

13

39
Q

What are methods for cervical ripening?

A

Mechanical cervical dilators and prostaglandin E1 and prostaglandin E2

40
Q

What are methods for mechanical cervical dilation for induction of labor?

A

Hygroscopic dilators, osmotic dilators, foley catheters (14-26 Fr) with inflation volume of 30-80cc, double balloon devices, and extraamniotic saline infusion using infusion rates of 30-40cc/h.

41
Q

Which mechanical method for cervical dilation is not associated with decreased risk of cesarean delivery (when compared to oxytocin alone)?

A

Extraamniotic saline infusion

42
Q

Which method of mechanical cervical dialtion is associated with increased peripartum infections?

A

Laminaria japonicum

43
Q

What are the advantages of foley catheter for mechanical cervical dilation compared to prostaglandins?

A

Low cost, stability at room temperature, reduced risk of uterine tachysystole with or without FHR changes

44
Q

What type of prostaglandin in misoprostol?

A

PGE1 analogue

45
Q

How is misoprostol administered for cervical ripening/induction of labor?

A

intravaginally, orally, or sublingually

46
Q

The majority of adverse maternal and fetal outcomes are associated with misoprostol therapy resulted from what dose of misoprostol?

A

Greater than 25mcg

47
Q

What type of prostaglandin is dinoprostone?

A

PGE2

48
Q

Do vaginal prostaglandins increase the risk of uterine tachysystole with associated FHR changes?

A

Yes

49
Q

How soon after infusion of oxytocin does uterine response ensue?

A

After 3-5 minutes

50
Q

How long does it take to achieve a steady level of oxytocin in the plasma?

A

40 minutes

51
Q

What factor determines how sensitive the uterus is to oxytocin?

A

Gestational age. Gradual increase in response from 20 to 30 weeks, plateau from 34wk until term, when sensitivity increases

52
Q

What factors are predictors of successful response to oxytocin for induction?

A

Lower BMI, greater cervical dilation, parity, gestational age

53
Q

What happens molecularly after membrane stripping/sweeping?

A

Significant increases in phospholipase A2 activity and prostaglanding F2alpha levels

54
Q

How does membrane stripping affect pregnancy/labor?

A

Increases the likelihood of spontaneous labor within 48 hours and reduces the incidence of induction with other methods

55
Q

Can you strip membranes for a patient who is GBS positive?

A

There is insufficient evidence to guide clinical practice

56
Q

Can AROM be used as a method of labor induction?

A

Yes, especially if the condition of the cervix is favorable

57
Q

What does ACOG say about using amniotomy alone for labor induction?

A

Insufficient evidnece on the efficacy and safety. Can be associated with unpredictable and sometimes long intervals before the onset of contractions

58
Q

When is it safe to AROM in GBS+ patient receiving intrapartum prophylaxis?

A

Insufficient data to guide the timing of amniotomy

59
Q

True or false, breast stimulation is associated with a decrease in postpartum hemorrhage?

A

True

60
Q

How long should a patient be in latent labor before diagnosing a failed induction of labor?

A

At least 12-18 hours

61
Q

How can you confirm a term gestation for scheduling induction?

A
  1. Ultrasound measurement at less than 20 weeks supports gestational age of 39 wks or greater
  2. FHT have been documented as present for 30wks by doppler ultrasonography
  3. It has been 36 weeks since a positive serum or urine hcg
62
Q

How does vaginal misoprostol compare to dinoprostone and oxytocin?

A

Less use of epidural anesthesia, more vaginal deliveries within 24 hours, more uterine tachysystole with or without FHR changes

63
Q

How should misoprostol be dosed for cervical ripening and labor induction?

A

25mcg should be considered as the initial dose. Frequency not more than q3-6h. Can use 50mcg every 6 hours, but associated with increased risk of complications (tachysystole and decels)

64
Q

How soon after misoprostol administration can you start oxytocin?

A

At least 4 hours after last misoprostol dose

65
Q

How long after removal of dinoprostone vaginal insert can you start oxytocin?

A

After 30-60 minutes

66
Q

What are recommendations regarding buccal or sublingual misoprostol for cervical ripening or induction of labor?

A

Not recommended for clinical use until further studies support their safety (2004)

67
Q

What induction agent is most associated with tachysytole?

A

vaginal misoprostol

68
Q

What induction agents should be avoided in patients with prior cesarean that desire TOLAC?

A

Prostaglandins

69
Q

Does irrigation of the cervix and vagina after removal of PGE2 (dinoprostone) vaginal insert help resolve tachysystole?

A

No

70
Q

What are some potential complications of foley catheter placement for mechanical cervical dilation?

A

Vaginal bleeding in women with low-lying placenta, rupture of membranes, febrile morbidity, and displacement of the presenting part

71
Q

What are the recommended guidelines for fetal surveillance after prostaglandin use?

A

Patient recumbent for at least 30 minutes. FHR and uterine activity should be monitored continuously for 30 min to 2 hours after administration of PGE2 gel. FHR monitoring should be continued if regular uterine contractions persist.

72
Q

Can cervical ripening methods be performed outpatient?

A

In carefully selected patients. Evidence for intravaginal PGE2 gel for 5 days for women with Bishops score of 6 or less. Evidence for outpatient foley catheter placement (decreased hospital stay of 9.6 hours)

73
Q

What are potential consequences of uterine tachysystole?

A

Fetal heart rate abnormalities, placental abruption, uterine rupture (rare)

74
Q

Does oral or vaginal route of misoprostol administration, at equivalent dosage, produce greater clinical efficacy?

A

Vaginal

75
Q

What are potential risks of amniotomy?

A

Umbilical cord prolapse, chorioamnionitis, significant umbilical cord compression, rupture of vasa previa

76
Q

What should you remember when considering amniotomy for HIV+ patient?

A

Duration of ruptured membranes has been identified as an independent risk factor for vertical transmission of HIV infection

77
Q

What is a risk of rapid IV injection of oxytocin?

A

Hypotension

78
Q

Can you use prostaglandins in the setting of PROM for cervical ripening/induction oflabor?

A

Yes

79
Q

Can you use mechanical dilation in setting of PROM for cervical dilation/induction of labor?

A

Insufficient evidence to guide the physician

80
Q

What are management options for late second or third trimester IUFD?

A

D&E (if comfortable provider available) or labor induction

81
Q

At what gestational age cut off do you manage an IUFD with misoprostol alone vs a typical induction of labor with usual obstetrical protocols?

A

28 weeks

82
Q

What are the typical misoprostol doses for an IUFD <28wks?

A

200-400mcg vaginally q4-12 hours

83
Q

In patients with prior uterine scar up to how many weeks can you use misoprostol induction for IUFD?

A

28wks (can use 400mcg q6h)

84
Q

In patients with prior uterine scar how can you manage induction for IUFD after 28 weeks?

A

Cervical ripening with transcervical foley and pitocin.

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