1.1 - Induction Of Labour - exam Flashcards
1
Q
Types of inductions
A
- balloon catheter
- prostaglandins - prostub & cervidil
- oxytocin’s
- artificial rupture of membranes
- Membrane Sweep
2
Q
IOL indication & recommendation
A
- prolonged pregnancy - over 41+0 weeks
- Term PROM - GBS negative or unknown - IOL within 24 hours of confirmed PROM
- Term PROM - GBS positive, meconium liquor or suspected sepsis - immediate IOL
- PROM - <34/40 - expectant management (waiting for the miscarriage/birth to happen by itself naturally without treament)
- PROM >34/40 - consider balance of risk and benefits for woman and baby and availability of resources
- Previous Caesarean - individualise management - increased risk of uterine rupture and emergency caesarean
- maternal request - do not routinely offer IOL for maternal request
- Breech presentation - IOL may be offered if clinical circumstances are favourable and the woman wishes to have a VBAC
- History of precipitate labour - do not routinely offer IOL for history of precipitate labour
- Suspected fetal macrosomia - IOL not indicated for suspected macrosomia
- AMA - IOL not indicated for AMA as an isolated risk factor
- BMI > 50 - delivery recommended at 38-39 weeks
- Ethnicity - IOL not indicated for maternal country of birth alone
3
Q
Inducing agents
A
- prostin cervididil
- balloon catheter
- syntocinon
- amniotomy - ARM
- membrane sweep
4
Q
what is the bishop score
A
considers aspects of the cervix:
- length
- position
- consistency
- dilatation
- station
this give a score to assess if the cervix is favourable or not favourable for induction and if prostaglandins are required to stimulate the ripening of the cervix for labour
5
Q
Prostin - short acting
A
indication:
- bishop score =<5
- unfavourable cervix if bishop score is =<5
Doses:
- Nuliparous
- 1st dose 1mg
- 2nd dose 1 or 2mg
- 3rd dose 1 or 2mg
- Multiparous
- 1st dose 1mg
- 2nd dose 1mg
- 3rd dose 1mg
Action:
- used for cervical ripening - softening and effacement
- stimulate myometrial contractions
- ensure woman has an empty bladder
- lie flat with feet in the modified lithotomy position
- insert the Gel into the posterior fornix of the vagina
- woman should remain in a lateral position for at least 30 minutes after insertion
- CTG monitoring for at least 30 mins post (have baseline CTG)
Contraindication:
- ARM should not be performed within 4/24
- Physiological management of third stage is contraindication when labour is induced
- previous c-section
- unstable lie
Potential Complications:
- bishop score must be <5 at the time of insertion
- must not be inserted into the cervical canal
- uterine hyperstimulation - oxytocin should not be commenced within 6/24 of gel insertion
- ARM should not be preformed within 4 hours of prostin being inserted
6
Q
Cervidil - long acting
A
indication: bishop score =<5
*
Action:
- continuous pessary contains 10mg dinoprostone PGE2 and releases a mean dose of approx 4mg over 12/24 or 0.3 mg per hour
- once inserted tuck any excess tape gently into the vagina and leave a small amt for retrieval is warranted
Contraindication:
- oxytocin should not be commenced with Dinoprostone whilst insitu or within 30 minutes of removal
- not to be inserted into the cervical canal.
- ARM should not be performed with the pessary insutu
- Physiological management of third stage is contraindication
- c-section
- unstable lie
Removal:
- spont rupture of membranes
- regular painful 3 minutely contractions (irrespective of cervical change)
- uterine hyperstimulation
- Abnormal CTG
- Maternal adverse reaction
- N&V
- Hypotension
- Tachycardia
- at least 30 minutes prior to commencing a oxytocic infusion
- insufficient cervical ripening after 24/24
Potential Complications:
- bishop score must be =<5 at the time of insertion
- must not be inserted into the cervical canal
- uterine hyperstimulation
- ARM should not be performed with dinoprostone continuous release vaginal pessary insitu
7
Q
Balloon catheter
A
indication:
- bishop score =<5
Action:
- a device to stretch the cervix
- mechanical cervical ripening by applying pressure on the internal OS of the cervices
- increasing the release of endogenous prostaglandins
- fill foley bulb with 30ml of sterile water
- cooks catheter two bulb
- able to allow ARM
Contraindication:
- woman will require further assistance to go into labour
Potential Complications:
8
Q
Syntocinon
A
indication:
- bishop score =>6
Dosage:
- 10 units of oxytocin to a 1000ml bag of CSL
- titrate up by 12 mls per hour at 30 min intervals if clinically safet to do so
- wanting 4:10 good contractions with resting tone and lasting 40 - 90 seconds
- titrate the infusion as indicate
Action:
- oxytocin increases the sodium permeability of the uterine myofibrils, indirectly stimulating contractions of the uterine smooth muscle.
- the uterus responds to oxytocin more readily in the presence of high estrogen concentrations
- and with increased duration of pregnancy
Contraindication:
- if the cervix is unfavourable (bishop score =<6)
- hx of c-section must be discussed with head ogby
- Oxytocin should not be used with 6 hours of prostin gel
- should not be used with dinoprostone while insitu or wait 30 mins post
- in a multipaous woman should be discussed with obgy prior to use, particularly if the woman has an epidural
Potential Complications:
- uterine hyperstimulation
- uterine hyoptonic
*
9
Q
ARM
A
indication:
- cervix is favourable
Action:
- amniotomy hook
- alligator or other toothed forceps should not be used unless the ARM is technically difficult
- the practice of obtaining fetal hair to confirm ARM is not usually necessary
Contraindication:
- Rapid labour
- grand multipartiy
- previous lower segment c-section
- woman wants to await spont labour
Potential Complications:
- cord prolaspe
- bleeding
- infection
- may need oxytocin
10
Q
Membrane sweep
A
indication:
- 40 - 41 weeks nulliparous women and at 41 week antenatal visits many be offered
Action:
- stretch and sweep involve the examining finger passing through the cervix to rotate against the wall of the uterus to operate the chorionic membrane from the decidera
- releases prostaglandin
Contraindication:
- no evidence of low-lying placental site
- GBS positive
Potential Complications:
- infection
- post procedure bleeding
- discomfort
11
Q
Maternal assessment - pre IOL
A
Documentation of
- blood pressure
- heart rate
- respiratory rate
- temperature
- any vaginal loss
- abdo palpation to ascertain fetal lie
- VE - determine of favourablity of the cervix
- Station
12
Q
Fetal survillance - pre IOL
A
CTG
- prior to commencement of IOL
- a baseline normal CTG should be demonstrated within 6 hours of insertion of the prostaglandin
- a normal CTG should be recorded prior to iv oxtocin infusion
13
Q
Maternal assessment - post IOL - cervical ripening
A
- Remain with the woman for the first 10 minutes
- observing the CTG
- Palpate uterine for activity
- if the first 10 minutes of CTG is reassuring
- review the woman and CTG every ten minutes
- 50 minutes
- vital signs
- blood pressure
- heart rate
- resp rate
- temp
- vaginal loss
- palp abdo
- CTG report
- vital signs
- After the first hour
- 30/60 vaginal loss
- 60/60 uterine activity palp over 10 minutes
- after 3/24 if no contractions and nil fetal concerns ceases freq obs
- 6/24 post prostin
- VE
- 12 to 24/24 remove cervidil if still insitu and reassess the bishop score
14
Q
Fetal assessment - post iol - cervical ripening
A
- continue CTG until normal trace
- after first 60/60 auscultate FHR every 30/60 for 3/24
*
15
Q
Maternal assessment - post IOL - oxytocic infusion
A
- same as above
- uterine palp and record uterine activity for 10/60 every 30/60
- offer support and analgesia
- record rate of oxytocic in mls/hr
