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A - MSRA Obstetrics [16] > [38] Induction of Labour > Flashcards

[38] Induction of Labour Flashcards

1
Q

What is induction of labour?

A

The process of starting labour artifically

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2
Q

What proportion of pregnancies will require induction?

A

Approx 1 in 5

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3
Q

In general, why might IoL be performed?

A
  • If it is thought that the baby will be safer delivered than remaining in utero
  • If there are concerns regarding the mother’s health
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4
Q

What are the indications for induction of labour?

A
  • Prolonged gestation
  • Premature rupture of membranes
  • Maternal health problems
  • Fetal growth restriction
  • Intrauterine fetal death
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5
Q

When should women with uncomplicated pregnancies be offered induction?

A

Between 40+0 and 40+14 week’s gestation

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6
Q

What is the aim of inducing labour in prolonged pregnancy?

A

Avoid the risks of fetal compromise and stillbirth associated with prolonged gestation

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7
Q

What should be done if the patient declines induction of labour for prolonged gestation?

A

The frequency of monitoring from 42 weeks onwards should be increased

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8
Q

What should be done for premature rupture of membranes over 37 weeks?

A

Either IoL or expectant management for a maximum of 24 hours

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9
Q

What % of women will spontaneously go into labour within the first 24 hours of premature rupture of membranes?

A

84%

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10
Q

Why should women not go for more than 24 hours with premature rupture of membranes?

A

Increases the risk of chorioamnioitis

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11
Q

What should be done in preterm premature rupture of membranes if <34 weeks gestation?

A

Delay IOL unless obstetric factors indicate otherwise, e.g. fetal distress

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12
Q

What should be done in preterm premature rupture of membranes if >34 weeks gestation?

A

The timing of IOL depends on risk vs beenfits of delaying pregnancy further, e.g. increased risk of infection

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13
Q

What maternal health problems are common indications for IOL?

A
  • Hypertension
  • Pre-eclampsia
  • Diabetes
  • Obstetric cholestasis
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14
Q

What is the second most common indication for induction of labour?

A

Fetal growth restriction

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15
Q

What is the aim of IOL for fetal growth restriction?

A

To deliver the baby before there is fetal compromise

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16
Q

When should IOL be offered for intrauterine fetal death?

A

If the mother is physically well with intact membranes

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17
Q

What are the absolute contraindications for IOL?

A
  • Cephalopelvic disproportion
  • Major placenta praevia
  • Vasa praevia
  • Cord prolapse
  • Transverse lie
  • Active primary genital herpes
  • Previous classical C-section (midline incision)
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18
Q

What are the relative contraindications for IOL?

A
  • Breech presentation
  • Triplet or higher order pregnancy
  • Two or more previous low transverse C-sections
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19
Q

Can IOL be offered to women who have had a previous C-section?

A

Yes, after she has been seen and assessed by a consultant

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20
Q

What should a woman having IOL after a previous C-section be made aware of?

A

She is at increased risk of emergency C-section and uterine rupture

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21
Q

What are the main methods of IOL?

A
  • Vaginal prostaglandins
  • Amniotomy
  • Membrane sweep
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22
Q

What methods of IOL have a lack of evidence

A
  • Homeopathy
  • Acupuncture
  • Sex (with the partner not a HCP)
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23
Q

What is the mainstay of induction of labour and the preferred primary method by NICE?

A

Vaginal prostaglandins

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24
Q

How do vaginal prostaglandins work in IOL?

A

They prepare the cervix for labour by ripening, and has a role in contraction of smooth muscle of uterus

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25
Q

What forms do vaginal prostaglandins come in?

A
  • Tablet
  • Gel
  • Controlled-release pessary
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26
Q

What constitutes 1 cycle of the tablet/gel routine of vaginal prostaglandins for IOL?

A

1 cycle = 1st dose + 2nd dose if labour not started within 6 hours

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27
Q

What constitutes 1 cycle of the pessary regime of vaginal prostaglandins for IOL?

A

1 cycle = 1 dose over 24 hours

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28
Q

What is the recommended maximum number of cycles when using vaginal prostaglandins for IOL?

A

1 cycle in 24 hours

29
Q

How long can IOL with vaginal prostaglandins take?

A

Days

30
Q

What is an amniotomy?

A

Where membranes are ruptured artificially using an instrument called an amnihook

31
Q

How does amniotomy work

A

It releases prostaglandins in an attempt to expedite labour

32
Q

When can amniotomy be peformed?

A

Only if the cervix is deemed as ripe

33
Q

What is often given alongside an amniotomy?

A

An infusion of artificial oxytocin (Syntocinon)

34
Q

What is the purpose of giving Syntocinon alongside amniotomy?

A

To increase the strength and frequency of contractions

35
Q

How is the dose of Syntocinon given alongside amniotomy determined?

A

Start low and titrate upwards, until there are 4 contractions every 10 minutes

36
Q

What are the NICE guidelines regarding the use of amniotomy +/- oxytocin?

A

It should not be used as the primary method of IOL, unless the use of prostaglandins is contraindicated.

37
Q

Give an example of when the use of prostaglandins might be contraindicated

A

High risk of uterine hyperstimulation

38
Q

When is the membrane sweep indicated?

A

Between 40 and 41 weeks gestation in nulliparous women, and 41 weeks in multiparous women

39
Q

What is the membrane sweep classified as?

A

An adjunct to IOL

40
Q

What does performing a membrane sweep achieve?

A

It increases the likelihood of spontaneous delivery, reducing the need for formal induction

41
Q

How is the membrane sweep performed?

A

By inserting a gloved finger through the cervix and rotating it against the fetal membranes

42
Q

What is the aim of the membrane sweep?

A

To separate the chorionic membrane from the decidua

43
Q

What does separating the chorionic membrane from the decidua achieve?

A

Helps to release natural prostaglandins in an attempt to kick-start labour

44
Q

What monitoring is done in induction of labour?

A
  • Bishop’s score

- Cardiotocography

45
Q

What is the Bishop’s score an assessment of?

A

Cervical ripeness

46
Q

What is the assessment of cervical ripeness in the Bishop’s scored based on?

A

Measurements taken during vaginal examination

47
Q

When is the Bishop’s scored checked?

A

Prior to induction, and during induction to assess progress (6 hours post tablet/gel, 24 hours post pessary)

48
Q

How is the Bishops score interpreted?

A
  • A score of 7 or more suggests the cervix is ripe or ‘favourable’
  • A score of under 4 suggests that labour is unlikely to progress naturally, and prostaglandin tablet/gel/pessary will be required
49
Q

What does the cervix being ‘favourable’ mean?

A

There is a high chance of a response to interventions made to induce labour

50
Q

What might happen if there is a failure of the cervix to ripen despite the use of prostaglandins?

A

May need C-section

51
Q

When should a CTG be used in induction?

A
  • Prior to induction of labour
  • After induction of labour, when contractions begin
  • If oxytocin infusion is started
52
Q

Why should a CTG be done before the induction of labour?

A

A reassuring fetal heart rate must be confirmed by CTG

53
Q

What CTG monitoring should be done after the induction of labour, when contractions begin?

A

Fetal heart rate should be assessed using continuous CTG until a normal rate is confirmed

54
Q

How should the fetal heart rate be assessed after induction of labour when the CTG has confirmed a normal heart rate?

A

Intermittent auscultation

55
Q

What CTG monitoring should be done if oxytocin infusion is started?

A

Continuous CTG throughout labour

56
Q

What are the complications of induction of labour?

A
  • Failure of induction
  • Uterine hyperstimulation
  • Cord prolapse
  • Infection
  • Pain
  • Increased rate of further intervention
  • Uterine rupture
57
Q

In what % of cases does failure of induction occur?

A

15%

58
Q

What should be done if failure of induction occurs?

A

Should offer a further cycle of prostaglandins, or C-section

59
Q

In what % of cases of IOL does uterine hyperstimulation occur?

A

1-5%

60
Q

What is uterine hyperstimulation?

A

When contractions last too long or are too frequent

61
Q

What can uterine hyperstimulation lead to?

A

Fetal distress

62
Q

How can uterine hyperstimulation caused by IOL be managed?

A

Tocolytic agents, such as terbutaline

63
Q

When can cord prolapse occur in IOL?

A

At the time of amniotomy, particularly when the presentation of the fetal head is high

64
Q

How is the risk of infection during IOL reduced?

A

By using pessary (vs tablet/gel)

65
Q

Why is the risk of infection during IOL reduced when using the pessary?

A

Fewer vaginal examinations are required to check progress

66
Q

Is IOL more or less painful than spontaneous labour?

A

More

67
Q

What is often required as pain relief in IOL?

A

Epidural

68
Q

What % of cases of IOL require an emergency C-section

A

22%

69
Q

What % of cases of IOL require instrumental delivery?

A

15%

A - MSRA Obstetrics [16] (61 decks)

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