CBL 4_Pharmacological Pain Management and Induction of Labour Flashcards
What is cervix ripening?
Process of stimulating
-softening
-effacement
-dilation of cervix, usually prior to induction of labour.
What are some non pharmaceutical methods for ripening the cervix at term?(8)
- Cervical sweeps
- balloon catheter
- acupuncture
- acupressure
- evening primrose oil
- castor oil
- nipple stim
- sex (with sperm [low level prostaglandins] or not)
What non-pharmacological methods of cervix ripening have research backing them? (4)
Castor Oil
Cervical Sweep
Nipple stimulation
Can all reduce the need for IOL
Balloon catheter recommended first line approach by. SOGC
What is the community standard on IOL for postdates?
Induction of labour should be offered to all clients at 41 weeks
ICD on postdates management
The vast majority of pregnancies aren’t associated with major or long-term complications, and although the chance of complications increases with a postdates pregnancy, the overall risk remains low.
The recommendation is to offer pregnant people with an ICD an induction between 41 and 42 weeks because it reduces the low risk of complication to an even lower risk.
If you choose to wait for labour to start, the recommendation is to monitor your baby to make sure they are well with at least one non-stress test and an assessment of the amniotic fluid starting at 41 weeks, as well as fetal movement counting.
You can choose to induce medically, non-medically, or wait for labour.
If you are waiting for labour to start, you can choose how to monitor your baby.
You can think about what we’ve talked about and take time to make your decision. While making your decision consider what’s important to you. I’m here to answer any questions now or later, and I’ll support you in choosing what feels like the best choice for you.
Options for postdates?
1) You can choose to induce labour medically:
· The recommendation is to offer pregnant people an induction between 41 and 42 weeks
2) You can choose to induce labour non-medically
· The recommendation is to offer pregnant people membrane sweeps from 38 – 41 weeks.
3) You can choose to wait for your body to go into labour (this is called expectant management)
Risk of stillbirth w/ expectant mgmt for postdates?
40 weeks 0.7/1000
41 wks 1.1/1000
42 weeks 1.9/1000
all rare
What is the ‘community standard’ for fetal monitoring at term?
NST and AFI (with FMC) at 41 weeks. (SOGC - Reasonable approach would be at least one NST and some sort of amniotic fluid assessment twice weekly.)
What is the evidence for the use of NSTs, AFI/AFV and BPPs as a means of predicting fetal well-being?
NSTs – false negative rates are low (normal NST 1.9/1000 SB within a week after reading); false positive high
BPP and modified BPP – false negative rates low (0.8/1000), but false positive rates high (60%)
What is the evidence for estimating, and inducing labour for, macrosomia for otherwise low risk pregnancies?
- There is no clear consensus in how to identify macrosomia; there are limitations of US prediction of EFW
- There is conflicting evidence about whether induction for suspected big babies can improve health outcomes
- A care provider’s “suspicion” of a big baby carries its own set of risks. This perception—whether it is true or false—changes the way the care provider behaves and how they talk about the pregnancy
BC Women’s guidelines for macrosomia?
U/S measured > 4000 g may request an induction of labour at 39 weeks.
Caregivers should discuss shortcomings of ultrasound diagnosis of macrosomia.
SOGC Guideline – there is insufficient evidence to recommend IOL at a specific GA for macrosomia; recommend considering Cesarean for >5000g
How accurate is U/S measuring fetal weight at term?
sensitivity 56%
specificity 92%
the tendency is to overestimate fetal weight
(+/- 15 %?)
SOGC recs for IOL for suspected macrosomia?
There is insufficient data to recommend IOL at a specific gestational age for suspected fetal macrosomia.
A risk reduction strategy giving importance to individual patient preferences should be taken.
When might C/S be considered for suspected macrosomia?
EFWT >4500 g with GDM
EFWT >5000 g without GDM.
What should an ICD on C/S for macrosomia include?
- The potential maternal morbidity associated with C/S delivery
- Risk of urinary and anal incontinence
- Risk of instrumental delivery
- Risk of shoulder dystocia to the mother and infant
- Neonatal risks associated with early term birth before 39 weeks
How do care provider, family and other societal influences impact decision making for IOL? How do racism and classism impact decision making for IOL?
Care providers/researchers may restrict choices and autonomy is impacted, e.g. race and class:
1) race – e.g. research finding Black women are at more risk of stillbirth, therefore more likely to be induced, rather than providing quality of care to communities that has been shown to reduce stillbirth risk.
“Achieving high quality national guidance also requires an examination of the impact of social, cultural, and political systems on health, wellbeing, safety, access to care, quality of care, and autonomy. ..Racism is a known determinant of health, occurring at systemic and individual levels. Its role in perpetuating the extreme disparities witnessed in maternity care needs to be addressed through “race conscious medicine”
BMJ – response to NICE recommendation in 2021 that all women from ethnic minority backgrounds should consider IOL at 39w even if no complications: “We are deeply concerned that if these recommendations are taken forward uncritically, they could further embed institutional racism in maternity care, strengthen racial biases and stereotypes, legitimise skin tone as clinically meaningful, pathologise healthy pregnancies in women from ethnic minority backgrounds, and undermine choice for black and brown women.”
2) Class:
BMC- The risk of labour induction differs by socioeconomic status, with nulliparous and multiparous women with fewer educational qualifications and those living in lower SEI locations having ‘a greater likelihood of labour induction than women with higher qualifications and women in advantaged electoral wards’
Why is it important to hydrate before an US for postdates?
Important to be well-hydrated systemically rather than just having a fully bladder.
We cannot distinguish oligo caused by isolated maternal dehydration vs. placental insufficiency
What are new antenatal FHS guidelines around defining oligo?
OLD WAY: AFI less than 5cm = more interventions without improved outcomes
NEW (evidene based way) SDP less than 2cm x 1 cm.
What is oligohydramnios?
decreased amniotic fluid for GA
Single deepest pocket less than 2cm (depth) by 1 cm (width)
Should a postdates client with oligo have IOL?
Labour induction is recommended in the postdates population when oligohydramnios is present. Induction should be considered as a priority 1 (< 8 hours). Obstetrical consultation is required prior to induction booking.”
What assessments should be done for admission for IOL?
Birther vitals
normal NST
abdominal assessment (confirm presenting part) & FM
VE
When may IOL be associated with more negative childbirth experiences? (3)
-** delays** in labor induction, delay in transfer to delivery ward, and delay in receiving pain relief
- a **lack of information and choice **as well as feelings of disappointment, anxiety, and neglect
- lack of continous support
Does it make a difference in outcomes if midwives are primary care providers for an IOL? If so, how? (3)
YES
- fewer other interventions –note less need for epidural
- fewer handovers = better client safety;
- maximizes health resources, enhances interprofessional practice, etc:
What is the Bishops score?
Position - post (0), Mid (1), Amt (2)
Consistency - firm (0), medium (1), soft (2)
Cervical length cm (effacment) = greater than 4 (0), 2-3 (1), 1-2 (2)
Dilation, cm = 0 (0), 1-2 (1), 3-4 (2)
Fetal station = -3 (0), -2 (1), -1/0/spines (2)
What is a favorable Bishops score?
7 or higher (associated with successful IOL)
Can the different bishops scores be used interchangeably?
No
What are the risks associated with IOL with a lower bishop’s score?
Higher rates of failed IOL and C/S
What is considered uterine tachystole in labour?
5 or more cx in 10 mins averaged over 30 minutes
Prerequisites for IOL?
ICD and consent
Vertex presi
Adequate fetal station
Determine bishop’s score
