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Induction of labour > Indications, methods and complications > Flashcards

Indications, methods and complications Flashcards

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1
Q

What is IOL?

A

Labour that is induced artificially

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2
Q

How is it different from Augmentation?

A

In augmentation, already established contractions are strengthened. IOL involves inducing labour, not building on pre-existing work

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3
Q

Why is IOL performed?

A

Indicated in any situation where allowing the foetus/mother to a risk greater than that of induction (in reality, this quantification is rarely simple)

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4
Q

What percentage of UK labours are artificially induced?

A

20%

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5
Q

What are the reasons for the majority (75%) of IOLs?

A

HNT
Prolonged pregnancy (after 41 w, inc risk of stillbirth)
Pre-eclampsia
Rhesus disease

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6
Q

What are less common (but still relevant) reasons for induction?

A 
Diabetes (and other maternal medicine complications)
Previous stillbirth
Abruption
Foetal death in utero
Placental insufficiency
IUGR
Foetal congenital abnormalities
Pre-labour prolonged rupture of membranes
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7
Q

What are contraindications?

A 
Malpresentation (inc breech)
Foetal distress
Placenta praevia
Cord presentation
Vasa praevia
Pelvic tumour (e.g. cervical fibroid)
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8
Q

What can be done to avoid IOL with medication?

A

Membrane sweep

There is no evidence for sex, castor oil, enemas, acupuncture, homeopathy, herbal supplements or hot baths

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9
Q

What are the risks of IOL?

A 
Prolonged labour duration
More likely to need regional anaesthesia (and an operative delivery)
Failure to establish labour (15%)
(NOT assoc with inc LSCS risk)
Postpartum haemorrhage
Intra and postpartum infection
Uterine hyperstimulation
Uterine rupture
Umbilical cord prolapse
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10
Q

What are the risks of delay labour beyond 40+12?

A

Increased perinatal mortality

Increased risk of intervention (LSCS)

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11
Q

What would a midwife typically do in a woman who has consented to IOL?

A

Confirm gestation
Palpate foetal lie, position and engagement
Perform CTG
Vaginal exam to assess cervical favourability

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12
Q

What is Naegle’s rule?

A

LMP -3mo +7d

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13
Q

When is the EDD typically calculated?

A

At dating scan (around 12w) from crown rump length

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14
Q

How is the state of the cervix assessed?

A

Bishop’s score

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15
Q

The risk of what increases if primips are induced with a Bishop’s <3?

A

Prolonged labour
Foetal distress
LSCS

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16
Q

What is a favourable Bishop’s?

A

> 5

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17
Q

What if Bishop’s >7?

A

Induction via ARM (avoids use of prostaglandins)

18
Q

What are the methods of IOL?

A

Prostaglandins (ripen cervix, enable amniotomy)
Amniotomy
Syntocinon infusion
Mechanical cervical dilators

19
Q

What forms of prostaglandin are available?

A

Pessary (Prostin) 10mg/24hr
Gel (Prostin gel) 1-3mg/6hrly
Slow-release preparation (Propess)

20
Q

When giving prostaglandins, what else should be performed?

A

CTG (pre PG use and 30mins after insertion

21
Q

How do prostaglandins induce labour?

A

Stimulate uterine contractions or precipitate labour

22
Q

If membranes cannot be ruptured 48hrs after PG use, what can be done?

A

Try IOL again

LSCS

23
Q

What is amniotomy?

A

Rupture of membranes, spontaneous or artificial (SRM/ARM)

24
Q

What is the woman at risk of from amniotomy?

A

Cord prolapse (MEDICAL EMERGENCY - compression/vasospasm that causes foetal asphyxia)

25
Q

How is cord prolapse managed?

A

Decompress cord by manual elevation of baby head and putting mother in prone knee-chest position or filling maternal bladder with saline
Unless woman is fully dilated, LSCS needs to be performed

26
Q

What should be done to the foetus once amniotomy has occurred (SRM or ARM)?

A

Intrapartum CTG

Allow woman to mobilise for 2-4hrs to induce contractions (if liquor clear)

27
Q

What if woman is not experiencing contractions after amniotomy?

A

Oxytocin 1-4 milliunits/minute, increasing every 30 mins until woman experiencing 4 contractions every 10 mins (typically 4-10MU/min)

28
Q

When should oxytocin/IOL be stopped?

A

If CTG shows foetal distress or uterine hyperstimulation (>5 contractions/10 mins with foetal compromise)

29
Q

Should women with previous caesarean sections have IOL?

A

Consult with senior (inc risk of scar rupture with prostaglandins and oxytocin)

30
Q

What alternative medication can be used to induce labour (and what is the condition for its use)?

A

Misoprostol
PO/PV has lower chance of hyperstimulation
Only use for IOL after intrauterine death

31
Q

What analgesia options are available for women in labour?

A 
Non-pharmacological
-Hypnotherapy/relaxation techniques
-Aromatherapy
-TENS
-Water
Pharmacological
-Simple analgesia
-Opioids (include PCA for IUD or where RA is contraindicated); short-term neonatal effects if delivery within 2 hrs of pethidine
-Entonox (gas and air)
-Regional anaesthetic (RA); assoc with increased risk of instrumental delivery
32
Q

How is the dose of syntocinon (oxytocin) titrated?

A

Titrated against the rate of maternal contractions

33
Q

What are the pathological causes of abnormal CTGs?

A

Hyperstimulation
Advancing labour
(Foetal hypoxia main concern)

34
Q

How to manage abnormal CTG in IOL?

A

Assess progress using vaginal exam

Turn down syntocinon to reduce frequency of contractions

35
Q

What are the next steps if contraction rate is slowed but CTG still abnormal?

A

Without foetal blood sample, difficult to ascertain cause.

50% of abnormal CTGs assoc with foetal compromise and so require urgent delivery

36
Q

What is a normal finding on foetal blood sampling?

A

> 7.25 (would need repeating in 1 hr if CTG remained abnormal)
If 7.20-7.25, repeat in 30 mins
If <7.20 foetus at substantial risk of hypoxia and needs urgent delivery

37
Q

If FBS is 7.32, cervix fully dilated and foetus in OA, what is the best mechanism for delivery?

A

Instrumental delivery (no point waiting to repeat FBS as foetus easily deliverable)

38
Q

What should be performed once baby is delivered?

A

Cord gas analysis

39
Q

What instrument can be used to rupture membranes artificially?

A

Amnihook

40
Q

When is the best time to perform IOL?

A

38w

Induction of labour (1 decks)

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