Induction and Augmentation of Labor Flashcards
List maternal indications for IOL
1) DM
2) renal disease
3) chronic pulmonary disease
4) cholestasis of pregnancy
5) gHTN or pre-eclampsia w/out severe features @ 37w
6) pre-eclampsia w/ severe features = ASAP
7) >41w GA - recommended at 42w0; indicated at 42w6d
8) chorioamnionitis
9) PROM after 34w
List fetal indications for IOL
1) IUGR
2) isoimmunization
3) non-reassuring fetal testing
4) multiple gestation
5) oligohydramnios
6) IUFD
What are contraindications to IOL?
1) problems of placentation (e.g. previa, prolapse)
2) hx myomectomy entering endometrial cavity
3) classical uterine incision
4) transverse lie
5) Cat 3 FHT
6) active genital herpes
7) elective IOL at <39w
What are maternal clinical considerations prior to IOL?
1) valid indication
2) no contraindications to vaginal labor/delivery
3) pelvimetry
4) Bishop score via cervical exam
5) review risks, benefits, alternatives to IOL
What are fetal clinical considerations prior to IOL?
1) GA based on final EDD - fetal lung maturity
2) fetal presentation and lie
3) EFW
4) Confirm Cat 1 FHT
What are risk factors for failed IOL?
1) nulliparity
2) post-EDC
3) low Bishop score
4) shorter stature
5) higher BMI
Describe Bishop scoring system
an assessment of cervical status to determine success of IOL
- > /= 8 –> favorable cervix
- =6 –> unfavorable cervix; may require ripening
0: posterior, firm, cervical length >4cm, 0/-3
1: midline, medium, 2-4cm, 1-2/-2
2: anterior, soft, 1-2cm, 3-4/-1 to 0
3: cervical length <1cm, >5cm/+1 to +2
Describe the latent phase of labor according to Zhang’s labor curve
regular, q10-20min, uterine ctxns lasting 15-20s –> intensifies to q5-7mins, lasting 30-40s
Describe active labor according to Zhang’s labor curve
cervical dilation starts at ~6cm –> ends with complete dilation
- nullips: 0.5-0.7cm/h or faster
- multips: 0.5-1.3cm/h
What are the 4 Ps?
1) powers
2) passenger
3) passageway
4) psyche
What are considered adequate contractions on pitocin?
q2-3mins lasting 60-90s
50-60 peak, 10-15 resting tone
150-350 MVUs
What is therapeutic rest?
“treats” prolonged latent phase
morphine sulfate IM +/- phenergan or vistaril
What is dx for protracted active phase?
multips: <0.5 - 1.5cm/h
nullips: <0.5 to 1.2cm/h
What is dx for arrest of active phase?
6cm or more, ROM, + one of following:
- 4h+ of adequate ctxn (>200MVU)
- 6h+ of inadequate ctxn
What is the mean duration of the second stage?
nullips: 50-60min
multips: 20-30mins
no max length identified
What is dx for protraction descent?
nullips: <1cm/h
multips: <2cm/h
What is dx for arrest of descent?
0 descent - time period not officially identified
nullips: 3h
multips: 2h
+1h for epidural
What are risks of >2h second stage?
1) low 5 min APGAR
2) increased neonatal depression
3) NICU admission
4) perineal trauma
5) chorio
6) PPH
7) instrumental deliveries
What are risk factors affecting length of the second stage?
1) parity
2) birth weight
3) OP position
4) BMI
5) epidural anesthesia
6) fetal station at complete dilation
7) delayed pushing
What are indications for C/S in the setting of IOL or augmentation?
1) >/= 6cm, ROM, and no cervical change over 4h
2) no cervical change in 6h of pit + inadequate uterine activity
3) failed induction = little to no cervical change for at least 24h in setting of pit + ROM
List cervical ripening agents
1) prostaglandin E2: dinoprostone (Cervidil or Prepidil)
2) prostaglandin E1: misoprostol (Cytotec) off-label
What are cervical ripening agents contraindicated?
1) prior to 40w GA
2) uterine scarring
What is the MOA of prostaglandins?
increase submucosal water content of cervix –> dissolution of collagen bundles
How should FHT be monitored during cervical ripening?
EFM for 0.5-2h
Continue to monitor if regular ctxns continue
