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OB > INDUCTION AND AUGMENTATION OF LABOR > Flashcards

INDUCTION AND AUGMENTATION OF LABOR Flashcards

1
Q

implies stimulation of contractions before the spontaneous on set of labor, with or without ruptured membranes

A

induction

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2
Q

refers to enhancement of spontaneous contractions that are considered inadequate because of failed cervical dilation and fetal descent

A

augmentation

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3
Q

pharmacologic or other means to soften, efface or dilate cervix to increase likelihood of a vaginal delivery with labor induction

A

Cervical ripening

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4
Q

induction of labor indications

A

When the risk of continuing the pregnancy exceeds the risk of induction

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5
Q

maternal indications

A

•Membrane rupture without labor
•Severepre-eclampsia,eclampsia
•Significantmaternaldiseaseunresponsive totreatment (DM, Chronic renal ds, pulmods)
Induction of Labor

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6
Q

FETAL INDICATIONS

A
  • IUGR
  • Chorioamnionitis
  • Suspectedfetalcompromise
  • Term/near termPROM
  • Oligohydramnios
  • Post term pregnancy
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7
Q

RELATIVE INDICATIONS

A
  • Chronic hypertension
  • Gestational DM
  • Logistic factors: risk of rapid labor, distance from hospital
  • Psychosocial indications
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8
Q

Indications–Unacceptable

A

•Suspected fetal macrosomia
•Absence of fetal or maternal indication
•HCP or patient convenience
Induction of Labor

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9
Q
  • gestation of >42wks
  • approximately6% ofbirths
  • Accurate dating of pregnancy very important
  • Significance
  • increased perinatal mortality, increased perinatal morbidity
  • increased operative delivery rates
A

Post-term pregnancy

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10
Q

Why induction is recommended

A

in order to avoid the risks associated with ‘post-term’ pregnancy

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11
Q

If induction not chosen

A
  • daily fetal movement counts

- twice weekly fetal surveillance

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12
Q

contraindication to induction

A
  • Any contraindication to labor

- Absence of indication for induction

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13
Q

contraindication to induction: any contraindication to labor

A
  • placenta previa, vasaprevia, cord presentation
  • abnormal fetal lie
  • prior CCS or inverted T C/S significant uterine surgery
  • active genital herpes, invasive cervical CA
  • previous uterine rupture
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14
Q

Strategies to Reduce the Need for Induction

A
  1. Use of dating ultrasound

2. Sweeping of membranes

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15
Q

MOST Likelihood of Successful Vaginal Delivery

A

favorable cervix
multiparous
previous vaginal delivery

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16
Q

LEAST Likelihood of Successful Vaginal Delivery

A

unfavorable cervix
nulliparous
previous CS

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17
Q

this Bishop score conveys a high likelihood for a successful induction

A

9

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18
Q

this Bishop score identifies an unfavorable cervix and may be an indication for cervical ripening

A

4 or less

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19
Q

Maternal parameters/assessment prior to IOL

A
  • Confirm indication for IOL
  • Review contraindications to labor and/or vaginal delivery
  • Assess shape and adequacy of the bony pelvis
  • Assess cervix (Bishop score)
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20
Q

Fetal parameters/assessment prior to IOL

A

Confirm AOG
Estimate fetal weight
Determine fetal position
Confirm fetal well-being

21
Q

METHODS OF INDUCTION OF LABOR for UNFAVORABLE CERVIX

A

–Mechanical methods

–Pharmacological methods

22
Q

METHODS OF INDUCTION OF LABOR for FAVORABLE CERVIX

A

–Amniotomy

–Oxytocin

23
Q

cervical ripening

A

unfavorable cervix –> favorable cervix

24
Q

Options for Cervical Ripening with an Unfavourable Cervix

A

1.Mechanical methods
•Transcervical balloon devices
•Extraamnionic saline infusion
•hygroscopic dilators

2.Pharmacologic options
•prostaglandins

25
Q

usually needed after cervical ripening

A

oxytocin

26
Q
  • Effective (but not as effective as vaginal prostaglandins)
  • No. 14-18, sterile technique, insert past internal os, inflated to 30-80 cc water
  • Contraindication: low placenta-relative contraindications: APH, PROM, cervicitis
A

Foley catheter

27
Q
  • effective

- Increased risk of neonatal infection

A

Hygroscopic dilators

28
Q

Prostaglandin Preparations

Cervical ripening

A
  • vaginal PGE2

- endocervical PGE2

29
Q

Prostaglandin Preparations

Labor induction

A

-vaginal PGE2

30
Q

Precautions with Prostaglandins

A
  • Vaginal gel should not be put in cervical canal
  • Should not be used to augment labour
  • Should not be followed by oxytocin in women with previous C/S
  • Use cautiously in the setting of ruptured membranes
31
Q

Guidelinesfor PGE2 Use

A
  • Done in controlled setting by experienced staff with resuscitation and delivery capabilities
  • Normal electronic fetal surveillance prior to application
  • PGE₂ applied by experienced caregiver
  • Monitor FHR and uterine activity (1-2 hours)
  • If no labor, reassess, repeat as necessary or choose an alternative induction method
32
Q

Prostaglandin E2 –Advantages

A
  • Improved patien tacceptance
  • Lower operative deliveryrate
  • Less need for oxytocin induction
33
Q

Prostaglandin E2 –Disadvantages

A 
•Adverserveactions
-hyperstimulation
-CVSevents
-nausea,vomiting, diarrhea
•Gel preparations are difficult to remove
•No cervical preparations in PROM
34
Q
  • Ideal dose, route & frequency of administration not firmly established
  • Only available in an oral form but tablet is readily absorbable trans-mucosally (sublingually, buccally, vaginally, or rectally)
A

Prostaglandin E1 (Misoprostol)

35
Q

Misoprostol –Disavantages

A
  • increased risk of uterine rupture with previous C/S

* Nausea, vomiting, diarrhea, shivering and chills

36
Q

Options for Induction–Favourable Cervix

A
  • Amniotomy
  • Oxytocin
  • Vaginal prostaglandins
37
Q

MECHANISM OF ARM

A
  1. Stretching of the cervix
  2. Separation of membrane (liberation of PGs)
  3. Reduction of amniotic fluid volume
  4. Fetal head serves as a more solid wedging pressure
38
Q

RISKS OF AMNIOTOMY

A
  1. Cord prolapse
  2. Intraamniotic nfection
  3. Accidental injury to the placenta, cervix, uterus, fetal parts or vasaprevia
39
Q
  • Creates commitment to delivery
  • Effective with favourable cervix
  • Often used in conjunction with oxytocin
  • Caution in cases of high presenting part
  • After amniotomy note amount and color of the fluid and assess fetal well being
A

Amniotomy

40
Q

Oxytocin Effects

A

•Myometrialcontraction
•Cervix -no direct effect
•Vasoactive
-hypotension possible with bolus IV administration
•Antidiureticactivity
-water intoxication possible with high dose oxytocin

41
Q

Oxytocin Protocol

A

•Cervix is ideally favourable (except can be used with PROM with unfavourable cervix)
•Experienced caregivers and adequate resources available to manage dystocia and other emergencies
•EFM according to guidelines for FHS
•Administration
-infusion pump into a mainline IV
-rates in milliUnits per minute (mU/min)
-concentrations vary but avoid large free water load

42
Q

Oxytocin endpoint

A
  • effective contractions leading to labor progress

- maternal and fetal well-being

43
Q

Oxytocin Dosage Low dose protocol

A

-Less hyperstimulation & overall smaller dose

44
Q

Oxytocin Dosage High dose protocol

A

-May shorten the length of labour

45
Q

Oxytocin Adverse Effects on Fetus

A

with hyperstimulation or / with normal contraction pattern

46
Q

Oxytocin Adverse Effects on Mother

A
  • discomfort secondary to contractions
  • uterine rupture
  • water intoxication
47
Q

if there is Excessive Uterine Activity

A

•Discontinue oxytocinor remove prostaglandinfrom vagina
•Intrauterine resuscitation
•Be prepared for emergency delivery
•Consider tocolyticagentsnitroglycerin 50 mcg IV push, repeatq3 to5 minutes to maximum of 200 mcg
Induction of Labor

48
Q

Induction for Term PROM

A

consider induction with oxytocin (rather than prostaglandin or expectant management)

49
Q

Conclusions in inducing labor

A 
•Indication must be VALID
•Match the method with the cervical status
•Ripen the cervix as much as possible
•Discuss risk and benefits with patient
Induction of Labor

OB (9 decks)

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