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GOSH > Induction and Augmentation of Labour > Flashcards

Induction and Augmentation of Labour Flashcards

1
Q

What proportion of women are commonly induced and what are some common reasons why a woman might be induced? (think fetal/maternal)

A

24%

Fetal

  • IUGR (baby will probably grow better outside the uterus)
  • PPROM (pre-term pre-labour rupture of membranes) Induction at 34-35w due to risk of chorioamnionitis
  • INTRAUTERINE DEATH/ reduced fetal movements
  • PROLONGED PREGNANCY (beyond 41 weeks) - if you allow pregnancy to continue there is a risk of placental insufficiency, fetal hypoxia/distress and meconium staining

Maternal

  • APH
  • DIABETES - women with maternal DM or GDM are induced at 38 weeks due to increased chance of placental insufficiency and increased size of babies
  • MATERNAL HYPERTENSION/pre-eclampsia
  • Obstetric Cholestasis/maternal cardiac disease
  • POOR OBSTETRIC HISTORY
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2
Q

What are some contraindications for induction? (absolute and relative)

A

ABSOLUTE CI (do C/S instead)

  • ACUTE FETAL DISTRESS - labour will lead to further distress for the baby
  • UNSTABLE LIE-transverse or breech lies won’t be delivered vaginally, induction shouldn’t be done
  • PLACENTA PRAEVIA - in the way
  • PELVIC OBSTRUCTION
  • PREVIOUS CLASSICAL C SECTION (scar looks like this I)

RELATIVE CI

  • PREVIOUS CS (increases risk of scar rupture)
  • BREECH - can be delivered vaginally with experiences obstetrician
  • PREMATURITY
  • HIGH PARITY (can increase risk of uterine rupture)
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3
Q

There are lots of different ways of inducing a woman, what should be tried before?

A

Before formal induction should try MEMBRANE SWEEP (STRETCH AND SWEEP)

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4
Q

When should a stretch and sweep be trialed?

A

Can try sweep at 40 weeks in nulliparous women and 41 weeks in parous women

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5
Q

What is a stretch and sweep?

How do stretch and sweeps work?

A

-Examining finger passes through cervix and rotates
against the wall of the uterus, to separate the chorionic membrane from the decidua

  • Separating the membranes from the cervix releases prostaglandins - it is hoped that this PG surge is enough to start labour
  • Women can be sent home to await the beginning of labour after a short period of observation (does not count as induction)
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6
Q

What is the bishop score?

What is it out of?

What number indicates induction is likely to be successful?

A

Bishop score is calculated to work out success of Vaginal Delivery using Induction of Labor

Out of 13 (13 is ready to deliver)

<6/13 - Unfavourable for induction
>8/13 -Favourable for induction

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7
Q

What factors are included in the Bishop’s score and how do they progress?

A 
Dilation of cervix (gets increasingly dilated) 
Length of cervix (longer>shorter) 
Station of baby's head
Consistency (firm>soft) 
Position (posterior>anterior)
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8
Q

After the stretch and sweep has been trialed what, more formal, methods can we use to prepare for induction?

Who is this contaraindicated in?

A
  • PRIMING OF THE CERVIX WITH EXOGENOUS PROSTAGLANDINS
  • Contraindicated in previous uterine surgery/previous CS and grand parity (5) (increased risk of uterine rupture)
  • More than one dose may be required but wait for a reaction first
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9
Q

How are exogenous prostaglandins given?

How long does it take?

A

-Prostaglandin Gel (known as Prostin) into the posterior fornix of the cervix

GEL (most common): 6 hours
PESSARY: 24h

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10
Q

How do we decide how much prostin to give?

A

Depends on woman’s parity
NORMALLY:
2mg doses are given 6hours apart (women sent home in mean time) - may need 2 or 3
MULTIP WOMEN may only need 1mg doses and might only need 1 (Obstetrician guidance)

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11
Q

What do we try after prostin gel?

A

IF THE CERVIX IS FAVOURABLE WE INDUCE LABOUR
(after prostaglandins or just from high bishop score)
1. Artificial rupture of membranes
2. Syntocinon therapy (if ARM doesn’t stimulate contractions)

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12
Q

How is ARM done?
How does ARM work?
Why is it a good method?

A

Artificial rupture of membranes/amniotomy
-An amnihook is inserted through the partially opened cervix and is used to make a hole in the membranes

  • It works by causing local PG release (effect the cervix) and increases pressure of head on cervix
  • It also allows for the assessment of the liquor (is it meconium stained)
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13
Q

What are the risks with ARM? How are these minimised?

A

Risk of cord prolapse - should make sure the head is well engaged with the cervix BEFORE rupture and should also make assessment with vaginal examination AFTER amniotomy has been performed.

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14
Q

What method can be used for induction after ARM has been tried?

A

SITUATION: cervix is favourable, ARM been tried

SYNTOCINON INFUSION

  • This is synthetic oxytocin (a hormone normally produced by posterior pituitary gland)
  • Causes myometrial muscles to contract
  • Given via a slow IV drip, dose titrated against contractions until regular contractions established
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15
Q

What is a risk of using Syntocinon?

How do we prevent?

A

RISK
-risk of hypertonic uterus which can cause fetal distress+placental abruption

(CTG MONITORING IS REQUIRED THROUGHOUT INDUCTION LABOUR)

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16
Q

What is hyper stimulation?

How should it be managed?

A

Hyperstimulation

  • This is a potential complication of induction of labour
  • Too many contractions (>5 in 10)

Management

  • If using syntocinon, the rate should be reduced
  • If this is ineffective, tocolytic drugs such as terbutaline should be considered to suppress contractions
17
Q

What is syntometrine? When is it given?

A

Syntometrine is a combination drug of oxytocin (syntocinon) and ergometrine

  • Both drugs cause the uterus to contract
  • injection of it is usually given in the third stage of labour to promote the dispelling of the placenta and help the uterus to contract down to reduce risk of PPH

(‘met’ the baby and placenta have met before)

18
Q

What are some potential complications of induction?

A
  • Unsuccessful> maternal exhaustion
  • Fetal distress (CTG monitoring throughout)
  • Precipitate delivery (unusually rapid labour)
  • Increased risk of instrumental labour (but not CS)
  • Uterine hypertonia - increased risk of UTERINE RUPTURE
  • Cord prolapse (risk of ARM)
  • Amniotic fluid embolus
  • Systemic effects
19
Q

Summarise induction of labour for women in stage 1 vs stage 2

A

BOTH

  1. Monitor fetal distress (CTG) (do not induce if distressed)
  2. Vaginal exam-to determine Bishop score

Stage 1

  • Cervical sweep
  • PV prostaglandins
  • ARM
  • IV syntocinon
  • C/S if obstructed

Stage 2

  • ARM
  • IV syntocinon
  • Intrumental help
  • C/S if obstructed

GOSH (29 decks)

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