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ACOG Practice Bulletins > Induction of Labor > Flashcards

Induction of Labor Flashcards

1
Q

Methods of labor induction

A

oxytocin, membrane stripping, amniotomy, nipple stimulation, prostaglandin E analogues

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2
Q

Cervical remodeling changes

A

collagen breakdown and rearrangement, changes in glycosaminoglycans, increased production of cytokines, and white blood cel infiltration

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3
Q

Bishop scoring system

A

Refer to album

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4
Q

Unfavorable cervix

A

Bishop score of 6 or less

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5
Q

Methods of cervical ripening

A

Mechanical dilation:

  • hygroscopic dilators
  • osmotic dilators (Laminaria japonicum)
  • Foley catheters (14-26 F) with 30-80 mL inflation volumes
  • double balloon devices
  • extra-amniotic saline infusions with rates of 30-40 mL/hr

Non-mechanical:

  • synthetic prostaglandin E1 (PGE1)
  • prostaglandin E2 (PGE2)
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6
Q

Complication of using Laminaria japonicum

A

possible increased infection rate

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7
Q

Benefits of mechanical dilation

A

decreased C-section rate with all except extra-amniotic saline infusions when compared to oxytocin alone

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8
Q

Advantage of Foley catheter over prostaglandins

A

low cost, stability at room temperature, reduced rate of uterine tahcysystole with or without FHR changes

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9
Q

Misoprostol

A

PGE1 analogue, used for cervical ripening and IOL

Route: vaginally, orally, sublingually

Dose: 25 mcg?

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10
Q

Dinoprostone

A

PGE2 analogue, used for cervical ripening

Route: gel (0.5 mg) and vaginal insert (10 mg)

  • Increase the likelihood of delivery within 24 hrs, don’t reduce the chance of C section, and increase the risk of tachysystole and FHR changes
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11
Q

Oxytocin

A

used for IOL

  • Stimulates uterine contraction within 3-5 mins of use, steady level achieved in 40 minutes
  • gradual increase in response from 20 - 30 weeks
  • Maximum amount of receptors present by 34 weeks
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12
Q

Predictors of successful response to oxytocin induction

A
  • Lower BMI, greater cervical dilation, parity or gestational age
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13
Q

Membrane stripping

A

Causes an increase in phospholipase A2 and PGF2alpha2
- Increases the likelihood of spontaneous labor within 48 hours

Side effects: discomfort, vaginal bleeding, and irregular contractions over the next 24 hrs

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14
Q

Membrane stripping in group B + patients

A

ify

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15
Q

Amniotomy

A

Typically used if the cervix is favorable

  • When used alone, it can result in long periods before contractions start
  • Unknown when the best timing is in patients being treated for group B strep
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16
Q

Nipple stimulation

A
  • Used in patients with favorable cervixes
  • No difference in rates of meconium stained amniotic fluid or C section rates
  • Decreased rates of postpartum hemorrhage
  • Not encouraged in unmonitored setting
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17
Q

Bishop score 0

A

closed, posterior, 0-30% effaced, -3 station, firm cervix

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18
Q

Bishop score 1

A

1-2 cm dilated, midposition, 40-50% effaced, -2 station, medium cervix

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19
Q

Bishop score 2

A

3-4 cm dilated, anterior, 60-70% effaced, -1,0 station, soft cervix

20
Q

Bishop score 3

A

5-6 cm dilated, anterior, 80% effaced, 1+, 2+ station, soft

21
Q

Normal contraction frequency

A

5 contractions or less in 10 mins, averaged over 30 mins

22
Q

Tachysystole

A

more than 5 contraction in 10 mins, averaged over 30 mins

- Always specify presence or absence of FHR changes

23
Q

Indications for IOL

A

placental abruption, chorioamnionitis, fetal demise, gestational HTN, preeclampsia, eclampsia, PROM, post-term pregnancy, maternal health problems, severe IUGR, isoimmunization, oligohydramnios

24
Q

Contraindications for IOL

A

vasa previa, active genital herpes, transvere lie, classical C section, umbilical prolapse, prior myomectomy into the endometrial cavity

25
Q

Confirmation of term gestation

A
  • Ultrasound at 20 wks or less supports gestational age of 39 wks or greater
  • FH tones have been documented for at least 30 weeks by Doppler
  • 36 wks since a positive beta HCG
26
Q

IOL risk in nulliparous pts with unfavorable cervix

A

twofold increased risk of C section

27
Q

Failed induction time period

A
  • Allow for at least 12-18 hours of latent labor before diagnosing failure
28
Q

What is the relative effectiveness of available methods for cervical ripening in reducing the duration of labor?

A

both Foley catheter placement and prostaglandin administration reduced length of labor and C section rates, but prostaglandins have an increased risk of tachnysystole

29
Q

Which is more effective misoprostol or dinoprostone

A

misoprostol

30
Q

Vaginal misoprostol

A

less use of epidural or analgesia, more vaginal deliveries within 24 hrs, and increased rates of tachysytole

31
Q

How should prostaglandins be administered?

A

Misoprostol: 25 mcg tablet, every 3-6 hrs with oxytocin administered not less than 4 hrs after, sometimes 50 mcg is acceptable

Dinoprostone: 1.5 mg in the cervix, 2.5 mg in the vagina

  • repeat dose can be given 6-12 hrs later
  • oxytocin can be given 6-12 hrs later
  • No more than three doeses or 7.5 mg of the gel
32
Q

Highest risk of tachysystole

A

vaginal misoprostol

33
Q

Risks of vaginal misoprostol

A

tachysystole, category III FHR tracing, and uterine rupture in women with C sections

34
Q

How to correct uterine tachysytole

A

removal of medication, terbutaline

35
Q

Maternal side effects from PGE2

A

very rare diarrhea, fever, vomiting
- Caution should be taken in women with glaucoma, severe renal or hepatic disease, and asthma (bronchodilator though so low risk)

36
Q

What are the recommended guidelines for fetal surveillance after prostaglandin use?

A

Patient should be recumbent for the first 30 mins

  • FHR and uterine activity should be monitored for the first 30 mins to 2 hrs after admin.
  • Peak contractions in the first 4 hrs
37
Q

Are cervical ripening methods appropriate in an outpatient setting?

A

yes, in selected patients (dioprostone and mechanical dilation)

38
Q

Complications of oxytocin

A

tachysystole, water intoxication

concentrated solutions can cause low BP

39
Q

Complications of amniotomy

A

fetal cord compression, and umbilical cord prolapse, chorioamnionitis
- Get FHR before and after amniotomy

40
Q

Membrane stripping

A

vaginal bleeding from undiagnosed placenta previa, accidental amniotomy

41
Q

Oxytocin regimen - high dose versus low dose

A

trade off between shorter labor times, c section for dystocia, and chorio and tachysystole

42
Q

Low-dose oxytocin dosing

A

0.5-2 initial dose, 1-2 mU/min, dose interval 15-40 mins

43
Q

High-dose oxytocin dosing

A

6 initial dose, 3-6 mU/min, dose interval 15-40 mins

44
Q

Are there special considerations that apply for induction in a woman with ruptured membranes?

A

IOL should be started at presentation to decrease risk of chorio; vaginal misoprostol ok

45
Q

What methods can be used for IOL with IUFD in the late second, third trimester?

A

D&E in late second trimester, oxytocin, vaginal misoprostol (200-400 mcg every 4-12 hrs ) (most useful before 28 wks)

ACOG Practice Bulletins (10 decks)

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