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Y4 - GOSH > Induction of Labour > Flashcards

Induction of Labour Flashcards

1
Q

What is meant by induction of labour?

A
  • an intervention to initiate the onset of labour
  • this is performed when the benefits of ending the pregnancy outweigh those of continuing it

AND

  • where vaginal birth is considered appropriate

the health of the mother and the foetus must be taken into account

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2
Q

When is IOL typically offered?

A
  • when patients surpass their due date
  • typically between 41-42 weeks gestation
  • it can also be performed at other times in situations when it is beneficial to start labour early
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3
Q

In what situations may it be beneficial to start labour early?

A
  • premature rupture of the membranes (PROM)
  • foetal growth restriction
  • pre-eclampsia
  • obstetric cholestasis
  • existing diabetes
  • intrauterine foetal death
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4
Q

What must be considered when inducing labour prior to 39 weeks?

A
  • there is an increased prevalence of special educational needs with earlier IOL
  • this is significant when IOL occurs prior to 37 weeks gestation

IOL at 39 weeks is not associated with increased risks such as C-section, foetal morbidity or instrumental delivery

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5
Q

What should always be explained to a woman considering IOL?

A
  • the reason the induction is being offered
  • the risks and benefits in their situation
  • that IOL may not be successful and other options
  • an alternative if the woman denies IOL
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6
Q

Why is IOL performed in prolonged pregnancy?

(between 41-42 weeks)

A
  • when pregnancy extends past the due date, there is an increase in perinatal mortality
  • this is due to decreased placental function
  • all healthy women should be offered IOL when pregnancy extends beyond 41 weeks
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7
Q

What are the absolute contraindications to IOL?

A
  • acute foetal compromise
  • unstable lie (transverse lie = indication for CS)
  • placenta praevia

  • acute foetal compromise requires immediate delivery and IOL takes time
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8
Q

What are the relative contraindications to IOL?

A
  • previous C-section
  • breech presentation
  • prematurity
  • high parity

many of the contraindications are due to insuitability of vaginal delivery

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9
Q

Why is previous C-section a relative contraindication to IOL?

A
  • there is a 1 in 200 risk of uterine scar rupture in VBAC
  • the risk of uterine rupture is increased by 3-4 x when IOL is used
  • continuous monitoring is needed to look for signs of uterine rupture

VBAC = vaginal birth after C-section

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10
Q

When is IOL offered for intrauterine foetal death?

A
  • IOL is offered immediately

OR

  • expectant management is appropriate if no signs of infection / bleeding + intact membranes
  • immediate IOL is required if there is signs of infection, bleeding or ruptured membranes
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11
Q

What is the regime for IOL following intrauterine foetal death?

A

oral mifeprestone
followed by misoprostol (oral / vaginal)

  • misoprostal 100 micrograms 6 hourly if < 26+6 weeks
  • misoprostal 25-50 micrograms 4 hourly if 27 weeks or more

  • NOT suitable for use when baby is alive
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12
Q

What scoring system is used to determine whether to induce labour?

A

Bishop score

score from 0 to 13

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13
Q

What is involved in calculating the Bishop score?

A
  • it involves a vaginal examination to assess 5 areas
  1. fetal station
  2. cervical consistency
  3. cervical position
  4. cervical dilatation
  5. cervical effacement
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14
Q

What Bishop score indicates IOL is suitable?

A
  • a score of 8 or more predicts successful IOL
  • a score below 8 indicates cervical ripening may be required to prepare the cervix

this assesses whether it would be possible for artificial rupturing of the membranes (ARM)

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15
Q

What procedure is often performed prior to IOL?

A

membrane sweep

  • this is provided as an assistance before full induction of labour is offered
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16
Q

What is involved in membrane sweep?

A
  • a finger is inserted into the cervix and rotated against the wall of the uterus
  • this separates the chorionic membrane from the decidua and begins the process of labour
  • if successful, it should produce the onset of labour within 48 hours
17
Q

When is membrane sweep offered?

A
  • it is used from 40 weeks gestation to attempt to initiate labour in women over their EDD
  • it cannot be offered prior to 37/38 weeks as the cervix needs to be ripe in order to allow insertion of the finger
18
Q

What is the main method of IOL?

A

artificial rupture of membranes (ARM)

  • an amniohook is inserted through the partially opened cervix to create a hole in the membranes
  • this increases pressure of the fetal head on the cervix + results in hormonal reactions
19
Q

Following successful ARM, what is done for women who have not been pregnant before?

A

augmentation:

  • exogenous oxytocin is given via a slow IV drip
  • this is syntocinon
  • syntocinon is started at 2ml/hour and slowly titrated to achieve regular contractions

the aim is to achieve 3-4 contractions every 10 mins

20
Q

What is the main complication associated with augmentation?

A

hyperstimulation

this is avoided by giving a slow IV drip

21
Q

Following successful ARM, what is offered to women who have previously been pregnant?

A
  • there is a delay of 4-6 hours to allow them to mobilise
  • they are more likely to have uterine contractions without exogenous oxytocin
  • syntocinon is given if contractions do not occur
22
Q

What is the preferred method of IOL?

A

cervical ripening:

  • this involves use of vaginal prostaglandin E2 (dinoprostone)
  • this is inserted as a gel, tablet (Prostin) or pessary (Propess) into the vagina
  • the pessary is similar to a tampon and slowly releases prostaglandins over 24 hours
23
Q

Can cervical ripening be repeated?

A
  • after the pessary has been in place for 24 hours, the woman is reassessed
  • their suitability for ARM is reconsidered
  • if still unsuitable, the another pessary is inserted for 24 hours
  • this can be repeated up to 3 times
24
Q

What is a cervical ripening balloon (CRB)?

A
  • a silicone balloon is inserted into the vagina
  • it is gently inflated to dilater the cervix
  • this is used when vaginal prostaglandins are not preferred
25
Q

When is the use of a cervical ripening balloon / mechanical methods preferred?

A
  • previous caesarean section (VBAC)
  • multiparous women where para 3+
  • vaginal prostaglandins have failed
26
Q

What are the 2 ways of monitoring during the IOL?

A

Bishop score:

  • performed prior to and during IOL to assess progress

cardiotocography (CTG):

  • assesses fetal HR and uterine contractions using USS
27
Q

Following IOL, what is the most common outcome?

A

most women give birth within 24 hours of the start of IOL

28
Q

If progress is slow / there is no progress following IOL, what can be done?

A
  • further vaginal prostaglandins
  • cervical ripening balloon
  • ARM + oxytocin infusion
  • elective C-section
29
Q

What is the main complication of IOL with vaginal prostaglandins?

A

uterine hyperstimulation

  • the contraction of the uterus is prolonged and frequent
  • this can result in foetal distress / compromise if prolonged
30
Q

What are the 2 typical criteria for diagnosing uterine hyperstimulation?

A
  • individual uterine contractions lasting for > 2 mins
  • > 5 contractions within 10 mins
31
Q

What are the most significant consequences of uterine hyperstimulation?

A
  • foetal compromise with acidosis + hypoxia
  • uterine rupture
  • emergency C-section
32
Q

How is uterine hyperstimulation managed?

A
  • remove the vaginal prostaglandins / stop the syntocinon
  • perform tocolysis with terbutaline

Y4 - GOSH (62 decks)

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