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IOL Flashcards

1
Q

What are the pre-requisites for IOL?

A
  • able to perform CS if necessary
    • maternal
      • ripe cervix, open os
      • if cervix not ripe, use prostaglandin vaginal insert (cervidill)
    • fetal
      • normal fetal heart trace
      • cephalic presentation
      • adequate fetal monitoring available
  • likelihood of success determined by Bishop score (>6 favourable)
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2
Q

What is the Bishops score?

A
  • Position
  • Consistency
  • Effacement
  • Dilation
  • Station
  • Favourable cervix = >6
  • score 9-13 = high likelihood of vaginal delivery
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3
Q

What methods are there for IOL? How do you decide which one to use?

A
  1. balloon catheter
  2. ARM
  3. dinoprostone
  4. oxytocin

Based on:

  • membranes ruptured?
    • yes = oxytocin
    • no = check bishop score
  • cervix favourable?
    • yes = ARM
    • no = balloon catheter OR dinoprostone
    • no + previous CS = balloon catheter only
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4
Q

What are the indications for balloon catheter?

A
  • Indications
    • MBS ≤ 6
    • Previous CS
    • Following dinoprostone if no/minimal effect on cervical ripening and ARM not technically possible
    • Reduced risk of uterine hyperstimulation is desirable
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5
Q

Contraindications for balloon catheter?

A
  • Contraindications
    • Ruptured membranes
    • Undiagnosed bleeding
    • Simultaneous use of prostaglandins
    • Low lying placenta
    • Polyhydramnios
    • Abnormal FHR auscultation or CTG
  • Relative contraindications
    • Antepartum bleeding
    • Lower tract genital infection
    • Fetal head not engaged
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6
Q

How much longer after balloon catheter is inserted does it need to be reviewed?

A
  • 12 hours
  • DO NOT LEAVE IN FOR >18HRS
  • if no SROM recommend ARM
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7
Q

What are the indications for dinoprostone?

A

Prostaglandin E2

Indications

  • Unfavourable cervix (MBS ≤ 6)
  • Following balloon catheter if no/ minimal effect on cervical ripening and ARM not technically possible
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8
Q

What are contraindications to prostaglandin E2?

A

Contraindications

  • Known hypersensitivity
  • Ruptured membranes
  • Multiparity ≥ 5
  • Previous CS or uterine surgery
  • Malpresentation/high presenting part
  • Undiagnosed PV bleeding
  • Abnormal CTG/fetal compromise
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9
Q

What should you be cautious of when using prostaglandin E2?

A

Cautions

  • Multiple pregnancy
  • Asthma, chronic obstructive pulmonary disease: may cause bronchospasm
  • Epilepsy
  • Cardiovascular disease
  • Raised intraocular pressure, glaucoma
  • Avoid concurrent oxytocin use
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10
Q

When should you review prostaglandin E2 lady?

A
  • gel = 6 hours
  • pessery = 12 hours

Then recommend ARM regardless of MBS

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11
Q

Indications for ARM?

A

Indications

  • After cervical ripening method
  • Favourable cervix (MBS ≥ 7)
  • Before oxytocin infusion commenced
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12
Q

Relative contraindications of ARM?

A

Relative contraindications

  • Poor application of the presenting part/unstable lie
  • Fetal head not engaged
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13
Q

Inducing a lady for labour. Need to do a vaginal exam. What do you assess?

A

VE to identify:

  • Stage of labour
  • MBS
    • consistency
    • effacement
    • position
    • dilation
    • station
  • Presentation
  • Position and descent
  • Membranes
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14
Q

What clinical concerns do you need to assess for when thinking about performing an ARM?

A
  • Polyhydramnios
  • Head not engaged
  • Malpresentation
  • Possible cord presentation
  • Unstable lie

if any of the above, consult obstetrician

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15
Q

What do you need to check for AFTER performing ARM?

A
  • fetal heart rate
  • liquor abnormality

if nil, commence oxytocin !!!!!

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16
Q

Indications for oxytocin in IOL?

A

Indications

  • IOL with ruptured membranes
17
Q

What do you need to be cautious of when giving oxytocin?

A
  • Do not commence oxytocin within:
    • 6 hours of dinoprostone gel
    • 30 minutes of removal of dinoprostone pessary
  • Discuss with obstetrician if:
    • Previous uterine surgery (e.g. CS)
    • Multiple pregnancy
    • More than 4 previous births
    • Cardiovascular disease
18
Q

What are the potential side effects of oxytocin?

A
  • Uterine hyperstimulation
  • Nausea and vomiting
  • Water intoxication or hyponatremia with prolonged infusion (rare with isotonic infusion)
  • Primary postpartum haemorrhage
  • If planned VBAC: uterine dehiscence and rupture
  • Rarely (< 0.1%) arrhythmias, ECG changes, anaphylaxis, tetanic contractions, transient hypotension, reflex tachycardia
19
Q

What kind of contractions are you aiming for when giving oxytocin?

A

Aim for contractions:

  • 3–4 in a 10 minute period
  • Duration of 40–60 seconds
  • Resting period not less than 60 seconds
20
Q

For uncomplicated pregnancies, when should you recommend IOL?

A

41 weeks

21
Q

Why should you induce at 41 weeks as compared to expactant management in an uncomplicated pregnancy?

A

IOL from 41+0 weeks, compared with expectant management, is associated with:

  • Fewer perinatal deaths [0.4 versus 3.2 per 1000 women]
  • Less meconium aspiration syndrome [40 versus 66 per 1000 newborns]
  • No difference in neonatal intensive care (NICU) admissions
  • Fewer caesarean sections (CS) [168 versus 225 per 1000 women]
  • Most women prefer IOL at 41 weeks over serial antenatal monitoring
22
Q

For women >40 years old, when should you suggest IOL?

A

39-40 weeks

23
Q

When should you induce a lady who’s baby has fetal macrosomia?

A

Discuss IOL after 38+0 weeks if EFW greater than:

  • 3.5kg at approximately 36 weeks
  • 3.7kg at approximately 37 weeks
  • 3.9kg at approximately 38 weeks
24
Q

What do you need to do in your assessment immeadiately before IOL?

A
  • Immediately prior to IOL:
  • Review maternal history
  • Confirm gestation
  • Perform baseline maternal observations (e.g. temperature pulse, respiratory rate and blood pressure)
  • Perform abdominal palpation to confirm presentation, attitude, lie, position, and engagement
  • Assess membrane status (ruptured or intact)
  • Vaginal examination (VE) to assess the cervix
  • Assess fetal wellbeing:
    • FHR
    • Confirm CTG is normal
    • If CTG abnormal, escalate as per local protocols
  • Assess for contraindications to IOL
  • consider urgency of IOL
25
Q

Why is misoprostol not indicated for IOL?

A
  • higher odds of uterine hyperstimulation with FHR changes
26
Q

What are the benefits of balloon IOL?

A
  • When compared to vaginal prostaglandins:
    • Less uterine hyperstimulation and tachysystole
    • No difference in CS rate
    • No difference in overall number not achieving vaginal birth within 24 hours
  • Low cost and no specific storage or temperature requirements
  • No evidence of an increased risk of infection although data is limited
27
Q

What are the risks of balloon IOL?

A
  • Placental abruption
  • Uterine rupture
  • Device entrapment
  • Maternal discomfort during and after insertion
  • Failed dilatation and inability to perform ARM
  • Cervical laceration or ischaemia (if prolonged use) There is limited data comparing single to double balloon catheter

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