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My MRCOG Part 2 > Module 7 - NICE 207 +TOGs - Inducing Labour > Flashcards

Module 7 - NICE 207 +TOGs - Inducing Labour Flashcards

1
Q

Define tachysystole

A

> 5 contractions in 10 minutes
For more than 20 minutes.

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2
Q

Define hyperstimulation

A

Overactivity of uterus (as result of IOL).
Tachysystole or hypertonicitiy with or without CTG changes.

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3
Q

Define hypertonicity

A

Contraction lasting > 2minutes.

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4
Q

If unable to carry out membrane sweep via the cervical os, what alternative method of membrane sweep can be used?

A

Massaging the fornicies.

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5
Q

Define precipitate labour.

A

Baby born within 3 hours of onset of labour.

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6
Q

What proportion of pregnancies are induced?

A

20%

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7
Q

What information should be given to women about the medicalisation of of IOL?

A

Increased number of VEs
Limited places to deliver
Possibly limit pool use
Increased risk of instrumentals (therefore increased risk of OASI)
Hyperstimulation
Longer labour and hospital stay.

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8
Q

What are the risks of IOL?

A

Increased pain
Increased risk of instrumentals (therefore increased risk of OASI)
Hyperstimulation

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9
Q

What is the stillbirth rate according to MBRRACE in white women?

A

34 / 10,000

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10
Q

What is the stillbirth rate according to MBRRACE in black women?

A

x2 of white women
74 / 10,000

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11
Q

What is the stillbirth rate according to MBRRACE in Asian women?

A

x1.5 of white women
53 / 10,000

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12
Q

What needs to be ruled out before IOL or membrane sweep is carried out?

A

A low lying placenta or placenta previa.
Non-cephalic lie.
Regular contractions.
(also ensure normal CTG).

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13
Q

How is Bishop Score calculated?

A

Dilatation
(0: 0cm dilated.
1: 1-2cm dilated.
2: 3-4cm dilated.
3: 5-6cm dilated).

Position
(0: posterior
1: mid
2: anterior).

Effacement
(0: 0-30%
1: 40-50%
2: 60-70%
3: 80%+).

Station
(0: -3
1: -2
2: -1 to 0
3: +1 to +2).

Consistency
(0: Firm
1: Medium
2: Soft).

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14
Q

When can foetal monitoring can be reverted to IA during IOL process?

A

If CTG is normal and woman is low risk.

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15
Q

What is the difference in IOL outcomes between inpatient and outpatient IOL?

A

There is no difference in outcomes.

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16
Q

When should women undergoing outpatient IOL contact mw?

A

PVB.
SROM.
RFM.
No contractions within set timeframe.
Lost pessary/mechanical induction.
Onset of contractions.

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17
Q

What type of hormone is misoprostol?

A

PGE1
(Prostaglandin E1)

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18
Q

What is the dose of misoprostol?

A

Range based on gestation (800 to 25 micrograms).
Reduces with gestational age.

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19
Q

What type of hormone is dinoprostone?

A

PGE2
(Prostaglandin E2)

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20
Q

What are the maternal side effects of misoprostol?

A

Flactulence
Diarrhoea
Abdominal pain
FEVER
Nausea and vomiting
Shivering
PVB
Headache
SINUS TACHYCARDIA
(hyperstimulation, uterine rupture)

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21
Q

What is the duration of action and peak onset of action of misoprostol when given:
1. PO
2. Sublingual
3. PV
4. Buccal

A
  1. (PO) Duration of action - 2 hours
    Peak onset in 30 mins.
  2. (SL) Duration of action - 3 hours
    Peak onset in 30 mins.
  3. (PV) Duration of action - 4 hours
    Peak onset in 70-80 mins.
  4. (Buc) Duration of action - unknown.
    Peak onset in 70-80 mins.
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22
Q

What are the contra-inductions to dinoprostone use for IOL?

A

Active cardiac or pulmonary disease (including severe asthma).
Untreated pelvic infection.
Major CPD.
Hepatic or renal impairment.
Uterine surgery.
SROM.
Grand multip (>P4).
Foetal distress.
Foetal malpresentation.

(Caution in asthma, glaucoma, raised intra-ocular pressure, epilepsy, DIC and HTN).

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23
Q

What are the potential SEs of Dinoprostone?

A

Fever
Infection
Hypotension
PV Itching or burning
Uterine atony
GI upset
Genital oedema.

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24
Q

What is used for tocolysis?

A

Terbutaline 250 micrograms SC.
Up to 2 doses.
Repeat can be given after 30 minutes.

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25
Q

Above what Bishop Score should ARM and syntocinon be offered as method of IOL?

A

6+

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26
Q

Below what Bishop Score should mechanical or pharmacological IOL be offered?

A

Less than 6.

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27
Q

What method of IOL has the lowest risk of hyperstimulation?

A

Mechanical IOL.

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28
Q

What method of hormonal IOL is associated with the lowest risk of hyperstimulation?

A

PO Misoprostol <50 micrograms.
(OR 1.5 compared to spontaneous labour).

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29
Q

What is the increased risk of hyperstimulation when dinoprostone PV TABLETS are used, compared to spontaneous labour?

A

OR 2

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30
Q

What is the increased risk of hyperstimulation when dinoprostone PV GEL are used, compared to spontaneous labour?

A

OR 3.5

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31
Q

What is the increased risk of hyperstimulation when dinoprostone PV pessary are used, compared to spontaneous labour?

A

OR 5

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32
Q

What is the increased risk of hyperstimulation when misoprostol SL or Buccal routes are used to induce labour, compared to spontaneous labour?

A

OR 7

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33
Q

What monitoring should be offered to women who are >42/40?

A

Twice weekly CTGs and weekly deepest pool.

34
Q

Beyond what gestation is there no difference in meconium aspiration risk, HIE or instrumental delivery rates?

A

39/40

35
Q

What % of women will labour spontaneously before 31 weeks?

A

2.4%

36
Q

What proportion of women will labour spontaneously in each week between 32 and 37+6 weeks?

A

5%

37
Q

What proportion of women will labour spontaneously in their 38th week of pregnancy?

A

12.5%

38
Q

What proportion of women will labour spontaneously in each week in their 39th week of pregnancy?

A

25%

39
Q

What proportion of women will labour spontaneously in their 40th week of pregnnacy?

A

32.5%

40
Q

What proportion of women will labour spontaneously in their 41st week of pregnancy?

A

16%

41
Q

If a women has not laboured by 42 weeks, what is the chance that she will spontaneously labour?

A

<1%

42
Q

What are the benefits of membrane sweep?

A
  • Increased chance spontaneous labour (therefore reduced need for IOL).
  • No increase in infection rate.
  • Shortens IOL to delivery time.
43
Q

Is membrane sweep safe for GBS carriers?

A

YES

44
Q

What is the NNT for membrane sweep to induce one labour?

A

NNT = 8

45
Q

What type of IOL balloon has the shortest IOL to delivery time?

A

Follys catheter.

(cooks double balloon is longer).

46
Q

What is the difference in LSCS and PPH rate between balloon IOL compared to prostaglandin IOL?

A

There is no difference in PPH or LSCS rates.

47
Q

What is the balloon catheter volume for folly’s and cook’s catheter?

A

Folly’s - 30mls
Cook’s - 80mls.

48
Q

Which balloon is associated with greater maternal satisfaction?

A

Cook’s balloon.

49
Q

What are the risks associated with balloon IOL methods?

A

Foetal malposition
Increased cord pH
Infection.

50
Q

Does balloon traction or taping catheter to thigh affect outcomes?

A

NO.

51
Q

What is the difference in APGAR scores between balloon catheter and misoprostol?

A

There is NO difference.

52
Q

What additional procedure can be considered after double balloon catheter has been inserted, to aid with IOL?

A

EASI
Extra-Amniotic Saline Infusion.

53
Q

What are Laminaria?

A

Seaweed based IOL rods (seaweed Dilapans).

54
Q

What is the mechanism of action of Dilapan?

A

Dehydrates the cervix.
Applies pressure on the cervix.
Swells the cervix.
Causes local prostaglandin and oxytocin release.

55
Q

How many dilapan should be used for IOL?

A

4-5

56
Q

Is dilapan or Laminaria associated with a shorter IOL to delivery time?

A

Dilapan is associated with a shorter IOL to delivery time.

57
Q

What methods of IOL are NOT supported by evidence?

A

IV/PO Dinoprostone.
PV PGF2.
IV Oxytocin alone (ie no ARM).
Herbal supplements.
Acupuncture.
Hyaluronidase.
Oestrogen.
Relaxin.
Homeopathy.
Corticosteroids.
Caster oil.
Mifeprostone (except IUFD).
PV N.O Donors (GTN or isosorbate mononitrate).
Sex.
Enemas.

58
Q

For what method of IOL is LSCS rates lowest.

A

Lowest for low dose PO misoprostol - 21%

(highest for high dose PV misoprostol).

59
Q

What is the rate of hypersimulation with low dose oral misoprstol?

A

3.6%

60
Q

What is the rate of hypersimulation with dinoprostone?

A

8.7%

61
Q

Where is oxytocin produced?

A

In the hypothalamus.

(then stored in and released by posterior pituitary).

62
Q

Where does oxytocin act on?

A

Uterine receptors.
NO ACTION ON CERVIX.

63
Q

What are the risks of oxytocin use in IOL?

A

Increased surgical intervention.
Increased rates of foetal heart rate concerns.

64
Q

What is EASI?

A

Extra-Amniotic Saline Infusion.
Aims to strip membranes from decidua.
No increased infection rate.
Historically used for IUFD IOL.

65
Q

What should be done in the case of failed IOL?

A

Fully reassess including CTG.
Discuss rest and retry IOL, expectant mx or LSCS.

66
Q

What precautions can be taken to prevent cord prolpase?

A
  • Do not dislodge head.
  • Assess engagement (PA).
  • Palpate for cord on VE.
  • If PP not well applied or stable after SROM then start cCTG.
67
Q

What is the risk of uterine rupture in VBAC when induced?

A

1%
(double of VBAC spontaneous labour).

68
Q

At what gestation is post dates pregnancy defined?

A

> 41/40

69
Q

What are the risks that are increased after 41/40?

A

Increased LSCS,
Increased NNU admission,
Increased stillbirth/ neonatal death.

70
Q

What affect does IOL at 41/40 have on LSCS rates?

A

Reduces LSCS rates (compared to serial CTG monitoring).
No difference in perinatal morbidity and mortality.

71
Q

What is the risk of perinatal death (when mixed partity data is considered) for women at 41/40 compared to women at 42 or 43/40?

A

At 41/40: 4 / 10,000

At 42-43/40: 35 / 10,000.

SIGNIFICANT INCREASE AT 42/40.

72
Q

Below what gestation should IOL NOT be carried out in PPROM patients?

A

<34/40
(unless there is an obstetric indication)

73
Q

How is PPROM managed?

A

Expectant management until 37/40

(unless GBS positive 34-37/40 - then consider risks and balances and d/w patient).

74
Q

What options can be offered for PROM at term?

A

Expectant management for 24 hours.
But augment immediately if GBS positive.

75
Q

Can IOL be offered in IUGR?

A

Yes, unless there is confirmed foetal compromise (e.g. raised dopplers).

76
Q

Define foetal macrosomia.

A

EFW>95th

77
Q

What is the risk of IOL for LGA?

A

Increased rates OASI.

(no difference in LSCS, brachial plexus or perinatal death rates).

78
Q

What is the benefit of IOL for LGA?

A

Reduces risk of shoulder dystocia.
(no difference in LSCS, brachial plexus or perinatal death rates).

79
Q

Should women who have had a previous precipitous labour be routinely offered IOL?

A

No.

80
Q

By how much is the rate of requiring an LSCS increased when women who have had a VBAC are induced?

A

1.5x increased risk of requiring LSCS

My MRCOG Part 2 (37 decks)

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