WK1: Prolonged pregnancy, IOL, precip labour Flashcards
Define IOL
Induction of labour is the intervention to initiate the process of labour by any or all artificial means.
- it usually involved more than one agent.
What are some maternal and fetal indications for IOL?
Generally when it it believed that maternal or fetal condition suggests a better outcome if the pregnancy is not continued.
Maternal indications include
- prolonged pregnancy
- PROM (infection risk for baby )
- mat condition e.g. renal, resp or cardiac that are exacerbated by pregnancy
- hypertension, PE, GDM on insulin
- Previous obstric hsiotry e.g. still birth at term, IVF
- social/psychological reasons, antenatal depression, family/violet situation (may have support at a specific time * consider the whole picture)
Fetal indications include
- FGR and/or potential compromise (if straight compromised= C/S)
- non-reassuring fetal surveillance e.g. doplers show blood flow is impacted
- Rhesus isoimmunisation with heamolysis
- Fetal death in utero (FDIU) to birth baby
- seven congenital abnormlaities
Joint indications
- Preeclampsia
- Unstable lie= baby continually moving (risk of cord prolapse when ROM)= OB and RM will AROM and both externally and internally guide baby into pelvis is correct position (DIFFERENT TO MALPRESENTATION)
- APH- antepartum heamorrhange e.g. if placenta starts to seperate of uterine wall or from babys cord attachment
Explain the cascade of intervention and give an example
Cascade of intervention= when one intervention increases the likelihood of anther being used.
e.g. synt + CSL
= CTG indicated= immoblaised, prevents water/shower use
= more uncomfortable and longer labour as baby turns
= may require epidural
= increased risk of
- instrumental birth
- C/S
- episiotomy
- PPH
- Separation of mother and baby
- Extended hospital stay
- Neonatal resus
- engorgement / BF issues
What is the impact of intervention on oxytocin production?
= intervention reduces the production of natural oxytocin therefore the women misses the psychological benefits.
- less endorphins are produced so increased pain percieved= less able to cope= increased incidence of epidural and therefore instrumental.
Define augmentation of labour
labour began spontaneously and intervention occurred later in response to either failure to progress, suspected low fetal reserves
What are some contraindications for IOL?
Anything that is contraindicative of a vaginal birth
e.g. active genital herpes, placenta previa, vaso previa, mal presentation
- CTG where birth is required immediately
- Previous major uterine surgery - classice C/S or myomectomty e.g. of she is going for an VBAC and has to have an IOL then this is dangerous as syntocin for example caussing increased likleyhood for the uterine scar to rupture, absolute cephalo/celvic disproportion/previous pelvic injury e.g. screws in her pevis from previous surgery
Define mal presentation
oblique or transverse lie, footing breech, brow presentation
Complications of IOL? and who is more at risk?
Iatrogenic prematuirty= babys born prematurely by utalising medical intervention/IOL
Uterine hyperstimulation= artificial oxytocin cause to much contraction of the uterine muscle (tachysystole + hypertonous)
Non-reassuring FHR tracing/fetal disresees= due to quick succession of progression of labour
Process ‘fails’ to bring on labour
Increased risk of;
- operative delivery
- shoulder dystocia
- PPH (due to uterus fatigue and inability to contact after birth)
More risk= nulliparous women
Outline the process of IOL
- Give information (risks + benifits + any questions she may have) and time for decision making
- gain informed consent
- document indication for IOL
Ensure no contraindications
*once confirmed EDB + gestational age + parity - perform documentation and cervical assessment (Bishops score) + abdo assessment + FHR
Explain a Bishops score + its features
- Indicated the degree of cervical ripening and therefore level of induction/agents needed.
- done via VE
<6 Bishops score= cervix is unfavourable or indication
0 1 2 3
Dilation: <1cm 1-2cm 2-4cm >4cm
Cervix length: >4cm 2-4cm 1-2cm <1cm
Station: -3 -2 -1/0 +1/+2
Consistency: Firm Average Soft -
Position: Posterior Mid Anterior -
List some alternative and natural methods of induction
These are anecdotal (not scientific) and hot harmful.
Intercourse
- women releases oxytocin= relaxes and initiates contraction
- Male sperm is prostaglandin rish= ripens cervix* (*may contribute, only about 1% of when we use in medical procedure)
Nipple and clitoral stimulation (oxytocin production)
laxatives/castor oil/spicy foods= laxitives which cause bowels crams which can stimulate initiation of labour
Acupuncture or acupressure (blood flow to uterus/oxytocin due to relaxation)
Raspberry leaf tea (herbal uterotonic agent)
*still consider the risks + benefits
*no need to discuss/reccomended before 40 weeks
*suggest she refers to someone in that area e.g. natropath
What are the 3 types of IOL + cervical ripening?
Medical/pharmacological
- Oxytocin drip
- Dinoprostone preparations (prostaglandin E2, PGE2, PG gel, Prostin E2, Cervidil)
* Prostaglandin E2 vaginal gel (Prostin)
* Standardised regimen (CPG)
Prostaglandin E2 continuous release pessary (Cervadil)
Standardised regimen (CPG)
Inserted into the posterior side of the cervix
Inserted for 12hrs
Surgical
- ARM (helps apply head on cervix better to streach it)
Mechanical
- stretch and sweep
- transcervical catheter (e.g. foley= 1 ballon or cooks= 2 ballons)
What are some key practice points for prostaglandins
*different is every hospital
30mins FHP monitoring
the give prostaglandin
Stay with mother for 30 mins
Ensure no adverse reactions
Closely monitor for 12hrs
What are the risks/complications and benefits of prostaglandins?
Risks/complications
- uterine hypertonous
- uterine tachysystole
- FHR abnormalities
- Placenta abruption
- uterine rupture
- GI effects, back pain, pyrexia, warm feeling in the vagina
Benefits
- ripening of the cervix
- can go home after insertion (unless high risk)
- pessary can be removed if complication occurs
- can be used again if cervix is not yet favourable
What are some contraindications for prostaglandins?
- a bishops score <6
- abnormal CTG
- persistent increased maternal temp
- vaginal bleeding
- known hypersensitivity
- spont labour already occured
Explain the insertion of a prostaglandin?
- Get a normal CTG
- do abdominal palpation
- VE
- endure indication and no contraindications
- insert syringe or yel
Explain the action/benefits and complications of a ballon catheter.
Ballon catheter= foleys (one ballon) or cooks (two ballons)
Action/benifit
Strips the membranes form the lower uterine segment inducing prostaglandin formation.
- the pressure is also applied to the cervix to shorten and stretch it.
Complications
- Pre labour ROM
- infection
- APH
- Presenting part displaced from pelvis
Explain the procedure of a ballon inserting
- a speculum is used to place the catheter
- Catheter introduced into endocervix by direct visualisation or blindly by sliding it over finger through the endocervix into potential space between amniotic membrane and lower uterine segment
- Balloon inflated with 50mL (Foley) or 80mL per balloon (Cooks) of sterile water
- retract so that it rests on the internal os
- Catheter removed at time of membrane rupture or may be expelled spontaneously indicating cervical dilatation
- Usually left in for around 12 hours *depending on where you are
- Can fall out its self when women dilate
What is the theory behind a membrane sweep and how is it performed?
Goal: to facilitate the production of natural prostaglandins in the womens body
*Despite it being non medicated- it is still an intervention and non a may not always be considered natural
*still can initiate a casacde on intervention
- involves the midwife inserting one to two fingers into the cervix
- putting pressure onto the cervix in a circular sweeping motion
- with the intention to separate the chorioamniotic membranes from the decidua and thus encourage prostaglandin release to increase cervical ripening.
- This requires the cervix to be open enough to fit one to two fingers of course, so if the cervix is completely closed or too posterior to be reached, a S&S cannot be performed.
Explain an ARM or amniotomy and some key practice points.
Use= used to stimulate or augment labour
- accelerates progress by increasing the frequency and strength of contractions
- allows viewing of liquor (colour and amount)
Key practice points
- birth should occur in 24hrs or PROM can increase infection
- ARM (augmentation) should only be used in cases of abnormal labour progress
What are the benefits of membranes staying intact? (therefore for risks of ARM)
- reduced pain as there is cushioning on cervix
- reduced risk of infection
- facilitates fetal movement/positioning better
- facilitated descent of baby
- protects from cord compression
- prevents cord prolapse
Direct complications of ARM?
- Cord prolapse
- Chorioamnionitis (infection of the membranes)
- Sepsis
- Umbilical cord compression (head may have been kept of the cord by fluid)
- rupture of vasa praevia (vessels in membranes)
- Malpresentation