1.1 - Induction Of Labour - exam

Question 1

Types of inductions

Answer 1

• balloon catheter
• prostaglandins - prostub & cervidil
• oxytocin’s
• artificial rupture of membranes
• Membrane Sweep

Question 2

IOL indication & recommendation

Answer 2

• prolonged pregnancy - over 41+0 weeks
• Term PROM - GBS negative or unknown - IOL within 24 hours of confirmed PROM
• Term PROM - GBS positive, meconium liquor or suspected sepsis - immediate IOL
• PROM - <34/40 - expectant management (waiting for the miscarriage/birth to happen by itself naturally without treament)
• PROM >34/40 - consider balance of risk and benefits for woman and baby and availability of resources
• Previous Caesarean - individualise management - increased risk of uterine rupture and emergency caesarean
• maternal request - do not routinely offer IOL for maternal request
• Breech presentation - IOL may be offered if clinical circumstances are favourable and the woman wishes to have a VBAC
• History of precipitate labour - do not routinely offer IOL for history of precipitate labour
• Suspected fetal macrosomia - IOL not indicated for suspected macrosomia
• AMA - IOL not indicated for AMA as an isolated risk factor
• BMI > 50 - delivery recommended at 38-39 weeks
• Ethnicity - IOL not indicated for maternal country of birth alone

Question 3

Inducing agents

Answer 3

• prostin cervididil
• balloon catheter
• syntocinon
• amniotomy - ARM
• membrane sweep

Question 4

what is the bishop score

Answer 4

considers aspects of the cervix:

• length
• position
• consistency
• dilatation
• station

this give a score to assess if the cervix is favourable or not favourable for induction and if prostaglandins are required to stimulate the ripening of the cervix for labour

Question 5

Prostin - short acting

Answer 5

indication:

• bishop score =<5
• unfavourable cervix if bishop score is =<5

Doses:

• Nuliparous
  
  • 1st dose 1mg
  • 2nd dose 1 or 2mg
  • 3rd dose 1 or 2mg
• Multiparous
  
  • 1st dose 1mg
  • 2nd dose 1mg
  • 3rd dose 1mg

Action:

• used for cervical ripening - softening and effacement
• stimulate myometrial contractions
• ensure woman has an empty bladder
• lie flat with feet in the modified lithotomy position
• insert the Gel into the posterior fornix of the vagina
• woman should remain in a lateral position for at least 30 minutes after insertion
• CTG monitoring for at least 30 mins post (have baseline CTG)

Contraindication:

• • ARM should not be performed within 4/24
• Physiological management of third stage is contraindication when labour is induced
• previous c-section
• unstable lie

Potential Complications:

• bishop score must be <5 at the time of insertion
• must not be inserted into the cervical canal
• uterine hyperstimulation - oxytocin should not be commenced within 6/24 of gel insertion
• ARM should not be preformed within 4 hours of prostin being inserted

Question 6

Cervidil - long acting

Answer 6

indication: bishop score =<5
*

Action:

• continuous pessary contains 10mg dinoprostone PGE2 and releases a mean dose of approx 4mg over 12/24 or 0.3 mg per hour
• once inserted tuck any excess tape gently into the vagina and leave a small amt for retrieval is warranted

Contraindication:

• oxytocin should not be commenced with Dinoprostone whilst insitu or within 30 minutes of removal
• not to be inserted into the cervical canal.
• ARM should not be performed with the pessary insutu
• Physiological management of third stage is contraindication
• c-section
• unstable lie

Removal:

• spont rupture of membranes
• regular painful 3 minutely contractions (irrespective of cervical change)
• uterine hyperstimulation
• Abnormal CTG
• Maternal adverse reaction
  
  • N&V
  • Hypotension
  • Tachycardia
  • at least 30 minutes prior to commencing a oxytocic infusion
  • insufficient cervical ripening after 24/24

Potential Complications:

• bishop score must be =<5 at the time of insertion
• must not be inserted into the cervical canal
• uterine hyperstimulation
• ARM should not be performed with dinoprostone continuous release vaginal pessary insitu

Question 7

Balloon catheter

Answer 7

indication:

• bishop score =<5

Action:

• a device to stretch the cervix
• mechanical cervical ripening by applying pressure on the internal OS of the cervices
• increasing the release of endogenous prostaglandins
• fill foley bulb with 30ml of sterile water
• cooks catheter two bulb
• able to allow ARM

Contraindication:

• woman will require further assistance to go into labour

Potential Complications:

Question 8

Syntocinon

Answer 8

indication:

• bishop score =>6

Dosage:

• 10 units of oxytocin to a 1000ml bag of CSL
• titrate up by 12 mls per hour at 30 min intervals if clinically safet to do so
• wanting 4:10 good contractions with resting tone and lasting 40 - 90 seconds
• titrate the infusion as indicate

Action:

• oxytocin increases the sodium permeability of the uterine myofibrils, indirectly stimulating contractions of the uterine smooth muscle.
• the uterus responds to oxytocin more readily in the presence of high estrogen concentrations
• and with increased duration of pregnancy

Contraindication:

• if the cervix is unfavourable (bishop score =<6)
• hx of c-section must be discussed with head ogby
• Oxytocin should not be used with 6 hours of prostin gel
• should not be used with dinoprostone while insitu or wait 30 mins post
• in a multipaous woman should be discussed with obgy prior to use, particularly if the woman has an epidural

Potential Complications:

• uterine hyperstimulation
• uterine hyoptonic
  *

Question 9

ARM

Answer 9

indication:

• cervix is favourable

Action:

• amniotomy hook
• alligator or other toothed forceps should not be used unless the ARM is technically difficult
• the practice of obtaining fetal hair to confirm ARM is not usually necessary

Contraindication:

• Rapid labour
• grand multipartiy
• previous lower segment c-section
• woman wants to await spont labour

Potential Complications:

• cord prolaspe
• bleeding
• infection
• may need oxytocin

Question 10

Membrane sweep

Answer 10

indication:

• 40 - 41 weeks nulliparous women and at 41 week antenatal visits many be offered

Action:

• stretch and sweep involve the examining finger passing through the cervix to rotate against the wall of the uterus to operate the chorionic membrane from the decidera
• releases prostaglandin

Contraindication:

• no evidence of low-lying placental site
• GBS positive

Potential Complications:

• infection
• post procedure bleeding
• discomfort

Question 11

Maternal assessment - pre IOL

Answer 11

Documentation of

• blood pressure
• heart rate
• respiratory rate
• temperature
• any vaginal loss
• abdo palpation to ascertain fetal lie
• VE - determine of favourablity of the cervix
• Station

Question 12

Fetal survillance - pre IOL

Answer 12

CTG

• prior to commencement of IOL
• a baseline normal CTG should be demonstrated within 6 hours of insertion of the prostaglandin
• a normal CTG should be recorded prior to iv oxtocin infusion

Question 13

Maternal assessment - post IOL - cervical ripening

Answer 13

• Remain with the woman for the first 10 minutes
• observing the CTG
• Palpate uterine for activity
• if the first 10 minutes of CTG is reassuring
  
  • review the woman and CTG every ten minutes
• 50 minutes
  
  • vital signs
    
    • blood pressure
    • heart rate
    • resp rate
    • temp
    • vaginal loss
    • palp abdo
    • CTG report
• After the first hour
  
  • 30/60 vaginal loss
  • 60/60 uterine activity palp over 10 minutes
• after 3/24 if no contractions and nil fetal concerns ceases freq obs
• 6/24 post prostin
  
  • VE
• 12 to 24/24 remove cervidil if still insitu and reassess the bishop score

Question 14

Fetal assessment - post iol - cervical ripening

Answer 14

• continue CTG until normal trace
• after first 60/60 auscultate FHR every 30/60 for 3/24
  *

Question 15

Maternal assessment - post IOL - oxytocic infusion

Answer 15

• same as above
• uterine palp and record uterine activity for 10/60 every 30/60
• offer support and analgesia
• record rate of oxytocic in mls/hr

Question 16

Fetal assessment - post iol - oxytocic infusion

Answer 16

• noted on CTG contemporaneously
  
  • infusion rate
  • colour of liquor
  • VE findings
  • FHR
  • fetal movements

Question 17

The following risk factor are absolute contraindication for labour

Answer 17

Footling breech

Question 18

Membrane sweeping is recommended to be offered to nulliparous women at what gestation

Answer 18

40 and 41 weeks

Question 19

The recommended time that should elapse between insertion of prostaglandin gel and commencement of oxytocin

Answer 19

6 hours

Question 20

Vaginal prostaglandin is used to promote cervical ripening.

Relative Contraindication

Answer 20

• ruptured membranes
• Grand mutiparity >5
• multiple pregnancy
• Asthma

Question 21

Vaginal prostaglandin is used to promote cervical ripening.

Contraindication

Answer 21

• vaginal bleeding
• bishop score of =>6
• spontaneous labour

Question 22

Women with uncomplicated pregnancies should have induction of labour recommend between 41+1 and 42 weeks

Answer 22

False