Please enable JavaScript.
Coggle requires JavaScript to display documents.
Induction of Labour and Term PROM - Coggle Diagram
Induction of Labour and Term PROM
Induction of Labour (IOL)
Definitions
IOL - Induction of Labour
The artificial process of initiating labour before spontaneous onset using mechanical or pharmacological methods
Augmentation of Labour
The artificial stimulation of uterine contractions in women that have spontaneously initiated labour, but are exhibiting inqdequate progress
Indications
Maternal
Pregnancy induced HTN / PET
Gestational DM
Hx of precipitous labour
Maternal medical conditions
Advanced maternal age >40
Maternal request
Intrauterine foetal death
Fetal
SGA / IUGR
Fetal macrosomia
Post-term pregnancy
Preterm prelabour rupture of membranes (PPROM)
Term prelabour rupture of membranes (PROM)
Reduced foetal movements at term
Twin pregnancy
Aim
Soften and liate cervix to the extent that an artificial rupture of membranes can be performed and oxytocin infusion can be started
Contraindications
Placenta / vasa praevia
Transverse lie
Umbilical cord prolapse
Primary episode of genital herpes
Prior classical uterine incision / myomectomy
Triple or higher pregnancy
Breech presentation
2+ prior CS - some will not induce if 1 prio
Maternal / foetal anatomical abnormality that c/i vaginal delivery
Process of Inducing Labour
History
WIIPER
PC
Indication for IOL
Circumstances -
pains, bleeding, SROM, reduced foetal movement
Hx of current pregnancy - insight into indication
Obs hx
Prior CS
limits options for IOL
PMhx
C/i to IOL
Risk factors during IOL / Labour
Meds
Fhx
Shx
Systems review
Exam
Abdominal Exam
Leopold's Manouvre
Lie - must be lonitudinal
Presentation - must be cephalic
Engangement - if 5/5 palpable ther is a risk of unstable li / cord prolapse on ARM
Estimated size of fetus - large or small clinically?
Vaginal Exam
Bishop's Score
Used to determine how favourable the cervix is
Higher score - more favourable
Score >7 suitable for ARM
Cervical dilation
Consistency of cervix
Length of cervix
Position of cervix
Station of presenting part
https://www.mdcalc.com/calc/3814/modified-bishop-score-vaginal-delivery-induction-labor
Process
Admit pt
Perform CTG
Take hx
Perform exam - abdominal and vaginal - Bishop's score
Begin induction - administer prostaglandins for cervical ripening
Reassess +/- prostaglandins
When cervix sufficiently dilated, transfer to labour ward for augmentation → ARM + Oxytocin
Methods of Induction
Mechanical / Non-hormonal
Membrane sweep (in antenatal clinic)
Timing
39+0 weeks
Process
Pass finger through cervix - move in circular motion to separat membranes from cervix
If cervix closed - massage
Local release of prostaglandins encourage spontaeous onset of labour
Can reduce need for IOL by 33%
Balloon catheter
Process
Pass foley catherter through cervix
Inflate balloon with air - leav for 24hr
Balloon pressures cervix - stretching releases local prostaglandins
USe
Previous CS
Less common in ireland
Dilapan rods
Process
Osmostic cervical dilators
Multiple rods inserted for up to 24hrs
Absorb fluid to expand and causecervical dilation
Use
Previous CS
Less common in ireland
Artificial rupture of membranes
Process
Use amnihook to puncture amniotic sac
Increases direct pressure of fetal scalp on cervix
May increase cervical dilation and cause uterine contractions
Use
Augment labour before oxytocin
May b require in SROM if forewaters present
Hormonal
Propess (Dinoprostone/ Prostaglandin E2
Process
Tampon called propess inserted into vagina at cervix
Releases prostaglandin hormones over 24hr
Softens and dilates cervix
If insufficient aft 24hr, Prostin gel may be given twice 6 hr apart
Benefit
Can be removed if uterine hyperstimulation
Prostin gel (Dinoprostone/ Prostagladin E2)
Process
Insert into posterior fornix
Absorbed locally
Causes softening and dilation of cervix over 6 hours
First dose 2mg nulliparous
1mg for mutiparous
Insufficient dilation after 6hr → further 1mg may be given 2x 6hr apart
Misoprostol (Prostaglandin E1)
Only in management of IUGF
Use
Induction of labour in
intrauterine fetal demise
(IUFD, Stillbirth)
Process
200mg of mifepristone stat PO
Pt can go home for 48 hrs
Pt returns - give 25-200mcg of misoprostol every 6hr until labour established
IF prior CS - lower dose
Epidural analgesia and oxytocin can be used if needed
IV oxytocin
Process
Start low dose infusion and titrate upwards until regular contractions
Reduce/ stop if hyperstimulation, tachysystole, fetal distress
Not initiatedprior to ARM
Use
Induction
Augmentation
Special Cases
Term Pre-Labour Rupture of Membranes (PROM)
Management
IV benzylpenicillin 3g loading dose followed by 1.8g 4 hourly until delivery
At 18 hrs post SROM
Transfer to labour warf for oxytocin 24hr post-SROM
Assess for forewateres +/- ARM prior to starting oxytocin
Known GBS Management
Immediate IV abx + Induction
Meconium stained liqour
Expidited induction
Intrauterine Foetal demise (IFUD)
Protocol for management
Traumatic
Important to be sensitive and empathetic
Bereavement services will provide input and follow up
IOL does not need to be started immediately unless threat to mother
Investigations
Maternal
Assess risk, document features that may contribute to determining cause
Kleihauer-Betke test
Rh- negative mothers
Assess severity of fetomaternal haemorrhage
FBC
Group and Antibody screen
Coag - Test for acquired thrombophilias
HbA1c
Serum bile acids (SBA)
Serology
CMV
Toxoplasma
Parvovirus
Rubella
Foetal
Post mortem exam (PME)
Posterm Pregnancy
Risks of Prolonging
Stillbirth
When to induce
Uncomplicated singleton: 41+0
Gives opportunity of spontaneous labour
Importance of having proper dating US in 1st trimester to avoid unnecessary induction
Low risk woman declines IOL
Twice weekly CTG and AFI (amniotic fluid infex)
Complications of Induction of Labour
Failed induction
Allow rest period and repeat IOL attempt (uncommon)
Delivery by CAt 3 CS
Uterine Hyperstimulation
Remove vaginal prostaglandin if possible
USe tocolytic - terbatuline
Stop / reduce rate of oxytocin infusion if relevatn
Foetal distess
Use tocolytic if uterine hyperstimulation
Stop / reduce oxytocin if relavent
Consider immediate delivery by CS if not resolving / severe foetal distress - low threshold for IUGT
Uterine Rupture
Continous CGT
Higher rate in VBAC
Titrate oxytocin infusion rate with care
C-Section
IOL increases risk of CS
