LABOR INDUCTI0N GUIDELINES

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LABOR INDUCTI0N GUIDELINES

• Oguchi Andrew Nwosu MD, FAAFP
• Asst. Prof. Emory Family Medicine
• January 28th 2010

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Introduction

• ACOG practice bulletin 107, August 2009
• Up To Date September 9, 2009
• Def IOL refers to iatrogenic stimulation of
  uterine contractions to accomplish delivery prior
  to the onset of spontaneous labor
• Benefits of expeditious delivery should outweigh
  risks of preg. continuation
• Rate doubled from 9.5 to 22.5 b/w 1990 2006.
  Why?

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Objectives

• Classify indications contraindications
• Review current methods of cervical ripening and
  IOL
• Summarize effectiveness of these approaches based
  on research
• Describe the agents used for cervical ripening
• Cite methods used for IOL
• Outline requirements for the safe clinical use of
  the methods for IOL

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• What are the indications and contradindications
  to induction of labor?

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Indicationsx and Contraindications

• Abruptio placentae
• Chorioamnionitis
• Fetal Demise
• Gestational Hypertension
• Preeclampsia, eclampsia
• PROM
• Postterm Pregnancy
• Maternal medical conditions
• Fetal compromise eg IUGR
• Logistics

• Vasa previa
• Complete placenta previa
• Umbilical cord prolapse
• Previous classical C/S
• Active genital herpes
• Previous myomectomy entering endo. cavity

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• What criteria should be met before the cervix is
  ripened or labor is induced?

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Criteria

• Assessment of gestational age, how?
• Consideration of potential risks to mother or
  fetus
• Appropriate counseling including C/S risk
• Plan on allowing 12 to 18 hours for latent labor
  b/4 diagnosing failed induction
• Assess cervix, pelvis, fetal size and
  presentation
• Monitor FHR and uterine contractions
• Have physician capable of C/S readily available

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Bishops scoring system
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• Methods for cervical ripening and IOL?

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Methods

• Cervical ripening

• Induction of Labor

• Foley catheters
• Hygroscopic dilators
• Osmotic dilators (Laminaria)
• Double balloon devices
• Extraamniotic saline infusion
• Misoprostol (i/vg,po,s/l)
• Dinoprostone insert (cervidil)
• Dinoprostone gel (prepidil)

• Misoprostol
• Oxytocin
• Membrane stripping
• Amniotomy
• Nipple stimulation

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Relative effectiveness

• Systematic review- foley decreased duration of
  labor if used prior to oxytocin
• SR No difference in duration of induction to
  del. or C/S with foley or PGE2 gel. PGE2 - more
  tachysystole
• Intravaginal misoprostol reported as either
  superior to or as efficacious as PGE2 gel. Less
  epidurals, more del. within 24hrs, more
  tachysystole
• Pharmacological methods for cervical ripening do
  not decrease the likelihood of C/S

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• What are the potential complications with each
  method of cervical ripening and IOL and how
  should the be managed?

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Complications of cervical ripening

Misoprostol Uterine tachysystole /- FHR changes 50gt25mg Meconium stained amniotic fluid Uterine rupture in scarred uterus (avoid in 3rd trimester in these pts)
PGE2 Uterine tachysystole. lt misoprostol
Laminaria Hygroscopic dilators Increased maternal and neonatal infections
Foley catheter Significant PV bleeding (placenta previa) ROM Febrile morbidity Displacement of head
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Complications of IOL

Oxytocin Uterine tachysystole , can lead to fetal distress, uterine rupture, abruptio placentae Water intoxication with hyponatremia Hypotension
Amniotomy Cord prolapse Cord compression Chorioamnionitis Rupture of vasa previa Increased transmission of HIV
Membrane Stripping Bleeding from undiagnosed PP Accidental amniotomy
Bilateral breast stimulation Uterine tachysystole /- FHR changes Increased perinatal death- systematic review
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Management of complications

• Complications of prostaglandins and oxytocin tend
  to be dose dependent
• Remove cervidil
• Discontinue or decrease oxytocin dose
• Turning patient to her side
• Oxygen administration
• I/V fluid administration
• Terbutaline (0.25mg s/c) or other tocolytic
• C/S

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• Are there special considerations that apply for
  induction in a woman with ruptured membranes?

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PROM

• Large randomized study found that oxytocin
• Reduced
• Interval between PROM and delivery
• Frequency of chorioamnionitis
• Postpartum febrile morbidity
• Neonatal antibiotic treatments
• No increase
• C/S deliveries
• These data suggests that for women with PROM at
  term, labor should be induced at the time of
  presentation , generally with oxytocin infusion,
  to reduce the risk of chorioamnionitis
• Adequate time for latent phase progress should be
  allowed

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PROM

• Intravaginal prostaglandins for IOL in women with
  PROM appears safe and effective
• No evidence that increases risk of infection
• Insufficient evidence for use of mechanical
  dilators
• IOL in PROM vs. expectant mx. significant
  reduction in chorioamnionitis, endometritis and
  neonates admitted to NICU

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• What methods can be used for induction of labor
  with intrauterine fetal demise in the late 2nd or
  3rd trimester?

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Intrauterine fetal demise

• Method depends on gestational age, presence of a
  uterine scar and maternal preference
• In 2nd trimester, D/C can be offered
• Labor induction is appropriate for later
  gestations
• B/4 28weeks gest., vag misoprostol appears to be
  most efficient regardless of Bishops score.
• After 28 weeks, usual protocols. Avoid
  misoprostol with scar
• Avoid C/S if possible, maternal morbidity, no
  fetal benefit

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• Summary of Recommendations Conclusions

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Level A R C

• PGE analogues are effective for cervical ripening
  IOL
• Low or high dose oxytocin regimens are
  appropriate for women that IOL is indicated
• B/4 28W gest., vag. misoprostol most efficient
  method of IOL regardless of Bishops score. High
  dose oxytocin also acceptable choice
• Consider 25mcg of misoprostol initial dose for cx
  ripening and IOL. Administer Q 3-6 hours

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Level A R C continued

• Intravaginal PGE2 for IOL in PROM appears to be
  safe and effective
• Misoprostol use in women with prior C/S or major
  uterine rupture associated with uterine rupture.
  Avoid in 3rd trimester
• The Foley catheter is a reasonable effective
  alternative for cervical ripening and IOL

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Level B R C

• Misoprostol (50mcg Q 6hours) to induce labor may
  be appropriate in some situations, although
  higher doses are associated with increased risk
  of complications including uterine tachysystole
  /- FHR decelerations

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Elective induction

• That is induction with no medical/obs. Indication
• Increased C/S rates
• Iatrogenic prematurity
• Higher health care costs
• No proven medical/obs. benefit

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Questions?