Induction of Labour (IOL)
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Induction of Labour (IOL)

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What additional indications may justify induction of labor (IOL) if membranes rupture before 34 weeks?

Suspected maternal infection, fetal compromise, or growth restriction.

Why is IOL typically recommended between 41 and 42 weeks of gestation?

To reduce the risks of stillbirth, fetal compromise in labor, and mechanical problems at delivery.

What is the most common reason for recommending IOL?

Prolonged pregnancy.

How does induction for prolonged pregnancy affect the rate of cesarean sections?

<p>It decreases the need for cesarean sections.</p> Signup and view all the answers

What are some absolute contraindications to IOL?

<p>Placenta praevia and severe fetal compromise.</p> Signup and view all the answers

What scoring system did Bishop develop to assess labor readiness?

<p>The Bishop score.</p> Signup and view all the answers

What does a high Bishop score indicate about the cervix?

<p>It indicates a 'favorable' cervix, associated with an easier, shorter induction process.</p> Signup and view all the answers

Why is breech presentation considered a relative contraindication to IOL?

<p>It poses a greater risk for complications during delivery.</p> Signup and view all the answers

What is the primary goal of induction of labour (IOL)?

<p>The primary goal of IOL is the planned initiation of labour prior to its spontaneous onset when risks to the mother or fetus outweigh the benefits of continuing the pregnancy.</p> Signup and view all the answers

What percentage of deliveries in the UK involve induction of labour?

<p>Approximately 20–25% of deliveries in the UK occur following IOL.</p> Signup and view all the answers

Identify two indications for induction of labour related to maternal health.

<p>Pre-eclampsia and deteriorating maternal illness are two indications for IOL related to maternal health.</p> Signup and view all the answers

What complication is associated with prolonged rupture of membranes (PROM)?

<p>The complications associated with PROM include an increased risk of ascending infection, such as chorioamnionitis.</p> Signup and view all the answers

Under what circumstances is induction of labour recommended after PROM at term?

<p>IOL is recommended approximately 24 hours following PROM at term to reduce the risk of infection.</p> Signup and view all the answers

What is a significant risk of not inducing labour after PROM in a term pregnancy?

<p>A significant risk of not inducing labour after PROM in a term pregnancy is the increased chance of chorioamnionitis and other infectious morbidities.</p> Signup and view all the answers

Name one social reason that may justify the induction of labour.

<p>One social reason that may justify IOL is if the mother is a student with exams approaching, indicating a need to schedule delivery.</p> Signup and view all the answers

What should be assessed before performing an induction of labour?

<p>Before performing IOL, the risks to the mother and fetus must be assessed to ensure they are acceptable and that there is a reasonable chance of success.</p> Signup and view all the answers

What is a membrane sweep and what is its purpose in induction of labor?

<p>A membrane sweep is a technique where a gloved finger is inserted through the cervix to detach the chorionic membrane from the decidua, releasing natural prostaglandins to stimulate contractions.</p> Signup and view all the answers

What conditions must be met before performing a membrane sweep?

<p>The cervix must be beginning to dilate and efface, and placenta praevia must be excluded before the procedure.</p> Signup and view all the answers

Describe the administration and rate adjustment process for oxytocin during labor induction.

<p>Oxytocin is administered intravenously as a dilute solution, starting at a low infusion rate that is incrementally increased every 30 minutes until 3–5 contractions occur in 10 minutes.</p> Signup and view all the answers

What factors influence the dosing of synthetic prostaglandin E2 (PGE2) in labor induction?

<p>The dosing of synthetic prostaglandin E2 is influenced by gestational age (GA), parity, and previous cesarean sections.</p> Signup and view all the answers

What is the purpose of Mifepristone and Misoprostol in labor induction?

<p>Mifepristone and Misoprostol are used to induce labor following intrauterine fetal death, functioning as an antiprogesterone and a prostaglandin, respectively.</p> Signup and view all the answers

How does the infusion of oxytocin relate to the assessment of labor progress?

<p>The infusion of oxytocin is adjusted based on the frequency of contractions, aiming to achieve 3–5 contractions in every 10 minutes.</p> Signup and view all the answers

What is the role of the controlled-release pessary in labor induction?

<p>The controlled-release pessary is used to administer prostaglandin E2 for up to 24 hours to facilitate cervical ripening and initiate contractions.</p> Signup and view all the answers

In what circumstances should induction methods be considered following the failure of other measures?

<p>Induction methods should be considered if the cervix is favorable, and if non-invasive measures, like membrane sweeping, have not been successful.</p> Signup and view all the answers

What is the likely effect of induced labour on pain levels compared to spontaneous labour?

<p>Induced labour is likely to be associated with more pain than spontaneous labour.</p> Signup and view all the answers

What complications can arise as a result of uterine hyperstimulation during induced labour?

<p>Uterine hyperstimulation can lead to fetal compromise, bradycardia, and may result in an emergency caesarean section.</p> Signup and view all the answers

What should be done if contraction frequency exceeds 5 per 10 minutes during oxytocin administration?

<p>The oxytocin should be stopped, and if necessary, a tocolytic drug such as terbutaline should be administered.</p> Signup and view all the answers

How does the risk of uterine rupture change for women with a previous caesarean section when induced?

<p>The risk increases from 1 in 200 during spontaneous labour to as high as 1 in 70 with induction using prostaglandins.</p> Signup and view all the answers

What defines a failure of induction of labour?

<p>Induction is considered failed if an ARM is impossible after maximum prostaglandin doses, or if the cervix remains less than 3 cm dilated after 6-8 hours of oxytocin.</p> Signup and view all the answers

What are the options available if induction of labour fails?

<p>Options include a rest period before attempting induction again or proceeding to a caesarean section.</p> Signup and view all the answers

In what situations would delaying delivery after a failed induction be acceptable?

<p>Delaying delivery may be acceptable if there is no major threat to maternal or fetal health, such as in failed social inductions.</p> Signup and view all the answers

What is the relationship between epidural analgesia and rates of instrumental delivery during induced labour?

<p>The use of epidural analgesia during induced labour is associated with higher rates of instrumental delivery.</p> Signup and view all the answers

Study Notes

Induction of Labour (IOL)

  • IOL is the planned initiation of labour before it starts naturally.
  • Around 20-25% of births in the UK happen after IOL.
  • IOL is performed when the risks of continuing the pregnancy outweigh the risks of ending it for the mother and/or baby.
  • IOL should only be done if there is a good chance of success and the risks to the mother and baby are acceptable.

Indications for IOL

  • Prolonged pregnancy (usually offered after 41 weeks).
  • Premature Rupture of Membranes (PROM).
  • Pre-eclampsia and other maternal hypertensive disorders.
  • Fetal Growth Restriction (FGR).
  • Intrauterine Fetal Death (IUFD) or history of it.
  • Diabetes Mellitus (DM).
  • Fetal Macrosomia.
  • Deteriorating maternal illness.
  • Unexplained antepartum haemorrhage (APH).
  • Twin pregnancy beyond 38 weeks.
  • Intrahepatic Cholestasis of Pregnancy.
  • Maternal isoimmunization against red cell antigens.
  • ‘Social’ reasons (e.g. mother is a student and has exams in 2 weeks).

Prelabour Rupture of Membranes (PROM)

  • Risk of ascending infection (chorioamnionitis) and related complications increases with time between membrane rupture and delivery.
  • IOL is recommended about 24 hours after PROM at term (beyond 37 weeks).
  • IOL reduces chorioamnionitis, endometritis, and neonatal unit admissions.
  • Evidence is less clear for preterm PROM (PPROM)
  • Before 34 weeks, IOL requires additional indications (infection, fetal compromise, growth restriction).
  • Between 34 and 37 weeks, individual risk-benefit assessment is necessary.

Prolonged Pregnancy

  • The most common reason for IOL.
  • Pregnancies beyond 42 weeks have a higher risk of stillbirth, fetal compromise during labor, meconium aspiration, and delivery complications.
  • IOL is usually advised between 41 and 42 weeks.
  • IOL does not increase the chance of Caesarean section (C/S) and may reduce the need for it.

Contraindications to IOL

  • Absolute contraindications: placenta praevia, and severe fetal compromise.
  • Relative contraindications: breech presentation, previous C/S (increased risk of uterine rupture), and preterm gestation.

Bishop Score

  • Assesses cervical readiness for labor.
  • Higher scores ("favorable cervix") are associated with easier, shorter inductions with less likelihood of failure.
  • Lower scores ("unfavorable cervix") suggest a longer, more likely to fail induction, potentially leading to C/S.

Methods of IOL

  • Membrane Sweep (offered weekly from 40 weeks).
  • Prostaglandin gel, tablet, or pessary to ripen the cervix and initiate contractions.
  • Artificial Rupture of Membranes (ARM) (only when the cervix is favorable).
  • Oxytocin infusion (membranes must be ruptured first, spontaneously or artificially).
  • Mifepristone and Misoprostol (for intrauterine fetal death).
  • Extra-amniotic saline infusion.

Membrane Sweeping

  • A gloved finger is inserted into the cervix and rotated around its rim.
  • Strips off the chorionic membrane, releasing prostaglandins.
  • Can be uncomfortable.
  • Effective if the cervix is starting to dilate and efface.
  • Can be performed multiple times.
  • Reduces the need for induction.
  • Usually performed at term, excluding placenta praevia.
  • An adjunct to normal induction process.

Oxytocin and Prostaglandin

  • Oxytocin:
    • Short half-life.
    • Given intravenously as a diluted solution.
    • Variable response with strict administration protocol (increasing dose every 30 minutes until 3-5 contractions within 10 minutes).
    • Dosage depends on gestational age, parity, and previous C-sections.
  • Synthetic Prostaglandin:
    • Most common: prostaglandin E2 (PGE2)
    • Vaginal tablet or gel application to the posterior fornix.
    • Often requires two doses, 6 hours apart.
    • Controlled-release pessary available for up to 24 hours.
    • Mifepristone (antiprogesterone) and Misoprostol (another prostaglandin) can also be used, but complication rates are higher.
    • This combination is currently only used in the UK for IOL after intrauterine fetal death.

Complications of IOL

  • Increased pain.
  • More frequent use of epidural analgesia.
  • Higher rates of instrumental delivery with epidural use.
  • No evidence of increased C/S rate.
  • Long labors augmented with oxytocin increase the risk of postpartum hemorrhage (PPH) due to uterine atony.
  • Fetal compromise, partly attributed to uterine hyperstimulation from prostaglandins and oxytocin.

More Complications of IOL

  • Uterine hyperstimulation:

    • 5 contractions in 10 minutes.

    • Treatment: stop oxytocin, possibly administer tocolytic (e.g., terbutaline).
    • May lead to fetal bradycardia and emergency C/S if heart rate doesn't recover.
  • Cord Prolapse:
    • If ARM is performed when the fetal head is high.
    • Emergency C/S required.
  • Uterine Rupture:
    • Higher risk in women with previous C/S.
    • Increased risk with prostaglandin use during IOL.

Failure of IOL

  • Defined as:
    • ARM not possible after maximum prostaglandin doses.
    • Cervix remains uneffaced and <3cm dilated after ARM and 6-8 hours of oxytocin with contractions.
  • Options:
    • Rest then attempt induction later.
    • C/S.
  • Delaying delivery is only acceptable if there's no major maternal or fetal risk (e.g., failed social induction).
  • Failed induction with pre-eclampsia or FGR usually necessitates C/S.

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This quiz covers the essential aspects of Induction of Labour (IOL), including its purpose, indications, and the circumstances under which it is performed. Understanding IOL is crucial for healthcare providers to ensure the safety of both mother and baby. Explore the various scenarios that may lead to the decision of inducing labor.

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