Labor Induction Factors and Fetal Monitoring

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Questions and Answers

What should be considered when determining the timing of induction of labor in women with uncomplicated singleton pregnancies?

The woman's level of education

Only the woman's age

The hospital's policies on induction

Local circumstances and identified risk factors (correct)

Which of the following factors increases the risk of complications when considering induction of labor?

BMI below 30 kg/m2

Age below 35 years

Having more than one previous pregnancy

Assisted conception (correct)

What is advised for women who choose not to have their labor induced?

They should undergo increased fetal monitoring (correct)

Only minimal fetal monitoring is necessary

All monitoring must be continuous throughout pregnancy

They should not receive any form of monitoring

Which statement regarding fetal monitoring is accurate?

Fetal monitoring is merely a temporary assessment. Signup and view all the answers

Why is it essential to discuss care options with the woman if she chooses not to have induction of labor?

To support her preferences regarding how she wishes to proceed Signup and view all the answers

Under what condition should oxytocin be considered in multiparous women after ARM?

If there has been no contraction after 2 hours Signup and view all the answers

Which of the following is NOT a potential risk associated with the use of PGE2?

Infection (chorioamnionitis) Signup and view all the answers

What is the first action to take after performing amniotomy?

Assess fetal heart rate (FHR) immediately for one full minute Signup and view all the answers

In the case of uterine hyperstimulation, what should be monitored for in relation to maternal effects?

Tachycardia Signup and view all the answers

What indicates that a cervical ripening procedure should be discontinued?

Maternal nausea and vomiting are present Signup and view all the answers

What must be assessed before performing an amniotomy?

Cervix status and presentation Signup and view all the answers

What is a rare but serious risk of PGE2 use?

Uterine rupture Signup and view all the answers

Which assessment is crucial to perform after the mother has received PGE2 and has no contractions?

Assessment of uterine activity and fetal movements Signup and view all the answers

When can oxytocin be commenced in nulliparous women after ARM?

Only if BISHOPs score is less than 7 Signup and view all the answers

What is the common method of administration for oxytocin?

Intravenous infusion diluted with Normal Saline Signup and view all the answers

Which of the following is a risk associated with oxytocin use during labor?

Decreased mobility Signup and view all the answers

What is the recommended use of oxytocin for inducing labor?

Combined with amniotomy as the primary method Signup and view all the answers

Which method does NOT typically augment labor?

Analgesic administration Signup and view all the answers

What observation is critical to monitor during prelabor rupture of membranes?

Time, amount, colour, and odour of liquor Signup and view all the answers

Patients using oxytocin may experience which of the following complications?

Fluid retention due to its anti-diuretic effect Signup and view all the answers

How is the oxytocin dose adjusted during labor management?

Using a volumetric pump for titration Signup and view all the answers

What symptoms should a woman report if she experiences prelabour rupture of membranes?

Flu-type symptoms and abdominal pain Signup and view all the answers

What is the recommended course of action if a woman has prelabour rupture of membranes at term and a positive group B streptococcus test?

Immediate induction of labour or caesarean birth Signup and view all the answers

What should be assessed during the abdominal examination for a woman with prelabour rupture of membranes?

Fetal presentation and uterine tenderness Signup and view all the answers

Which of the following is true regarding the management of women with a previous lower segment caesarean birth who experience intrauterine fetal death?

They should be advised about the risk of uterine rupture Signup and view all the answers

What is the maximum duration a woman may be managed expectantly after a prelabour rupture of membranes?

24 hours Signup and view all the answers

What type of care should be provided to women with a history of lower segment caesarean birth during induced labour?

One-to-one midwifery care Signup and view all the answers

What imaging technique is used to assess liquor and diagnose rupture of membranes?

Ultrasound scan Signup and view all the answers

Which medication is contraindicated in women with a uterine scar during labour induction?

Dinoprostone Signup and view all the answers

What is the primary purpose of induction of labour?

To artificially initiate labour Signup and view all the answers

Which maternal condition could be an indication for induction of labour?

Gestational diabetes Signup and view all the answers

At what gestational age is it generally recommended to offer induction of labour for uncomplicated singleton pregnancies?

41 weeks Signup and view all the answers

Which of the following is a fetal indication for induction of labour?

Suspected fetal compromise Signup and view all the answers

What should be discussed with a woman before considering her request for induction of labour?

The benefits and risks of induction Signup and view all the answers

What does expectant management of prolonged pregnancy typically involve?

Monitoring until labour starts naturally Signup and view all the answers

Which of the following complications is NOT a maternal indication for induction of labour?

Macrosomia Signup and view all the answers

What is a common concern regarding induction of labour at term?

Increased risk of caesarean delivery Signup and view all the answers

What is the definition of prolonged pregnancy?

A pregnancy lasting more than 42 completed weeks Signup and view all the answers

Which of the following is a risk associated with continuing pregnancy beyond 41 weeks?

Increased likelihood of stillbirth Signup and view all the answers

What is a contraindication for induction of labor?

Oblique fetal lie Signup and view all the answers

What is the primary purpose of using the modified Bishop's score?

To evaluate the favorability of the cervix for induction Signup and view all the answers

Which of the following methods may be offered for induction for women with a Bishop score of 6 or less?

Vaginal gel of dinoprostone Signup and view all the answers

What action should be taken if the CTG is confirmed as normal during labor monitoring?

Use intermittent auscultation if low risk Signup and view all the answers

Which condition would make induction of labor with caution advisable?

Multiple pregnancy Signup and view all the answers

What characteristic does not represent a favorable cervical condition in the modified Bishop's score?

Closed cervix with firm consistency Signup and view all the answers

What is a potential outcome of a pregnancy that extends beyond 42 weeks?

Increased risk of assisted vaginal birth Signup and view all the answers

Study Notes

Induction of Labour

Induction of labour is the artificial initiation of labour before spontaneous onset
It can be viewed as any procedure or intervention that starts labour rather than allowing it to commence spontaneously (Brodrick 2024).

Indications for Induction of Labour

Maternal indications:
- Prolonged or post-term pregnancy
- Medical problems (e.g., diabetes, hypertension, cholestasis)
- Poor obstetric history (previous stillbirth)
- Prelabour rupture of membranes (>24 hours)
- Advanced maternal age (Brodrick 2024)
- Maternal request (consider after discussing benefits/risks)
Fetal indications:
- Suspected fetal compromise (e.g., IUGR)
- Reduced fetal movement
- Macrosomia
- Rhesus isoimmunisation
- Severe congenital abnormalities
- Fetal death (NICE 2021, Brodrick 2024)

Prevention of Prolonged Pregnancy

Explain that labour usually starts naturally by 42+0 weeks
At 38-week antenatal visit, reconfirm preferences for birth and discuss options (expectant management, induction, planned caesarean)
For uncomplicated singleton pregnancies, offer induction at 41+0 weeks, or soon after
Women’s preferences, local circumstances, and identified risks will determine the timing
(NICE 2008 updated 2021).

Prevention of Prolonged Pregnancy - Risks of Continuing Beyond 41+0 Weeks

Increased likelihood of caesarean birth
Potential increased likelihood of the baby needing admission to neonatal intensive care unit
Potential increased likelihood of stillbirth and neonatal death
Potential increased likelihood of assisted vaginal birth (forceps or ventouse)
(NICE 2021) - Monitoring might consist of twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth(2008, amended 2021)

Prolonged Pregnancy (Post-Term)

Often used interchangeably with postmaturity
Prolonged pregnancy is one that exceeds 42 completed weeks or 294 days from LMP
It refers to the duration of pregnancy, not a maternal condition
Postmaturity describes the baby born after 42 weeks

Contraindications for Induction of Labour

Placenta praevia or vasa praevia
Oblique or Transverse lie
Malpresentation (breech)
Cord presentation or cord prolapse
Severe fetal compromise (Brodrick 2024)

Assessment Before Induction

Abdominally assess the level and stability of the fetal head in the lower part of the uterus at or near the pelvic brim
Assess and record the Bishop score
Confirm normal fetal heart rate pattern and absence of uterine contractions
Ensure facilities are available for cardiotocography if induction of labour is started (NICE 2008, amended 2021).

Modified Bishop Score

A method of assessing whether the cervix is favourable for induction
Decide which method is suitable
For women with a Bishop score of 6 or less offer induction with vaginal dinoprostone
vaginal tablet, gel or controlled-release vaginal delivery system or with low dose( 25 microgram) oral misoprostol tablets (NICE 2021)

Monitoring After Induction

When uterine contractions begin, assess fetal well-being and uterine actions with intrapartum CTG interpretation
If CTG is normal, consider intermittent auscultation for low risk situations
If abnormal fetal heart rate or excessive uterine contractions, stop additional doses and remove any vaginal pessaries/delivery systems
Reassess Bishop score at appropriate intervals to monitor progress (NICE 2008, amended 2021).

Membrane Sweeping

Might make labour more likely to start naturally
Offer women a vaginal examination for membrane sweeping before formal induction of labour
Consider additional membrane sweeping if labour does not start spontaneously, however discomfort and vaginal bleeding are possible (NICE 2008, amended 2021).

Alternative Methods of Labour Induction

Herbal supplements, acupuncture, homeopathy, castor oil, hot baths, enemas, and sexual intercourse are not supported by current evidence (NICE 2008/2021).

Prostaglandins (PGE2)

Locally acting chemical compounds used for ripening the cervix
Available in gel or pessary form
Most commonly administered vaginally in posterior fornix
Contributes to uterine contraction
Success rate of 30-50%
Monitor fetal heart and contractions

Using Propess

Slow release of prostaglandin over 24 hours
Similar purpose – to soften cervix
Assess maternal well-being
Informed consent required
Insert pessary to cervical canal, positioned behind posterior vaginal fornix to keep it in situ
(NICE 2008, amended 2021)

When to Remove Propess

When regular, painful contractions are established
Spontaneous rupture of the membranes or amniotomy
Suggestion of uterine hyperstimulation or hypertonic uterine contraction
Evidence of fetal distress
Evidence of maternal systemic adverse dinoprostone effects (e.g., nausea, vomiting, hypotension or tachycardia)
At least 30 minutes before starting an intravenous infusion of oxytocin
After 24 hrs if cervical ripening has not been achieved

Prostaglandin Regimen (Primigravida and Multiparous) - (See details in full reference file)

Risks Associated with Oxytocin

Uterine hyper stimulation/hypertonus
Fetal hypoxia/asphyxia
Fluid retention
Uterine rupture
Amniotic fluid embolism
Postpartum haemorrhage (PPH)
Increased need for epidural analgesia
Restricted mobility (NICE 2008, 2021)

WHO Recommendations on Induction of Labour

Induction recommended at or beyond 41 weeks (>40+7 days) of gestation.
Recommendation doesn't apply to situations where gestational age isn't reliably estimated.
Potential need for women (post-term pregnancy) discussed in advance so questions, benefits and risks are understood
Not recommended at gestational age less than 41 weeks. Insufficient evidence for uncomplicated pregnancies before 41 weeks.

Augmentation of Labour

Accelaration of labour
Methods:
Amniotomy
Syntocinon

Prelabour Rupture of Membranes at Term

Accurate history (time, amount, colour, odour of liquor/vaginal loss)
Note pain, discomfort, contractions, history of similar episodes, fetal movements
Monitor and record all vitals
General wellbeing, and abdominal examination to establish gestation, lie, position, presentation
Auscultate fetal heart with Pinnards/Doppler, note uterine tenderness, note vaginal loss. Four-hourly observations (or sooner).
Advise woman to report changes (wellbeing, flu-type symptoms, abdominal pain, tenderness, fetal movements)
Speculum not necessary if liquor is visible.

Prelabour Rupture of Membranes at Term - Fetal Assessment

Abdominal examination to estimate growth, position, presentation to exclude uterine tenderness
CTG if criteria are met
Ultrasound scan assessment of liquor (if required) to diagnose rupture and fetal wellbeing.
Offer women with prelabour rupture of membranes choice of induction or expectant management (24 hours, consideration of IOL after 24 hrs, NICE 2008, updated 2021)
Support woman's decision if they choose not to be induced, and discuss care options
If woman has prelabour rupture (37+0+5 weeks), positive group B streptococcus - immediate induction/caesarean birth (NICE 2021)

IOL after Previous LSCS

Advise previous LSCS women that uterine scar increases uterine rupture risk with induction.
If IUFD and previous LSCS, follow recommendations for monitoring, and offer one-to-one midwifery care during labour and birth
Dinoprostone and misoprostol contraindicated (NICE 2021)

IOL for IUD

More than 85% of women with IUFD labour spontaneously within three weeks of diagnosis.
Support the woman’s preferences regarding the timing of IOL
Delaying IOL a few days is acceptable if membranes intact and no signs of infection (NICE, updated 2008).

IOL in Specific Circumstances

Previous Caesarean section (avoid if classical incision)
History of precipitate labour (not routinely offered)
Fetal macrosomia without diabetes
Consider maternal requests after discussing benefits and risks.

Outpatient Induction

Consider outpatient induction (with vaginal preparations or mechanical methods) in women with uncomplicated conditions
Ensure safety and support
Agree a review plan with the woman before she returns home
Schedule for observation/contact obstetrician/midwife when contractions start, if no contractions, ruptured membrane or other concerns arise (NICE 2008, amended 2021)

Role of the Midwife

Planning: Good communication skills, information and informed consent, provide support
Labour: Monitor maternal and fetal wellbeing, assess pain, assessment of progress, accurate record keeping

NICE Guideline - Summary

Update to 2008 version recommends induction at 41 weeks.
Woman's decision to not induce should be supported and care options discussed.
Research shows higher infant mortality after 42 weeks without induction

Summary - NICE 2021 (IOL Overview)

Explain reasons for induction, procedures, support/pain relief, alternatives if no induction, risks/benefits/induction methods
- Discuss induction may not be successful and what woman's options would be.

IOL for Post-term

By 40/40 weeks, 58% deliver, 74% by 41/40, 82% by 42/40
Stillbirth incidence increases with gestation
18% may remain pregnant after 42/40 without induction.

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Description

This quiz covers key considerations for the timing of labor induction in uncomplicated singleton pregnancies. It explores factors influencing the risk of complications, advises women who opt out of induction, and verifies accurate statements regarding fetal monitoring. Understanding these aspects is crucial for informed decision-making during pregnancy.