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Essay 308 - IOL

Posted by Bindi J.
BJ:

(A) Post date pregnancy is associated with increased fetal morbidity especially after 42 weeks due to declining placental function. Meconium staining of liquor due to fetal distress and intra uterine death may occur. This should be discussed with the mother and close fetal surveillance is indicated. This is achieved by twice weekly electronic fetal monitoring(CTG) and ultrasound measurement of liquor volume. If CTG is not reassuring or scan reveals decreasing liquor volume induction of labour should be offered again.If pathological CTG, then umbilical artery doppler and biophysical profile should be done. If absent or end diastolic flow or biophysical score less than six , emergency caesarean is recommended. Otherwise,expectant management should be reviewed again at 42 weeks to rediscuss IOL. Clear documentation of discussion, options and patients choice should be made . Leaflets should be provided.

(B)
IOL should be done in a consultant led maternity unit where obstetric emergency can be managed immediately.Prior to commencing the process maternal and fetal assessment should be done. Per abdominal examination to confirm longitudinal lie and cephalic presentation and fifths palpable should be done. A 30 minute trace of electronic fetal monitoring to confirm fetal heart activity is reassuring should be done. After the woman has emptied her bladder an internal assessment is made with consent to determine the modified bishop score . For a score of 6 or less, a 3mg prostaglandin tablet or 1 mg gel or a continuous release pessary is recommended. For a score more than 6, ARM is offered for induction . For a high presenting part with a bishop score of more than 6, oxytocin drip may be offered( with a caution as she is multiparous) prior to ARM to facilitate engagement of fetal head and avoid the possible risk of cord prolapse. Following prostaglandin, CTG trace should be obtained for 20-30 mints and Cervicometric assessment should be repeated in 6-8hrs time ,preferably by the same examiner to decide for further dose of prostaglandin but earlier in case of fetal distress or uterine hyperstimulation. Following ARM examination should be repeated in 4 hours unless indicated as before. Pain relief options should be offered. If no progress is seen after 3 doses(3mg each) of prostin tablet further management options of repeating induction or caesarean section should be discussed with the patient. At all times support should be provided to her.

(c) Maternal risks include uterine hyperstimulation, uterine rupture, increased need for epidural analgesia and interventions like instrumental delivery, failure of induction necessitating caesarean section. Fetal risk includes fetal distress.
Posted by SRABANI M.
a. Firstly, I would like to explain to her about the risks of post dated pregnancy & try to convince her to consent for IOL. At this point I have to respect her decision & if she does not want to have IOL after knowing all the risk factors involved, I would like to discuss further management plan . She will be offered at least twice weekly CTG as well as twice weekly USS to measure amniotic pool depth from 42 weeks onwards.Her family should be involved at this stage , if she wishes.She should be given all informations regarding management plan preferably in writing. An well documented management plan will be helpful from litigation point of view . She will also be informed about all the possible emergency situations like less fetal movement, rupture of fetal membrane , vaginal bleeding or abdominal pain.This will help us to avoid any maternal and fetal complication as well as IUD.
She will be offered membrane sweep before starting formal IOL if she is happy about it.I would explain about membrane sweep & advantage of it.Membrane sweep might help her to start labour spontaneously & she might not need formal IOL.
If membrane sweep fails once, I would try once again after checking that placenta is not low lying.
She should also be informed about the methods like Accupancture, Homeapathy etc are not recommended alternatives for IOL
She should be informed about the process of IOL if she opts for it along with all the risk factors involed with it.I would also discuss about plan of management if IOL fails.
Pain relief should be discussed with her as well .Finally , I would like to plan her delivery ( whether home/ hospital) & document it very clearly in her notes
b. It will an informed choice for this lady to opt for IOL. She will be given all information regarding when & where it will take place,who will be attending her & what are the options available.She will be informed about all the risk factors as well as advantages of IOL.she should know all the risk factors for prolonged labour.She should get information regarding pain relief during IOL. Family should be involved if she wants.
Any special requirements should be provided like disability, language problem etc
She should get all information regarding failed induction & further plan if it fails.She will be offered water birth if she wants. Her psychological stress should be taken into account very carefully.
After doing careful vaginal examination, She will be offered PGE2 pessary/gel /vaginal tablet. This is recommended as first choice for IOL if there is no complication present .It is cheap & effective.I would use one pessary & if it does not work I will use another after 6 hrs.PGE2 will help to ripen cervix & also for ARM if Cervix is favourable .Risk of using it is hyperstimulation & we can use tocolytic in that situation to minimise the effect.
Next available method is ARM with or without syntocinon.ARM is cheap very effective method if Cx is favourable.I would like to do careful vaginal examination before each step & look at Bishop’s score.
Syntocinon should be given along with ARM & should not be started alone if cervix is not favourable as it will prolong the duration of labour.
I should be carefull about the risk of ascending infection during ARM.
Syntocinon should be started if there is no contraindication for it & in this lady it should not be a problem until there is signs of uterine rupture.PGE2 also has got the same risk of rupture of uterus as well.
Other methods can be used are oestrogen and lamineria tent but they are not commonly used in UK.they are also cheap & can be used if other options are not available.
Though out the process of IOL careful monitoring of fetus & mother is essential.Continous fetal monitoring with required staff should be available.CTG & USS should be available all the time.
If IOL fails or any complication arises, induction should be stopped & will proceed for emergency C/section.at this point consultant obstetrician should be involved depending on clinical situation.Neonatologist & anaesthetist should be informed.The lady should be given all informations & documented.
c.Risks associated in this case are psychological stress of the lady as the pregnancy may be prolonged & risk of IUD if she does not want to go for IOL. She will be more stressed if IOL fails & she has to go for emergency section.There is also a risk of ruptured uterus as she is muptip although risk is less than if she had had previous section .Also there is a risk of hyperstimulation.
Finally , there is a risk of litigation if anything goes wrong as well .A good documentation & communication is required in this
Posted by H H.
Options include sweeping of membranes which might be uncomfortable to the patient and she is warned that she will feel pain,discomfort and might have some bleeding. This method reduce the need for formal induction of labour ,with no effect on the rate of vaginal or cesarean section delivery.
The 2nd option is induction of labour between 41 - 42 wk. This would reduce perinatal morbidity and mortality,reduce the need for operative vaginal delivery and would reduce cesarean section rate due to fetal distress. There is also less risk of me conium aspiration of newborn.
If patient declines both procedures, a wait and see policy for spontaneous labour is adopted ,with proper regular monitoring of fetal wellbeing ,but informing the patient that fetal wellbeing can not be surely predicted with the available monitoring procedures and that fetal compromise can take place anytime.
Some patients might choose to have a cesarean section if their pregnancy has passed date. Counselling regarding benfits and risks of cesarean is given, but maternal choice is respected.


B- History is taken from the patient regarding the previous two deliveries and wether they were spontaneous or induced and if any problems encountered. Patient given written information regarding induction of labour. Abdominal examination is done for presentation and head engagement. Local examination using the Bishop score for favorability of cervix(cx) . If cx unfavorable,long,posterior,os 1-2cm ,rigid and station high ,the patient is fitted with prostaglandin gel the night before in the antenatal ward following local guidelines and protocols for its application. In the morning she reassessed and see for need for another dose or need to transfer to labour ward for artificial rupture of membranes(ARM).
If cx if favorable for induction ,this can be accomplished by ARM on labour ward in the morning. Follow local guidelines and protocols for oxytocin augmentation. Continuous fetal monitoring is needed if oxytocin is applied. Regional analgesia given according to patient choice. The cervical assessment and progress done every 4 hours. Oral fluids allowed during 1st stage. Neonatologist available for neonatal assessment after delivery for fear of meconium aspiration.

C- Maternal risks include failure of induction and need for cesarean section, uterine hyper stimulation leading to fetal compromise,and risk of rupture uterus being a multifarious patient.
Fetal risks include fetal distress with need of cesarean section,and cord prolapse during artificial rupture of membranes,changing the situation into an emergency with need to perform a type 1 emergency CS.
Posted by Im F.
A
Women with uncomplicated pregnancy should be given every opportunity to go into spontaneous labour .she should be offered IOL between 41-12 wks .. If she refuses her wishes should be respected She should be informed the risk/benefits of IOL.
Option for management of postdates includes, expectant management, membrane sweep and prostaglandin.
Expectant management explain to her that most women will go into spontaneous laboue by 42 wks.but need to monitor fetal heart twice weekly.and ultrasound estimation of liquor.
Explain to her membrane sweep procedure and inform her that it makes spontaneous labour more likely but could result in bleeding and pain.
Induction with prostaglandins is another method which is in the form of gel ,tablet or pessary. There is risk of hyperstimulation or failed induction with this..this is the preferred method but is expensive and needs fetal heart rate monitoring. Amniotomy alone or with oxytocin is not considered as primary method unless there is a high risk of hyperstimulation.
She should be that non pharmacological methods such as herbal,homeopathy,castor oil or intercourse is not supported with evidence.

B
If she accepts IOL she should be informed the method of IOL to be used its benefits risk Allow her time to discuss with her partner. Encourage her to check out information source and allow her to ask question Outpatient if support and safety procedures are in place can be allowed other wise admit her.
An IV line to be secured and relevant investigation sent and reviewed. Induction with prostaglandin pessary to be done in the morning hrs. CTG before IOL to confirm normal FHR..She should be told that this would require continuous fetal heart monitoring which could make her immobile. A bishop score needs to be done before and after 6 hrs or if controlled release after 24 hrsa score of 8 or more is considered favourable.. She should be informed that IOL can be painful so options for pain relief informed if she has any hyperstimulation tocolysis should be considered. if IOF fails then to induce further or caesarean section to be offered informing risk and benefits of both.

C
Risk associated in this case are uterine hyperstimulation,failed IOL.Less likely uterine rupture.
Posted by F N.
Most pregnant women deliver before 40 weeks however a small percentage of women( about 5%) remain undelivered by 42 weeks.These pregnancies are associated with increased perinatal morbidity and mortality.
This lady should be informed about the risks of placental insufficiency leading to IUGr and still birth.Reasons for refusal of induction of labour should be explored as it might help in further management.
she should be monitered for fetal welbeing after 42 weeks gestation.She should keep a record of baby movements though there is poor evidence that it can predict fetal wellbeing.She should be booked for daily cardiotocographic recording of baby heart.This test has a sensitivity of over 90% in predicting fetal distress however it has poor specificity,leading to unnecessary ceasarean section.
She can be monitered by ultrasound measurement of biophysical profile,which includes liqour volume,fetal movement,fetal breathing and umbilical artery doppler studies.There is poor evidence regarding the how frequently these scan should be done,however the commen practise is once or twice weekly.
she should be made aware of the maternal risk in the form of DIC/coagolopathy,and should have Platelets and clotting profile checked.
membrane sweep should be offered as it doesnot involve any medication and it might start the labour by releasing local prostaglandins.
Induction of labour either by prostaglandins(tabelets,gel,intracervical catheter) and artificial rupture of membranes should be explained in detail.choice of induction agents is made according to the Bishops score which includes cervical lenght,effacement,dilatation and station of presenting part.The local availibility of the induction agent can influence the choice as well.
if the cervix is not favourable,preferred method of induction is by vaginal prostaglandins.fetal heart rate is monitered for 30-40 minutes before and after administeration of each dose.
Local protocols regarding the dosage in primiparous and multiparous women should be in place.If possible same person should carryout the vaginal assessment to establish a change.
If the cervix is favourable then artificial rupture of membrane can be carried out followed by syntocinon infusion depending on uterine activity.Continous monitering of fetal heart rate should be carried out with syntocinon infusion.The dosage of syntocinon should be adjusted according to the uterine activity,progress in labour,fetal wellbeing.facilities for adequate analgesia should be in place as these labours tend to be more painful.If possible same person should assess the progress in labour to avoid the discrepency.
The risks associated with IOL can be maternal and fetal.
maternal risks are increased need for analgesia as induced labour tend to be more painful.There is increased risk of instrumental delivery,c/section, and uterine rupture.
The fetal risks are primarily fetal distress,shoulder dystocia(increased association with instrumental delivery).
Posted by Green K.
a) Post date pregnancies carries a risk of intrauterine death due to placental insufficiency. Risk of meconium aspiration syndrome increases due to higher chance of fetus passing meconium as pregnancy advances. Sweep and stretch reduces the need for formal induction. It should ideally be done by the midwives in the community. It is more successful for multiparous patients due to relative favourbility of the cervix and done at 40 weeks for primiparous and 41 weeks for multiparous patients. Procedure may be painful and may cause bleeding. There is no recommended frequency for the procedure to be done.

Formal induction of labour with prostaglandin E2 tablets or gel may require repeated course depending on patient\'s response. It is more successful after a sweep and stretch. It carries a risk of uterine hyperstimulation and uterine rupture and therefore should ideally be done in hospital.

Rupture of membranes followed by syntocinon infusion is the other option if Bishop\'s score is favourable and artificial rupture of membrane feasible. Onset of labour may be delayed or slow initially. It is safer than induction with prostaglandin as the rate of syntocinon infusion is controllable.

b) Assess fetal condition by enquiring about fetal movements followed by abdominal palpation and measurement of symphyseal fundal height to estimate fetal size, presentation and fetal head relative to the maternal pelvic brim. Electronic fetal monitoring to confirm fetal wellbeing and an obstetric ultrasound to measure liqour volume and estimated fetal weight. If the parameters are abnormal for example intrauterine growth retardation with oligohydramnios, delivery may be more urgent and a Caesarean section may be needed.
A vaginal assessment to assess Bishop\'s score and to decide suitability for artificial rupture of membranes with syntocinon infusion or needs ripening of the cervix with prostaglandin. A sweep and stretch would be done with consent during the time of assessment as it increases the success of subsequent induction with prostaglandin. Prostaglandin E2 gel or tablet 1mg may be used and a cardiotocograph done before placement. Informed consent would be obtained before induction. Bishop\'s score would be assessed again 6 hours after the first prostin and repeated if not favourble. If Bishop\'s score is favourable and membrane rupture feasible, patient would be sent to the delivery suite for a rupture of membranes and syntocinon infusion if not having regular contractions. If there is favourable change in the Bishop\'s score after 2 prostins, a reassessment of the pregnancy should be done and Caesarean section considered for failure of induction.

c)Risk of hyperstimulation due to over-respnse to prostaglandins leading to fetal distress and risk of uterine rupture.
Posted by Gowrishankar S.
a).Postdated pregnancies are associated with increased perinatal mortality. Induction of labour(IOL) is recommended if the pregnancy progresses beyond 42 weeks. It is costeffective, associated with lower caesarean section and operative delivery rate and lower perinatal mortality. But some women may decline this as it can be seen as a medical intervention. The other options are membrane sweep and expectant management. Mambrane sweep is associated with reduction in duration of pregnancy. But it can cause discomfort and bleeding during examination. Expectant management is an option for women who declines IOL. Though this is likely to result in a favourable outcome, fetus should be monitored from 42 weeks with atleast twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth. The role of these investigations in reducing perinatal mortality has not been proven. In formation leaflet should be provided to help the woman in making a decision.

b) Once the woman accepts induction of labour(IOL), membrane sweep should be offered after excluding a low lying placenta.The woman should also be informed about options for pain relief in labour. If labour does not start the bishop’s score should be assessed and fetal well being should be checked with electronic fetal monitoring(EFM). If normal EFM, vaginal PGE2 can be offered in the form of gel, tablet or controlled release pessary. The woman should be warned about the risk of uterine hyperstimulation. The bishop’s score should be reassessed after 6 hours or 24 hours if a controlled release pessary is used. If contraction begins, then fetal wellbeing should be checked with EFM and intermittent auscultation can be used unless there is an indication for continuous EFM. If no progress after 1st dose of vaginal PGE2 a further dose can be given. If no progress in bishop’s score the general condition of the patient and the pregnancy should be reassessed. The fetal well being should be checked. The woman and the partner should be provided with support and options such as further attempt of IOL or caesarean section should be offered. This should be made according to patient’s wishes and clinical circumstances.

c) The risks associated with IOL in this case are uterine hyperstimulation and uterine rupture.
Posted by Chitra.s M.
Prolonged pregnancies are at an increased risk of perinatal mortality & morbidity.There is increase in the rate of antenatal & intrapartum fetal death after 40 weeks of gestation, though the absolute risk is small.The woman has to be counselled regarding the fetal risks of prolonged pregnancy.Induction of labour is offered between 40+0 to 40+6 weeks gestation or according to local unit protocols.The chance of caeserean section is not significantly increased in induction after 41 weeks.
The woman has to be offered a vaginal examination for assessment of cervical status.A membrane sweep is offered if the cervix is favourable to do so.She has to be informed what a membrane sweep is & that it reduces the need for a formal labour induction.She also should be informed that it might be painful & she might have some bleeding.
If the woman refuses a membrane sweep, her decision has to be respected.The reason for refusal can be sought & any fears allayed.She should be offered increased surveillance for fetal well being-twice weekly CTg & USg for amniotic fluid volume.
The discussion should be documented in case notes & information leaflet about labour induction given.
The reason for labour induction-postdated pregnancy,the time & place where the induction is going to take place has to be discussed,the exact timing taking into account the womans wishes.If outpatient induction is offered clear instuctions have to be given to report at the onset of contractions or in 6 hrs time.
Bisop score has to be assessed & documented prior to induction.Normal fetal heart rate has to confirmed.facility for continuous electronic fetal monitoring has to be present.
Pharmacological induction is with PGE2 gel(1mg) or sustained release pessary(3mg).She has to be monitored for uterine hyperstimulation. She is reassessed with onset of good contractions or in 6hrs time.Bishop score has to be documented & further doses of PGE2 given as per unit protocol.Fetal well being is monitored by continuous EFM.intracervical/extraamniotic PGE2 is not recommended for labour induction.
Even in the presence of a favourable bishop score ,amniotomy alone or amniotomy with oxytocin should not be offered as methods of labour induction.They are offred if there are contraindicatrions to PGs(eg-uterine hyperstimulation.)
It has to be recognised that induced labour is more likely to be painful than spontaneous labour & methods for pain relief discussed. Different strategies like nonpharmacological methods -deep breathing & relaxation, patient controlled analgesia & epidural analgesia offered.
If the woman does not enter into active labour with maximal doses of the preferred agent then further management of failed induction has to be discussed.She can be offerd tests of fetal well being & further attempt at induction later or Caeserean section .The womans wishes & unit protocols have to be taken into account.
The risks of labour induction are-maternal risks of uterine hyperstimulation,uterine rupture & failed induction necessitating ceserean section.The fetal risks are of cord prolapse with a high presenting part & FHR abnormalities in case of uterine hyperstimulation.
Posted by Chitra.s M.
sorry-induction of labour to be offered between 41+0 to 41+6 weeks
Posted by G. K.
A)
Postdates pregnancies i.e pregnancies that have gone beyond 42 weeks are associated with increased risk od perinatal morbidity and mortality due to placental insufficiency, meconium staining of liquor with risk of fetal meconium aspiration.Also there\'s increased risk of still birth associated with postdates pregnancy.
In addition, there\'s more chances of operative vaginal delivery, both instrumental and C/sec.Therefore it is justifiable to offer induction of labour to the patient under such circumstances. She should be councelled thoroughly and any verbal information should be backed up by written information as well.The patient should be inquired about the reason for declining induction and any grounds for anxiety explored and reassurance should be offered. A thorough obsteteric history should be taken with regards to the need for induction during previous pregnancies and any complications that were encounterd such as uterine hyperstimulation , since this will determine the method of choice for IOL in her case.
The options to be considered in this situation include a membrane sweep initially which tends to decrease the need for formal induction of labour(IOL) by 15-20%.At the same visit , the patient should be booked for induction in the next day or so if convenient for her. during the membrane sweep, her bishop score can be assessed to determine the best option for IOL. The recommended method of IOL is induction with prostaglandin E2 gel, pessary or tablet. If there was uterine hyperstimualtion with the use of prostaglandins during the previous pregnancies, amniotomy alone or in combination with syntocinon augmentation can be used provided the cervix is favourable with a bishop score of 6 or more.
B)The induction should be carried out in the morning when there is enough staff present on the labour ward for monitoring and care.Electronic fetal monitoring should be carried out prior to IOL to establish fetal well being.
Depending on the bishop score and after ruling out any risk for uterine hyperstimulation ,the patient can be induced with progtaglandin E2 preparation. If there are risks for uterine hyperstimulation and if the cervix is favourable, the labour can be induced with amniotomy with or without syntocinon .. If she begins spontaneous contractions which are adequate in intensity and frequency, she won\'t need syntocinon augmentation.She should be offered adequate pain relief either with pehidine or epidural analgesia since induced labours are quite painful. There should be continuous electronic fetal monitoring throughout the labour.
C)
The risks of IOL in this case can be failed induction, uterine hyperstimulation necessecitating the use of either intravenous ritodrine or subcutaneous terbutaline if IOL was carried out with PGE2, or discontinuation of of syntocinon infusion alongwith beta sympathomimetic tocolysis. The other risk is that of post partum haemorrhage with induced labours .
Posted by ASB -.
ASB
(a)Membrane sweep should be offered prior to induction of labour (IOL), at 40 weeks to nulliparous women and at 41 week to all women .This reduces the liklehood of formal IOL ,but may be associated with discomfort and vaginal bleeding . IOL should be offered to all women with uncomplicated pregnancy between 41 and 42 weeks .It is associated with reduced risks of perinatal mortality , meconium stained amniotic fluid and small decrease in risk of cesearean section (CS) compared to expectant managment . However , there are risks like failed induction, uterine hyperstimulation and uterine rupture . Expectant managment is offered to women who decline IOL. However,after 42 weeks , at least twice weekly cardiotocography (CTG) and ultrasound (US) for amniotic fluid should be performed .

(b)I would check placental site by US , then offer membrane sweep. If contraction do not begin, vaginal examination for Bishop score and electronic fetal monitoring (EFM) for fetal heart rate (FHR) pattern should be performed . If FHR is normal , I would offer IOL with vaginal prostaglandin (PG)E2 tablet, gel or controlled release pessary. Vaginal examination to monitor response after 6 hours of tablet or gel and after 24 hours of pessaries . If there are reasons that prevent use of PGE2 like risk of uterine hyperstimulation, amniotomy is an altrnative option but it should be avoided if fetal head is high to avoid risk of cord prolapse. When contractions begin , continous EFM followed by intermittent auscultation if FHR is normal .If uterine hyperstimulation develops , tocolytic therapy should be cosidered. If uterine rupture is suspected , delivery by emergency CS is indicated. In case of induction failure , alternative options should be discussed with the patient and decision taken in accordance to her wishes. Options include another trial of IOL or CS .

(c) Uterine hyperstimulation requiring tocolysis and uterine rupture requiring emmergency CS . Failed induction is another risk . If amniotomy is performed while head is high , there is risk of cord prolapse
Posted by Shamita S.
Post dated pregnancy is associated with increase in perinatal mortality rate,so women should be offered sweeping of membrane at term as it reduces the risks of pregancy going beyond 41wks.Women should be councelled for induction of labour at 41wks as it reduces the perinatal mortality rate and is not associated with increased rate of ceaserean section or operative vaginal deliveryif the cervix is made favourable ,if the patient opts to continue pregancy she should be managed by biweekly CTG and ultrasound estimation of maximum amniotic pool depth she should be well iformed that expectant management is associated with increase in perinatal mortality rate ,meconium stained liquor and incresed foetal surveillance .Monitoring the foetus with routine foetal movement count alone has not shown to reduce perinatal death,whereas CTG and measurement of amniotic fluid index has higher rate of ceaserean sections and meconium below the vocal cord and modified biophysical profile scoring results in abnormal results with no apparent benefit to the ,so there is no proven way of surveillance to idnetify at risk foetuses .The woman should be properly councelled and her decision should be followed.
Vaginal prostaglandinE2 ,in the form of gel ,tablet or controlled release pessaries is the preferred method of indution of labour .Before IOL bishops score should be assessed and foetsl heart rate pattern to be confirmed ,the recomended regimen would be one cycle of vaginal PGE2 gel or tablet followed by second dose after 6hrs controlled release pessary to be repeated after 24 hrs ,the bishops score to be reassesd after 6 hrs .If the induction fails the option of repest induction or caeserean section to be discussed with patient and decision to be taken by the consultant.IOL can be done in outpatient setting only if safety and support procedures are in place oterwise inpatient IOL is prefeerde,facilities should be available for monitoring of foetal heart rate and uterine contractions ,Women being offered IOL should be infomed that induced labour is likely to be more pinful than spontaneous labour and informed about the pain releif options in different settings .Amnitomy alone or with oxytocin should not be used as a primary method of induction unless there are specific reasons for not using prostaglandins .Other methods like use of ballon cathers ,i.v syntocinons alone ,vaginal nitric oxide donors are not accepted .
The risks of induction in this patient would be uterine hyperstimulation ,as the woman has previous two vaginal delivries ,she is also at a higher risk of uterine rupture ,and if the presenting part is not well engaged the chances of cord prolapse is high.
Posted by Naheed M.
A healthy 24 year old woman with two previous vaginal deliveries has been referred by her community midwife at 41+4 weeks gestation because she has declined induction of labour. Her pregnancy has been uncomplicated. (a) Discuss and justify the options for managing post-dates pregnancies [7 marks]. (b) Induction of labour is accepted. Describe your management of the process of induction of labour [11 marks]. (c) What are the risks associated with induction of labour in this case? [2 marks]

Woman should be informed about the risks risks associated with postdated pregnancy. There is increased risk of placental insufficiency, oligohydramnios, meconium stained liquor, fetal hypoxia, still birth and higher rate of perinatal morbidity and mortality. In addition, there is increased risk of operative delivery and emergency cesarean section.

Woman should be informed that inducton of labour reduces the risk of pstdated pregnancy associated complications (meconium stained liquor, fetal hypoxia, still birth) and operative delivery.
She should be given verbal and written (leaflet) information about available management options of induction.

The options of induction are: expectant, non-pharmocological,
pharmocological induction and surgical management.

If woman declines any intervention and accept expectant management she should be reassured that majority of deliveris take place in 4-5 days after 41 weeks of gestation. To avoid the risks of postdated pregnancy and timely identification of any complication close fetal surveillance is very important. She should observe fetal movements (not very reliable for fetal condition),twice weekly cardiotocography, weekly biophysical profile along with amniotic fluid volume (AFI should be less than 5 cm) and doppler ultrasound should be undertaken.

Nonpharmocological induction is undertaken through membrane sweeping; is assocaited with fewer postdated pregnancies if performed at term. This carries risk of maternal discomfort and sometimes cervical bleeding but is not associated with increased risk of fetal or maternal infection.

Medical induction option is widely used and includes prostaglandin E2 (tablet, gel and pessary form) and oxytocin infusion.

Misoprostol and mifepristone are other options but can be used in case of intrauterine dead fetus.

In case of failed conservative and medical induction options and any evidence of fetal compromise cesarean section can be employed according to the clinical situation.

B.
To choose method of inducton woman should be asked if there is any history of precipitated labour. They are at higher risk of uterine hyperstimulation. Woman should be informed about the risks and benefits associated with different induction methods.
After helping her make an informed decision and recording the conversation in notes suitable and accepted method of induction should be employed.
Before starting induction carditocography and bishop scoring should be checked and induction should be started. If she is on therapeutic dose of thromboprophylactic heparin the dose should be reduced to the prophylactic dose.

senior obstetrician, anaesthetist, neonatologist and labour team should be involved.

In case of failed induction with prostglandin E2 tablet or gel they can be repeated after 6 hours. The risks associated with induction should be borne in mind such as failed induction, increased pain and increased need of analgesia, inefficient labour, uterine hyperstimulation, fetal distress antepartum hemorrhage,rarely uterine rupture, blood transfusion and need of emergency delivery. Woman should be informed about these risks.

If cervix is favourably dilated oxytocin infusion is quiet effective option.

Continous electronic fetal monitoring is required.
There is increased need of analgesia in induced labours so adequate analgesia should be given.

Once labour starts it should be dealt as normal labour providing the woman support and monitoring. After delivery documentation should be completed and woman should be counselled about breast feeding and contraception.

C.
The risks of induction involved are: failed induction, abruptio placenta, inefficient labour, increased need of analgesics, uterine hyperstimulation and rarely rupture. Other risks may be emergency cesarean section and fetal distress.





Posted by tahira jabeen J.
this pt g3p2+0 was low risk preg till now as she is post term so she is high risk .since pt has declined iol her wishes should be respected.pt shouls be informed assosiated fetal risk like increase in still birth rate 6 time if preg more than 42 weeks ,risks of macrosomia& increase risk of intervention,increased risk of meconium stained liqour& meconium aspiration,etc so if pt wants conservative management she need regular fetal survillance.that is she needs to have ctg,biophysical profile ,liqour measurements,twice weekly as recomended by NICE .pt will be instructed to keep an eye on fetal movement if less than 10 in 12 hrs to report to hospital .although its role is not yet proved by evidence.if Bpp normal she can continue but if Bpp 4 she needs delivery.or if any problem with ctg also needs delivery.pt can be offered membrane sweeping asNICE recomends it & it will help a significant no of women to go into labour in 48 hrs .
now pt accepted iol she will be explained about process od iol
there are two types of iol mechanical & pharmalogical .mechanical is by membrane sweeping NICE has recomended it PGto have a sweeping at 40 weeks ,also in past there was use of osmotic dilators but no more used due to its side effects.by medicine there are differrenet prep rations lkie prostaglandins ,gel,tablets,sustained release prep & i/v pitocin .
pt will be advised to come in the morning,she will have ctg to assess fetal heart then abd exam to confirm presenting part,placntal position . then this prostin pge2 either gel or tablet will be given after vaginal examination if bishop score are less than 6then to insert pge2 ,tab is 3 mg maximum 2 doses,gel total 2 doses .will have review for progress of labour in 6 hrs time if not in labour can have second dose.but if bischop score more than 6 then can be induced with artificial rupture of membrane& piticin can be givento induce contractions but this arm also have some complications like cord prolapse if presenting part is high.pt shou;ld be explained that iol may be more painful so she will be given analgesia as she will wish i.e intra muscularor epidural.
pt will be informed about side effects of PGE2 can cause nausea, vomiting,giupet also can have hyper stimulation that is 5 or more contraction /10 min but can be treated bu salbutamol 250 mcg s/c ,.pt needs to have continous fetal heart monitoring when she will be in labour.may needs more analgesia. pt wishes will be considered at all times if she wants to continue iol or stop it. pt will be explained about complications of iol like failure of iol ,hyperstimulation,increased risk of instrumental delivery or c/s.
Posted by Dr Dyslexia V.
X

a. Options include expectant management, in which no active intervention are done but, regular CTG monitoring and ultrasound for reduction in amniotic fluid index till 42 weeks and then re-discuss regarding induction of labor. The need for vigilant monitoring should be informed as there is a higher risk of intrauterine hypoxic insult due to placental insufficiencies in post date placentas. Possibilities of going into spontaneous labor could occur while awaiting induction.

Informal form of induction could be offered such as membrane sweeping and cervical stretching. Patient should be informed this is very uncomfortable and pervaginal bleeding could be expected.

The other obvious options include induction of labor using prostaglandin or mechanical dialators. Based on studies, patient after 41 weeks should be given the option of induction as to reduce risk of operative delivery, shoulder dystocia and meconium aspiration syndrome in fetus. Clear documentation of patient’s wishes and delivery plan should be recorded and leaflets given in regards to induction and delivery.

b. Induction of labor could be done via prostaglandin E2 application or using mechanical dilators. The management of the process must adhere to guidelines and local protocols. Usually on admission the patient will be assessed of a full blood count for her hemoglobin status, levels of platlet and group screen and hold of 2 pint of blood is done. Abdominal examination done to assess fetal size, presentation and engagement. Non-engagement of head or non-cephalic presentation should be subjected to ultrasound to assess low lying placentas or abnormal presentation.

After that, a bishop scoring which include os dilatation, effacement, consistency, station and position determined. If bishop score not favorable, prostaglandin or mechanical dilators such as laminaria tent is placed in.

CTG monitoring of baseline prior induction and periodically after induction are important to assess for fetal distress or uterine hyperstimulation.

Regular vital sign monitoring should be done to look out for signs and symptoms as high presenting part and vaginal bleeding and low BP and tachycardia.

If bishop score if favorable then artificial rupture of membrane could be done and could be subjected to oxytocin induction.

c. Risk of induction of labor include failure of procedure which could end up in caesarean section. Risk of prostaglandin induction include uterine hyperstimulation which could cause fetal distress, placental abruption, post partum hemorrhage and uterine rupture. There is also risk of fetal infection. There is risk of increased operative vaginal delivery and shoulder dystocia.
Posted by drvimaladkm@yah K.
This particular pregnant woman having a postdated pregnancy with previous uncomplicated pregnancy is likely to have spontaneous delivery given a time. She has no previous H/O prolonged pregnancy where there is 30 to 40%chance of recurrence. However, there is a possibility of going for a prolonged pregnancy (& postmaturity)with its associated fetal risks of >ed perinatal morbidity & mortality, >d chances of meconium stained liquor & meconium aspiration syndrome & >ed C.Section rates. Maternal risks may also >e with higher incidences of C.sections & vaginal operative deliveries & Uterine dystocia. Hence options in this case is sweeping of memebranes or expectant line of management.(as she has declined IOL).
Her postdatism has to be confirmed first by correlating with her regular menstrual cycles with known LMP & 1st trimester (preferably at10 weeks) scan confirmed gestational age thereby reducing the risk of postmaturity or by atleast 2nd trimester scan( with in 20weeeks) with error of 5days in gestational age. Sweeping is then offered with its advantages as the woman may go for spontaneous delivery with less chances of IOL. But it may produce some discomfort &/ or bleeding with very less chances of infection. Sweeping may have to be repeated at intervals if Cervix is not favourable with good (>6) modified Bishop’s score.
Expectant line of management requires more monitoring of the woman with clinical assessment & at least twice CTG/week with maximum amniotic pool depth(vertical) by scan. Uterine artery Doppler & Biophysical profile may be required if any fetal risk occurs. . Psychologically mother may develop anxiety & apprehension regarding labour. Reoffer for IOL can be done again at 42 weeks. Caesarean section may become inevitable in cases of severe fetal compromise.
B) The woman has to be clinically assessed for presentation & engagement & Bishop score( for prognosis) after ruling out low lying placenta. Written consent is taken with explaination for the reason for IOL & methodology & place of IOL with its advantages & disadvantages. IOL decreases postmaturity & its associated risks & does not >e section rate. Labour analgesia has to be discussed with personal choice. Leaflet is provided.
Induction of labour is offered as Inpatient basis.Fetal assessment is done with admission 20mins CTG & PGE2 tabs (3mgs at interval of 6 hrs-2 doses)or gel or controlled –release pessary is given once for 24 hrs and for 1 hour postpessary CTG. Woman is further monitored for onset of labour with regular uterine contractions & intermittent FHR auscultation in low risk cases or with electronic fetal monitoring in cases of fetal compromise or with oxytocin usage. Amniotomy & Oxytocin augmentation may be required in cases of dystocia. 2nd stage of labour is conducted with episiotomy if needed. Active management of 3rd stage of labour is done with uterotonics & controlled cord traction to prevent PPH. In cases of foetal distress in 1st stage, caesarean section may be required or vaginal operative delivery may be expedited in 2nd stage of labour.
If there is failure of IOL, woman has to be reassessed & reoffered for IOL after a short interval of rest(for 24hrs) in the absence of any foetal or maternal compromise.
C) IOL produces more pain compared to spontaneous labour & is associated with drug side effects like hyperstimulation in some which is effectively treated with Terbutalin 250mcg. Other drug effects like pyrexia, nausea & vomiting may occur.Use of Oxytocics may produce hyponatremia in mother. Amniotomy may complicate with cord prolapse or abruption in cases of Polyhydramnios.
IOL is associated with PPH. Failure of IOL(3 to 5% with PGE2) may increase the chance of caesarean section.Grandmulties may have the risk of precipitate labour or uterine rupture especially withprevious caesareans. Neonatal hyperbilirubinemia is increased with IOL more so with prematures.
Vdkm.
Posted by S S.
The options for managing postdated pregnancy are induction of labour, expectant management and cesarean section.
Induction is usually preferred if there are no contraindications to it as there is increased risk of perinatal morbidity and mortality with postdated pregnancies especially after 42 weeks. These are fetal macrosomia and associated birth injuries, oligohydramnios, fetal distress and low apgars, meconium stained liquor, meconium aspiration and still birth. For mother postdates pregnancy means psychological stress and increased risk of operative delivery.
If induction is declined then a membrane sweep can be offered which increases the chance of spontaneous labour within a few days. Though it wont affect the route of delivery. It is uncomfortable and the woman can experience vaginal bleeding.
Expectant management beyond 42 weeks is by fetal suvellience by twice weekly CTG, umbilical artery dopplers, biophysical profile and estimation of amniotic fluid volume. however this does not gaurantee a successful outcome and fetal demise can still occur.
If none of the above is agreed then a cesarean section is the last option. It is associated with operative and anaesthetic complications. Psychologically it might be less stressful than waiting for induction or expextant management.
Whatever the managent, patient\'s concerns and choice should be taken into account and the discussion documented.

(b) Labour can be induced by either prostaglandins (gel, tablets and controlled release pessary), ARM with or without oxytocin or oxytocin alone. Membrane sweep offered. Patient is informed that she may experience pain and bleeding, and may go into spontaneous labour within a few days. Prior to commencing induction fetal and maternal assesment is done. fetal lie, presentation and engagement of presenting part is noted. Vaginal examination is done to calculate Bishop\'s score. CTG recorded for 30min. If Bishop\'s score is less than 6 then prostaglandin is used (1mg gel or 3mg tab or 10mg controlled release pessary). CTG recorded again for 30 min. consider tocolysis for hyperstimulation. If no progress in 6nrs than prostaglandin gel and tablet can be repeated upto a maximum of 3mg for gel ang 6mg for tab.
If Bishop\'s score is >6 , induce with ARM followed by oxytocin in 2 hrs if no contractions or progress is noted. If the head is unengaged then synto is startes first followed by ARM to aid in engagement. Caution is adviced for using synto in multiparas. Adequate pain relief and support is offered throughout. Regular assesments are done to note the progress of labour. In case of failed induction discuss the options of repeating the process or a Cesarean section.

(c) Risks of induction are related to the mother and the fetus. Risks to the fetus include fetal distress, meconim aspiration, shoulder dystocia and injury. Risks to the mothe include increased intervention, operative delivery, thromboembolism due to decreased mobility and stress.
Posted by L S.
a) First of all her past obstetric history in particular on her timing and duration of her labour, whether she was induced and any intrapartum complications explored. The reasons for declining induction and all other worries should be explored. She should first be counselled on risk of post dated pregnancies especially fetal mortality and morbidity. The risk of stillbirth was found to be increased from 1 in 3 at 37 completed weeks of gestation to 1 in 6 at 41 weeks gestation and doubles every week subsequently should be informed. She should be counselled on options which include expectant management for which due to the above risk will require close monitoring and review. This option is safe provided there is no signs of fetal distress by cardiotocography(CTG), amniotic volume however she should be counselled that these measurements have not improved fetal mortality rate. The next method is induction of labour via medical method with prostaglandin, artificial rupture of membrane(ARM) or oxytocin infusion. This has a higher success with increasing parity and with more favourable Bishops score. This requires continuous intrapartum surveillance and mother can be offered epidural for analgesia as it has lower pain threshold. The final method is caesarean section which carries both surgical, anaesthetic risk and post operative maternal morbidity.
b) She should be asked to determine day and time of induction. On the day agreed upon she will be admitted into the ward. Once admitted, the process of induction can be carried out based on Bishops score with the agreed local protocol for the method of induction on the score required either prostaglandin or if she is favourable for ARM. Pre induction CTG should be carried out as a baseline for fetal wellbeing. If she requires cervical ripening she will be inserted vaginal prostin 3mg not more than 6mg a day. She should be reviewed after 3 prostins by a senior consultant if she can be offered the 4th prostin or that she should be counselled on caesarean section for failed induction. She will require CTG 4 hourly during induction. She will be reviewed at end of 6 hours to decide on subsequent management either for another prostin or if she is favourable for ARM. Once she needs ARM she will be sent to the labour ward for continuous fetal monitoring and insertion of epidural if required. The partogram should be initiated once in the labour ward and she should be seen 2 hours after ARM to ensure adequate contraction or if she needs oxytocin infusion. Contraction should be optimised to 3 to 4 moderate in 10minutes. An agreed timing of review should be agreed upon usually 4 hourly or earlier if indicated. If oxytocin infusion is required, it will be started at 2 IU/min and increased slowly till optimal contraction is achieved. During oxytocin once the dose reaches 32 IU/min senior should be consultant on subsequent management. The patient should be counselled on an agreed time limit of alternative intervention if she does not deliver by the designated time and agree for caesarean section.
c) There is maternal risks which include uterine hyperstimulation, uterine rupture, increased need for
epidural analgesia and interventions like instrumental delivery, failure of induction necessitating caesarean section. Fetal risk includes fetal distress and increasing need for admission to neonatal unit.
Posted by Bgk H.
A.Prolonged pregnancy beyond 42 weeks is associated with maternal and fetal morbidity and mortality.She will have possible risk will be operative deliveries, psychological morbidity and perineal trauma. Fetal risks includes intrauterine death, meconeum aspiration syndrome and macrosomic baby.
When her date has been reclarified, she should be recouncelled and offered induction of labour to avoid the above mentioned risks. Since she has 2 previous vaginal deliveries, success rate of induction will be high up till 80% however it is not without risk. She need to be informed and aware abut themethod of induction and possible risk of IOL.
She can have the option ofcontinuing her pregnancy however she need to know the intrauterine death and increase antenatal surveillance. She need to have CTG done twice weekly and doppler ultrasound weekly done, however she should be aware none of these tests are reliable on predicting the fetal outcome. This will increase the total number of antenatal visits and proven not cost effective, However it may give higher maternal satisfaction.
Operative delivery which is LSCS is only on obstetrics indication and a request on it need to be addressed accordingly.
B.If induction of labour accepted, she should be explained regading the diferent methods of induction, benefits such as to avoid risk of macrosomic bby, and intrauterine death. The aim will be artificially initiate s the labour and ultimately delivery.
The procedure involves performing a vagina lexamination and scoring her cervical favourablity using Bishop scoring. Favourable cervix should be offered amniotomy and start on intravenous oxytocin induction simultaneously. It needs to be titrated up judiciously every 30 minutes to achive effective contraction. Continous CTG monitoring and effective analgesia should be offered.
If not favourable, prostaglandin induction should be offered. It involve applying prostaglandin at posterior fornix. She will then be ressessd in 6 hours. If still not favourable, another preparation should be given with the maximum total dose of 6mg perday only.
If favourable amniotomy should be done and start her on intravenous oxytocin. Continuos CTG monitoring should br offered and partogram should bestarted. Pimed review of progres should be done.
She should be given patient information sheet and given contact for support group.
C.Risk of induction include maternal and fetal risk. Maternal risk will beincrease pain morbidity and requirement of analgesia, uterine rupture, water intoxication and very small risk of failure of induction and need of opertive delivery if failed. Fetal risk includes fetl distress, cord prolapse during amniotomy, and neonatal jaundice
Posted by Seham S.
(a)prolonged pregnancy has incidence of 3-10% depending on us dating in early pregnancy.there is clear evidence that correct date of last menestrual period is associated with decrease incidence of induction.I will inform her that she may have spontaneous labour in the next few days,however post date pregnancy is accompanied with some complications as increase risk of perinatal mortality antenatal,intrapartum and neonatal.also, increase incidence of meconium aspiration,dystocia,operative vaginal deliveries and emergency C/S.sudden IUFD meight also happen.sweeping of membrane is one method of induction in which spontaneous labour pain may develop within 48h.woman should know that it meight be distressing procedure and can be followed by slight bleeding but no increase in infection rate.amniotomy followed by oxytocin if cervix is favorable for induction and opened.prostaglandins either (tab.,pessaries or gel) is another method of induction in which repeated doses may be needed.

(b)when labour pain started continous fetal monitoring is recommended.pateint may need more doses of analgesia.epidural analgesia can be offered.anaesthetist,neonatologist should be aware and included.hyperstimulation is managed with s.c terbutaline
if fetal distress developed emergency c/s is recommended.

(c)risk of IOL include failed induction,hyperstimulation of uterus.fetal distress and emergency c/s and its complications.
Posted by Seham S.
(a)cont. if pateint still refusing induction expectant managment is offered with twice weekly CTG ,umbilical artery doppler and us for amniotic fluid volume and BPP.
Posted by Sarika N.
POST DATE PREGNANCY INCREASE RISK OF PERINATAL MORBIDITY AND MORTALITY. ALL PREGNANT WOMEN SHOULD BE OFFERED INDUCTION OF LABOUR AT 42 WEEKS GESTATION AFTER CONFIRMATION OF THE GESTAION DATE ACCORDING TO LMP AND EARLY ULTRASOUND SCAN TO AVOID IATROGENIC PREMATURITY.
AT 41 WEEKS ANTENATAL VISIT BENEFITS AND RISK OF IOL SHOULD BE DISCUSSED AND CLEARLY DOCUMENTED IN HER NOTES AS WELL AS GIVING INFORMATION LEAFLET. MEMBRANES SWEEPING WILL BE OFFERED AS A NATURAL METHOD OF IOL AFTER EXCLUSION OF LOW LIE PLACENTA, IT IS OFTEN ACCOMPANIED WITH DISCOMFORT AND MILD BLEEDING BUT CAN REDUCE NUMBER OF CASES WHO WILL NEED FORMAL INDUCTION.
IOL BY PROSTAGLANDIN IS THE PREFRED METHOD IN CASES WITH UNFAVORABLE CERVIX BASED ON MODIFIED BISHOP SCORE BUT IT NEEDS PATIENT ADMISSION FOR FETAL MONITORING AND ANALGESIA. AND CARRIES RISK OF UTERINE HYPERSTIMULATION AND EMERGENCY CS FOR FETAL DISTRESS.

AMNIOTOMY IS ALWAYS INDICATED FOLLOWING CERVICAL EFFACEMENT BY PROSTGLANDIN OR AS A PRIMARY METHOD IF CERVIX WAS FAVORABLE AT INTIAL EXAMINATION ESPECILALLY IN PAROUS WOMEN. OXYTOCIN ALWAYS STARTED FOLLOWING AMNIOTOMY AND DOSE WILL BE TITRATED TO OBTAIN DESIRABLE CONTRACTIONS.
IN WOMEN WHO DECLINE IOL FURTHUR DISCUSSION WITH CONSULTANT IS OFTEN HELPFUL AND HER WORRIES ABOUT INDUCTION SHOULD BE DISCUSSED AND HER VIEWS SHOULD BE RESPECTED. ALL DISCUSSION POINTS SHOULD BE DOCUMENTED AND ALL RISK SHOULD BE EXPLIANED AND DOCUMENTED THEN EXPECTANT MANANGEMENT COULD BE OFFERED WHERE CTG, DOPPLER UMBLICAL ARTERY AND AMNIOTIC FLIUD VOLUME SHOULD BE ASSESSED TWICE WEEKLY, AND CONDITION WIL BE ASSESSED AGAIN BUT IT SHOULD BE EXPLAINED THEY DO NOT RELIABLY PREDICT ADVERSE OUTCOME.
B) WHEN IOL IS ACCEPTED PATIENT WILL BE ASSESSED AGAIN TO EVALUATE IF CERVICAL CONDITION CHANGED THEN SHE WILL HAVE ADMISSSION CTG FOR 30 MINUTES. PGE2 JEL OR TABLET WILL BE INSERTED IN POSTERIOR FORNIX IF UNFAVORABLE CERVIX AND BISHOP SCORE LESS THAN 4 THEN REPATED DOSE 6 HOURS LATER IF STILL UNVAFORABLE .ONCE CERVICAL CONDITION PERMIT AMNIOTOMY USUALLY AT BISHOP SCORE MORE THAN 8 AMNIOTOMY WILL BE DONE IN LABOUR WARD WHERE CONTINOUS FETAL MONITORING AND ADEQUATE ANALGESIA WILL BE GIVEN.
OXYTOCIN DOSES WILL BE TITRATED TO OBTAIN 3-4 CONTRACTIONS/10 MINUTERS AND PROGRESS OF LABOUR WILL BE MONITORED.
CASES OF FAILED PROSTAGLANDIN INDUCTION WILL NEED SENIOR CONSULTATION IN VIEW OF EITHER A REPEAT TRIAL OF IOL OR LSCS AND MATERNAL WISHES SHOULD BE RESPECTED.

C) RISK OF IOL ARE UTERINE HYPERSTIMULATION WITH SUBSEQUENT FETAL DISTRESS, RISK OPF UTERINE RUPURE ESPECIALLY IN MULTIPAROUS WOMEN .SECONDLY RISK OF FAILED IOL AND NEED FOR LSCS.
Posted by NAZ A.
(A) Post date pregnancy can be managed expectantly. Patient should be informed that most women will go into labour spontaneously by 42 she will be advised atleast twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth from 42 wks onward but expain that these method of antenatal monitoring are not reliable predictor of fetal compromise . Evidence support that Women with uncomplicated pregnancies should usually be offered induction of labour (IOL) between 41+0 and 42+0 weeks ,IOL decreases the risk of fetal and neonatal death, meconium aspiration,and increased caesarean section rate but may be failed to induce labour or can result in uterine hpyerstimulation,over benefits out weighs the risks. If she accepts IOL ,Offer membrane sweep( check for low-lying placental site first) it is an adjunct to induction it makes spontaneous labour more likely, and so reduces the need for formal induction of labour.it it is slightly uncomfortable and some patient have mild vaginal bleeding after it.Vaginal PGE2 is the preferred method of induction of labour, unless there are specific clinicalreasons for not using it (in particular the risk of uterine hyperstimulation). It should be administered as a gel, tablet or controlled-release pessary.
surgical method like amniotomy, alone or with oxytocin, as a primary method of induction should be offered unless there are specific reasons for not using PGE2 any other route of PGE2 adminstration other than vaginal is not recommended ,also use of vaginal nitriuos oxide doners, mechanical method of IOL, like balloon catheter ,laminara tent or herbal medicines,sexual intercourse ,hot baths not supported by evidence. Patient should be given time to ask any question ,to think & to discuss with her partner, written information should also be provided. Patient wishes and decision should be respected and documented properly.

(B) Patient can be induced as out patient setting only if safety & support procedure is available, I would admit the patient in consultant led hospital setting, time of induction would be according to patient preference & clinical circumstance. IOL should be started in morning time which gives more patient satisfaction.
.I check that patient has enough information and informed consent has been taken,I would discuss her preference for analgesia ,support in labour & water birth .I will do abdominal examination to confirm lie, presentation & engagement of fetus, bishop scoring and palpate for umbilical cord presentation during preliminary vaginal examination (avoid dislodging baby’s head),CTG before induction, to assess fetal wellbeing if normal then intermittent fetal heart auscultation after PGE2 Insertion. I will insert PGE2 tablet or gel: one dose, followed by a second dose after 6 hours if labour does not start (maximum two doses) pessary: one dose over 24 hours.I would reassess Bishop score 6 hours after each tablet or gel, or 24 hours after controlled-release pessary.
_ If woman goes home after tablet or gel, ask her to contact her obstetrician/midwife, when contractions begin or if she has had no contractions after 6 hours.
If failed induction further assessment of maternal fetal condition and plan for further intervention or conservative approach should be discussed and individualized according to patient wishes and clinical circumstances.

(C) risks associated are increased need for more analgesia in labour . failed induction. uterine hyperstimulation leading to fetal distress and rarely uterine rupture. risk of cord prolapse if amniotomy performed at high head.
Posted by Atashi S.
(a) Post dated pregnancy associated with increased risk of perinatal morbidity and mortality especially after 42 weeks. Prolonged pregnancy associated with risk of intrauterine foetal death, meconeum aspiration, foetal distress and need for emergency emergency C/S.Expectant management at this gestational age need foetal surveillance through CTG, amniotic fluid index, foetal kick chart, umbilical artery dopplar study although these parameter cannot reliably predict adverse foetal outcome. Induction of labor is to be selected after discussion with the pt including merits and demerits of all intervention. She should provide information leaflet. Cervical scoring is to be done to assess cervical condition which is need for successful outcome. Sweeping of the
membrane is to be discussed as it avoid the need for formal induction ,no risk of infection but it is associated with maternal discomfort and vaginal bleeding. If cervix is favourable then ARM is to be done. It is associated with maternal discomfort, vaginal bleeding, change of cord prolapse, risk of infection. Medical induction with prostaglandin in case when cervix is not favourable. Misoprostol vaginal tablet is more acceptable than oral as it is associated with GI side effect IV oxytocin induction can be done .it is more successful after ARM in case of favourable cervix. Information leaflet should be provided to the pt.
(b) Before going for induction. I will assess all maternal and foetal observation. I will note all vital sign. Bladder is to be evacuated. Per abdominal examination is to be done to assess foetal size, amount of liquor, to confirm lie and presentation of the foetus. Foetal heart rate is to be auscultated..P/V examination is to be done to note. Bishops scoring .Pt should be placed in a well equipt obstetric unit where continuous maternal and foetal monitoring is available. If cervical scoring<6 then It is better to use misoprostol preparation.. Vaginal tablet is preferable than oral to avoid GI side effect. Sweeping of the membrane can also be done for ripening of the cervix.. If cervix is favourable then ARM is to be done and colour of the liquor is to be noted. IV oxytocin drip is to be added to achieve effective uterine contraction. Maternal observation include pulse, BP, dehydration, urine output is to be monitored hourly or more frequently if needed. Continuous CTG monitoring is to be done .P/V examination is to be done 4hrly or earlier if any emergency arises. During misoprostol induction repeat dose can be used at 4 to 6 hr intervals if there is no progress and all maternal and foetal observation is satisfactory. Total 3 to 4 dose can be used. In oxytocin induction dose can be increased in escalating method to achieve 3 to 4 contraction per 10 minute.
All facilities should be kept ready in hand to do emergency C/S if needed. Information leaflet is to be provided to the patient.
(c)Maternal risk include uterine hyerstimulation, uterine rupture, post partem haemorrage, risk of emergency C/S..Foetal risks include foetal distress, IUD, meconeum aspiration.
Posted by SYAMALRANJAN S.
A healthy 24 year old woman with two previous vaginal deliveries has been referred by her community midwife at 41+4 weeks gestation because she has declined induction of labour. Her pregnancy has been uncomplicated. (a) Discuss and justify the options for managing post-dates pregnancies [7 marks]. (b) Induction of labour is accepted. Describe your management of the process of induction of labour [11 marks]. (c) What are the risks associated with induction of labour in this case? [2 marks]


Ans
a. Options are antenatal surveillance and awaiting spontaneous onset of labour. But monitoring by kick counts ,CTG, liquor volume , BPP, UADV are not always predict & prevent adverse fetal outcome. After 42 wks adverse fetal outcome are are increased compared to 40 wks.. Meconium staining of liquor & meconium aspiration syndrome , fetal distress, fetal acidosis, neonatal complications, cs rate, soulder dystocia are all increased . Data favours for IOL. All these discussion are documented. Further appointment & discussion about those risks should be done. Information leaflet explaining these information.
b. Thorough review of all previous reports & records including dating USG for confirmation of maturity. Full assessment by history , physical examination about maternal and fetal condition. Proper assessment of Bishop’s score. Options for IOL are membrane sweeping, ARM, PGS, oxytocin, stabilising induction. If cervix is favourable then membrane sweeping would reduce need for formal induction. ARM might be helpful. If cervix is not favourable then vaginal PGS . If head floating then option for stabiling induction would be helpful. Continuous CTG monitoring is indicated. Partogram will be helpful for detection of dystocia of labour. Information leaflet describing those matters. Woman’s wishes must be respected. Proper analgesia is important according to informed choice
c. Risks are hyperstimulations of uterus and fetal distress, nonprogress of labour, instrumental
delivery, PPH
Posted by walashawky S.
a)ask her about history of prolonged pregnancy as recurrence risk is 30% after one prevouse prolonged and 40%after two prolonged pregnancies any high risk features as prevouse still birth antepartum haemorrhage,hypertention..Ensure accurate pregnancy dating ,ask about early pregnancy scan,LMP is unreliabin in dating.Measure BP size of abdomen.Keep in mind increase in perinatal mortality and morbidity with prlonged pregnancy specialy after 42w due to placental insufficiancy. fetal riskes include meconeum stained liqour,meconeum aspiration,emergency cs,increased dystocia.maternal riskes inludeincreased risk of operative delivary,maternal anexiety.Assis
Posted by walashawky S.
cot. offer membrane sweeping as it is associated with duration of pregnancy and reduced frequency of pregnancy prolonged beyond 41 w.it is associated with discomfort uring examination bleeding irregular contractions.likehood of spontanouse delivary with in 48 hours.if she is not delivered offer either expectant managment or formal induction.induction at 41-42W reduce incedence of cs, meconeum stained liqour ,perinatal mortality.conservatve managment isalso likly to have favorable outcome.program of fetal surveilance including twice weekly CTG,umbilical artey doppler,assessment of liqour volume,method ofchoice is maximum volum pool depth of amniotic fliud ,BPD.THE ROLE OF THESES INVESTIGATIONS IN preventing perinata mortality not proven.40_50%of women will deliver 4-5 days after 42w.recommend formal induction if the woman not deliver at 42w. b)before induction assessment of fetal lie,presentaion,by abbdominal examination.VAGINAL EXAMINATIONand BISHOP SCORING if cervex is unfavorable and normal F.H.R by C.T.G offer formal induction with vaginal PGE2.check for low lying placental site before induction.offer PGas tablet ,gel or controlled release pessary.reasses BISHOP SCORE 6H after each tablet or gel or 24h after pessary.if contractions begine confirm fetal wellbeing by contanouse electronic monitoring .Provide adequate pain relief.If the cervix is favorable discuss amniotomy.discuss oxytocine which is best following ARM.PROVIDE WRITTEN INFORMATIONS. C)riskes associated with induction fetal riskes including fetal distress,inadvertant early delivary,neonatal jaundice.Maternal riskes include increase obstetric interventions,operative vaginal delivary cs .uterine hyper stimulation,requirments for anaelgesia increase,risk of uterine rupture and post partum haemorrhage,uterine infection and cord prolapse.explain that the benefits outweigh the riskes. offer written information.
Posted by AFSHEEN M.
A healthy 24 year old woman with two previous vaginal deliveries has been referred by her community midwife at 41+4 weeks gestation because she has declined induction of labour. Her pregnancy has been uncomplicated. (a) Discuss and justify the options for managing post-dates pregnancies [7 marks]. (b) Induction of labour is accepted. Describe your management of the process of induction of labour [11 marks]. (c) What are the risks associated with induction of labour in this case? [2 marks)



Accurate dating of pregnancy is of paramaount importance in prolonged pregnancy and I would confirm the dates by reviewing the casenotes,as to when the dating scan was performed, before discussing the options.
Once the dates are confirmed, I will discuss formal induction of labour at her gestation. The procedure is associated with reduced perinatal mortality, reduced incidence of meconium stained liquor and meconium aspiration and shoulder dystocia. Also, reduces maternal anxiety associated with prolonged preganancy; also reduces operative vaginal delivery rate including caesarean section due to failure to progress and fetal distress. However, is a medical intervention, which may be resented by many women. I would expolain the procedure involving prostin tablets/gel vaginally and provide her an information leaflet.
Cervical sweep is an alternative, if formal induction declined. It is usually offered to all women at term. It has been shown to decrease duration of pregnancy and frequency of prolonged pregnancy.It is not associated with increased risk of infection and may be repeated ,if required.owever, 7 sweeps will need to be performed to avoid one formal induction.It is also associated with irregular contractions and vaginal bleeding.
Expectant management beyond 42 weeks may be associated with favourable outcome, if monitored appropriately.40-50% women deliver within 4-5 days after 42 weeks. However, fetus should be monitored with at least twice weekly CTG and weekly or twice weekly doppler and liquor volume assessment.The role of these monitoring methods is not certain.


I will explain the process of induction of labour to the woman. CTG should be done prior to induction to confirm fetal well being.Prostin(prostaglandin E2) tablets/gel or pessaries are inserted vaginally and cervix assessed 6 hours later. Process should be started in the morning ideally. After 2 doses, further plan should be discussed with the woman regarding any further prostin required, according to the hospital protocols, if amniotomy is not possible. All inductions for prolonged pregnancy should be regarded as high risk and continuous CTG should be done. Options for analgesia should be discussed, including, entonox, pethidine and epidural once in established labour. Risks including failed induction and hyperstimulation, fetal distress and uterine rupture should be discussed. Verbal information should be supplemented with written informatio.



c- Possible risks are failed induction resulting in caesarean section. Also, uterine hyperstimulation, fetal distress and uterine rupture may also occur.
Posted by SUNDAY A.
sunday\'s answers

A) The options for managing post-dates pregnancies would take into consideration risk assessment of the pregnancy, fetal and maternal wellbeing, patient choice, local protocol and has to be individualised. The benefits and risks of the methods offerred must be discussed and documented in the notes and patient given information leaflets if available. Generally options include a conservative approach in which pregnancy is allowed to carry on beyond 42 weeks and patient would be offerred close monitoring with twice weekly CTGs and weekly scan for liquor volume. Approximately 40-50% of women would deliver 4-5days after 42 weeks but with increase risk of stillbirth despite fetal monitoring. The risk and benefit must be discussed with the patient. The second option is to offer a membrane sweep with the aim of achieving a spontaneous labour. There is increaserisk of vaginal bleeding and pain but high chance of success if patient agreeable to this. The last option is the use of prostaglandin( prostin) gel/tablets/pessary per vaginum in an inpatient setting combined with artificial rupture of membrane with or without oxytocin infusion. There is higher success rate with this regime with about 5% failure rate in multip and 20% failure rate in primiparous patients paticularly if offerred between 41-42 weeks of gestation. There is increased risk of discomfort and pain due to frequent vaginal examination and need for fetal monitoring.
B) Induction of labour should be conducted in the hospital setting and local protocol should be followed. The initial assessment of the patient should include confirmation of the gestational age , placenta location from dating and anomaly scans. The presentation, lie of the fetus should be confirmed and drug allergy checked. The patient understanding of the induction process and consent should be sought prior to induction. Any concerns, doubts should be addressed and her wishes respected. Thereafter the fetus should be monitored for ½ hour before and after prostaglandin (prostin) tablet /pessary / gel administered per vaginum (p.v) with documentation of the initial Bishop’s score.. Any suspicious features on the CTG or evidence of contraction would preclude the use of prostin. Further dose can be given as per protocol 6-8hours apart at doses not more than 4mg for prostin gel and 6mg for prostin tablet as per NICE guidelines. Bishop’s score of greater than 6 would be indicative of a favourable cervix at which artificial rupture of the membrane (ARM) can be attemped andsubsequent use of oxytocin infusion if required at least 6 hours from the last prostin dose. Labour can then be managed with continous fetal monitoring, regular vaginal assessment , adequate pain relief and one to one care. If unable to do ARM or cervix unfavourable after maximum prostin, then further management should be discussed with the patient and involving the consultant. Thereafter a caesarean section may be offered or repeat dose of prostin explaining the risk and benefits.
c) The risk involved would include failure of induction with recourse to caesarean section, risk of hyperstimulation of the uterus which may lead to fetal distress and obstetric intervention. The likelihood of causing more discomfort , pain is increased with frequent vaginal examination and maternal and fetal reaction to prostin and oxytocin infusion also a possibility.
Posted by Mohammad A.
(MA)
(a) Post date pregnancy can be managed by induction of labour or by expectant management. Patients should be provided both options with possible pros and each. Post date pregnancy should be confirmed firstly to avoid possible iatrogenic prematurity. This can be confirmed by sure for date of lat menstrual period or early ultrasound scan.
Induction of labour (IOL) as an active management should be offered for each pregnant lady of more than completed 41 weeks. It will decrease the incidence intra uterine foetal death. On the other hand the incidence of cesarean section will not significantly increase. Other risks of postdate includes, increase foetal weight with higher possibility of shoulder dystocia. Meconium stained liquour with higher incidence of meconium aspiration syndrome.
On the other hand, there is increase for pain related delivery course with increase of pain killer, narcotics, entonox and epidural. Time to delivery will be significantly longer than spontaneous labour. There is increase in instrumental delivery with IOL. Uterine hyperstimulation may occurred with use of either oxytocin or prostaglandin method. Continous monitoring should be offered and this may limit the activity of the patient.
Expectant management may be followed if patient insist against IOL despite the strong recommendation. Strict every other day monitoring of the baby with CTG and advice patient to observe foetal movements and to attend in case of movements decreased. In this case sweeping of membrane may be offered however it may cause some discomfort with possible minimal bleeding.

(b) Cervical assessment and evaluation of the favorability of the cervical score (Bishop’ score). Total of 5 findings should be evaluated of cervical dilatation, consistency, position, effacement and station of the head. Score can be calculated and method of induction can be discussed.
Artificial rupture of membrane (ARM) can be offered in case of score equal or more than 4, this may be enough to induce labour. Oxytocin may be added after one hour and titrated according to the local protocol. Dose can be doubled every 15 minutes till 3-4 over 10 minutes of moderate to strong contractions achieved. Maximum oxytocin infusion of 24 millinternational unit per hour. Coninous monitoring should be offered in active stage with syntocinon infusion. The frequency of internal examination significantly lower with this method of induction, so infection rate will be lower.
Prostaglandin(PG) use for IOL can offered for unfavourable cervix with score less than 4. PG E2 in for of tablet, jel of tape can be used. The dose can be repeated according to the local protocol if there is no change of maximum 3 doses. This may followed by ARM and/or oxytocinon infusion for augmentation. Uterine hyperstimulation may be expected with possibility of tocolytic use in form terbutaline subcutaneous. Cesarean section may be offered in case of failed induction.

(C) risks associated with IOL in this case, increase need of pain killer and increase time to delivery with stress. Also, frequent examination may increase the incidence of infection rate and possibility of chorioamniitis. Instrumental delivery will be significantly higher with IOL.
Posted by Harry B.
A) the options for managing post dated pregnancies are Induction of labour and expectant management
Induction of labour that includes Membrane sweeping, use of prostaglandin E2 and amniotomy with or without oxytocin infusion should be offered to women after 41 weeks of gestation in the absence of contraindications as IOL decreases the risks of macrosomia, associated fetal and maternal complications, meconium stained liquor, meconium aspiration syndrome and perinatal mortality.
If a woman declines IOL, then the reasons for declining IOL should be ascertained and any misconceptions addressed. Expectant management includes twice weekly CTGs and weekly assessment of liquor volume and the woman should be explained that there is an increased risk of perinatal mortality, especially after 43 weeks of gestation.
B) If the woman agrees for IOL, she should be offered membrane sweeping and a formal IOL should be booked after 48 - 72 hours. Membrane sweeping increases the chances of spontaneous onset of labour in multiparous women, but is associated with discomfort and vaginal bleeding. A further membrane sweeps may be required, but is not associated with other interventions.
Formal IOL depends on the favourability of the cervix (modified Bishop\'s score). With an unfavourable cervix, IOL by using PGE2 gel (1mg)/ tablet (3 mg)/ modified release pessary (10 mg) may be used. The situation should be reassessed after 6 hours unless SROM/PV bleeding/CTG abnormalities. The maximum dose of PGE2 gel is 3 mg, tablet is 6 mg and 10 mg pessary in 24 hours. The labour should be managed as low risk if she goes into spontaneous labour. Amniotomy should be offered if the cervix becomes favourable. Failed IOL should be managed by offering repeat procedure of IOL or caesarean section.
If the cervix is favourable (Bishop\'s score more than 6) amniotomy with or without oxytocin infusion will be the preferred method. continuous electronic fetal monitoring and analgesia in labour should be offered as there is a risk of fetal distress and uterine hyperstimulation. further reassesment should take place at regular intervals (4 hours) to assess the progress in labour.
C) The risks of IOL in this case are Failed IOL, Uterine hyperstimulation, Uterine rupture, fetal distress and incresed risks of shoulder dystocia, epidural analgesia and PPH.
Posted by H H.
Dear Paul, In the NICE guidelines, it says formal induction is by vaginal with vaginal prostaglandins , is this for all patients even if they have a favourable cervis with high Bishop score. We used to do amniotomy for favourable cervix as a method of induction. Much obliged
Posted by sutha  C.
SC

a) Prolonged pregnancy is associated with significant peinatal morbidity due to the reduced placental function towards term. In an uncomplicated pregnancy with no risk factors, the option of management could be either induction of labour or expectant management until the paitent goes into labour.

Prolonged pregnancy is associated with increase incidence of meconium stained liquor leading to meconium aspiration syndrome, oligohydroamnios and and sudden intrauterine death (IUD). Induction of labour can reduce these complications. Any decision for management is made together with the patient after she is explained all the risks and benefits. If she refuses induction of labour (IOL), the other option available is expectant management, though she should be advised that there is lack of reliablitity in the antenatal monitoring offered and lack of evidence that avoiding IOL can avoid cesarean section. Expectant management include cardiotocography and ultrasound assessment of amniotic fluid index (AFI).

On ultrasound assessment if AFI is less than 5 or the deepest pool is less than 1, she should be advised for delivery as there is increase risk of meconium aspiration syndrome, acidosis and birth asphyxia. If the AFI is normal, she is advised for monitoring every 3 days which is done together with a cardiotocography. Fetal movement activity is not a reliable too in reducing the incidence of sudden IUD, however it can be used in conjunction with other methods of monitoring to reduce the perinatal mortality rate.

b) Induction of labour consists of various methods. The choice of method would depend on the patients Bishop score. The Bishop score assess the state of the patients cervix.

If the Bishop Score is less than 6, she would need cervical ripening. Cervical ripening agents commonly used are intravaginal Prostaglandin E2 which is used every 6 hourly. Once her Bishop score is favourable, amniotomy is performed. Following amniotomy, depending of the progress of labour we can decide if she would need augmentation of the labour. If her progress is slow and is due to insufficient uterine contraction and cephalo pelvic disproportion has been ruled out, her labour can be augmented with oxytocin infusion with the dose titrated until she achievies optimal uterine contraction.

Other methods of cervical ripening would include mechanical method with the use of extraamniotic Foley’s catheter or extraamniotic saline infusion. Membrane sweeping is another method available, where endogenous prostaglandin is released with the hope of inducing labour. However it is associated with severe maternal discomfort. In patient with favourable cervix, method of induction are amniotomy with or without oxytocin infusion.

c) Risks associated with IOL are uterine hyperstimulation especially with the use of prostaglandin as compared to mechanical methods. There is also an increase risk of instrumental delivery. Caesarean section rate is increased due to poor progress of labour with its associated complications like post partum haemorrhage.
Posted by H H.
Dear paul, According to NICE amniotomy is not recomended as 1st option,so in a patient with a favourable cervix as assessed by Bishop score ,should we induce her with prostaglandins. much obliged