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MRCOG PART 2 SBAs and EMQs

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Essay 261 - Induction of labour

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		Posted by hoping .. Sun Feb 10, 2008 06:47 am
Induction of labour after 41 weeks gestation is recommended because it reduces risk of caesarean delivery compared to expectant management. It also reduces perinatal mortality rate. Induction of labour doesnot increase risk of instrumental delivery and is not associated with increased use of epidural analgesia. Induction of labour after 41 weeks is also costeffective compared to expectant management. I will discuss with patient that membrane sweep is associated with increased chances of delivering in following 48 hours to 7 days. It reduces need for formal induction.It doesnot increase infection risk. However it can cause discomfort and bleeding secondary to procedure. Other option is induction with prostaglandins which can be oral or vaginal. Preffered route is per vaginum. In absence of ruptured membranes it is agent of choice. It reduces duration from induction to vaginal delivery. It reduces caesarean section rate and use of epidural. It increases patient satisfaction. Induction of labour using syntocinon is equally effective option in presence of ruptured membranes and carries lesser risk of infection. Although epidural use increases. Both methods of induction carry 5% risk of hyperstimulation of uterus which can sometime cause fetal distress and require early delivery by caesarean section. With Oxytocin fetal heart rate and tocographic activity needs to be continuously monitored. I will respect patients opinion when she has been counselled and made informed decision. I will inform her that evidence suggests perinatal mortality increases significantly beyond 42 weeks and if she is undelivered at 42 weeks then frequent monitoring of baby should be performed. Monitoring doesnot reduce risks to baby but may aid in early identification of adverse signs and recounselling with mother can be done. Twice weekly monitoring of fetal heart and liquor volume is as effective as other complex monitoring assesments. Umblical artery doppler can be useful but commonly changes in blood flow are subtle. Mother should be advised to observe pattern of fetal movements and her blood pressure and urine should be checked atleast weekly.
		Posted by Elizabeth V. Sun Feb 10, 2008 09:11 am
A pregnancy that continues beyond 294 days since last mensrual period is considered a prolonged pregnancy and around 3-10% pregnanccies are prolonged. Induction of labour would be reccommended after 42 weeks ,provided her dates are correct or she has an early dating ultrasound confiming the gestation. Induction of labour would be reccommended at 42 weeks as it has been shown that pregnancies beyond 42weeks are associated with increased perinatal mortality,meconium stained liquor,dytocia and risk of emergency cesarean section due to fetal distress.These are attributed to declining placental function. It is also associated with increased risk of operative vaginal deliveries. Risks associated with induction of labour depends on the method used.prostaglandins are associated with hyperstimulation leading to fetal distress and the need for emergency cesarean section.This can be reversed with subcutaneous terbutaline and removal of the prostaglandin from the vagina. Oxytocin when used for induction can also cause hyperstimulation and in a multiparous patient rarely cause rupture uterus.This can be avoided by careful administration of oxytocin infusion ,continuous CTG monitoring and reducing the dose when hyperstimulation occurs. Failure to repond is another outcome.Repeated vaginal examination and and artificial rupture of membranes can be associated with endometritis. Method used for induction of labour depends on the cervical score of the patient.With a cervical score of less than 5 prostaglandins are reccommended .They are inserted vaginally and act to improve the score and thereby allow an artificial rupture of membranes . Oxytocin can be used as an infusion to stimulate cntractions and induce labour especially in the presence of ruptured membranes.This is done under continuous CTG monitoring.Artificial rupture of membranes is done in the presence of a favourable Bishop\'s score ( >5).Sweeping of membranes at term is associated with decreased frequency of pregnancy progressing beyond 41 weeks ( RR -0.62),but can be associated with discomfort and blood stained vaginal disharge.It is not associated with increased risk of infection. After having discussed the benefits and risks of induction if the patient declines induction then we have to honour patient\'s wishes and a plan for monitoring and review should be made in discussion with the patient.After 42 weeks monitor the fetus using CTG twice weekly and ultrasound for liqour volume and dopplers to be done weekly . This can be supplemented with maternal monitoring of fetal movements . None of these monitoring modalities have been of proven benefit in preventing perinatal mortality.30- 40 % women deliver a few days after 42 weeks.However a plan on a review date to re evaluate the risks if undelivered should be made.
		Posted by Srivas P. Sun Feb 10, 2008 09:44 am
a) The IOL at 41 weeks is associated with decrease in PNM and a decrease in C.S rate compared with expectant management while the rate of instrumental vaginal delivery is unaffected. The risk of meconium staining of liquor is also decreased. There are lower fetal heart rate abnormalities with induction at 41 wks. If she declines induction at 41 weeks she would need increased fetal surveillance which increases the costs compared to routine induction at 41 weeks. b) There is risk of failed induction and increased C.S due to this but the overall C.S rate by induction is still lesser compared to expectant management and labor following prolonged pregnancy. She is at risk of hyperstimulation following induction of labor with PGE2 or Oxytocin, causing persistent FHR abnormalities, which may not be reversed by uterine relaxants or stopping oxytocin and she may need emergency C.S. If her prior deliveries have been by C.S she is at greater risk of scar dehiscence or uterine rupture. The risks are more with PG compared to Oxytocin. If ARM done for induction she is at risk for cord prolapse, cord compression. c) Membrane sweeping is a simple, cost effective method and it increases her chance of spontaneous labor in 48 hrs and birth within 7 days. It also increases her response to induction if she chooses that method. It does not cause increase in maternal or neonatal infections but can be painful. PGE2 given by vaginal tablets or Gel is very effective in inducing labor within 24hrs, whether membranes are present or absent but there is risk of hyper stimulation which can be reversed by S/C terbutaline. Occasionally leftover tablet in vagina can be removed but this is not possible with gels. Vaginal tablets are preferred compared to gels because they are less invasive and is cheaper method. Patient can be ambulant after 30 mins of administration. Intravenous titrated Oxytocin is an effective method for induction of labor. Complication includes hyperstimulation, which can be reversed by stopping or reducing the dose. It is less effective than PGE2 when membranes are present. Patient is restricted to bed during infusion and this may not be liked if she likes moving around in labor. She would also need Continuous electronic fetal monitoring. Rarely, it can cause water intoxication in high doses. I/V Misoprostol (PGE1)is more effective than oxytocin and PGE2 in induction of labor but is still under review and trial due to fear of increased risk of hyperstimulation. If she is against any form of induction, nipple stimulation can be advocated. This is without any deleterious effects and decreases number of woman not in labor in 72 hrs. (d) I would explain to her the risks associated with her going into possible prolonged pregnancy beyond 42 weeks. I would explain risk of still birth at 3 per 3000 at 42 weeks and 6 per 3000 at 43 weeks, risk of macrosomia which increases risks of 3rd degree perineal tears, PPH and shoulder dystocia and risks of oligohydramnios, cord compression and birth asphyxia. She is also at risk of prolonged labor and increased C.S rate due to this and FHR abnormalities. These risks when explained are likely to increase maternal anxiety. I would allay her fears by explaining she can be managed by increased fetal surveillance beginning at 41 weeks if resources permit or from 42 weeks. Twice weekly CTG and US estimation of AFV is useful in assessing fetal well being. AFI is superior to estimation of deep pool depth. BPP is also useful, has 99.9% negative predictive value but is time consuming and requires skilled operator. I would do biweekly BPP if possible or a CTG+ AFV biweekly.Fetal Kick count chart is useful when used along with above. When she goes into labor I will have Continuous EFM, Scalp electrode after ROM and ensure pediatrician is present at delivery.
		Posted by S M. Sun Feb 10, 2008 11:41 am
The induction of labour after 41 completed weeks has the following advantages- It decreases peri natal mortality and morbidity. The risk of still birth increases from 1 in 3000 births at 37 weeks of gestation to 3 in 3000 at 42 weeks and 6 in 3000 at 43 weeks of gestation. There is greater risk of meconium stained liquor and fetal distress due to decrease liquor after 41 weeks of gestation. Also there is increase occurrence of fetal macrosomia and associated complications like shoulder dystocia. If accurate dating has not been performed in early pregnancy, Induction of labour can read to prematurity and the risks associated with it. Induction of labour can be associated with multiple vaginal examinations. And it can also be more painful. There is increased need for analgesia in general including increased use of epidural during labour. There is a chance that induction can fail, in which case the maternal and fetal situation would need to be reassessed and Caesarean section to be performed. Also there is increased association of induction with instrumental delivery. The methods of induction can be non pharmacological, pharmaceutical and surgical. Stretching and sweeping the cervix leads to local release of prostaglandins and can start labour. Prostaglandins in oral form (eg Mifepristone licenced only in cases of Intra uterine death) and vaginal tablets, gels and pessaries have been used of induction of labour. Oxytocin infusion is also used for induction and augmentation of labour. Artificial rupture of membranes can initiate labour. Laminaria tents and intrauterine balloons have been used in some countries for induction of labour but not in the UK. If a lady declines induction at 41 weeks, she should be counselled about the associated risks of increase perinatal mortality and morbidity associated with postmaturity. She should be given a kick chart and asked to keep a close eye on fetal movements and to come in asap if concerns. Also she should be seen twice every week in the day assessment unit for CTG and in order to measure the deepest pool of amniotic fluid. Any concerns regarding either should warrant delivery.
		Posted by Sarwat F. Sun Feb 10, 2008 03:31 pm
Induction of labour after 41 weeks of gestation reduces perinatal mortality rate. Also it reduces the risk of emergency caesarean section, instrumental vaginal delivery and meconium staining of liquor. It reduces the risk of neonatal admission to special care baby unit as well. So overall induction of labour in post term pregnancies is associated with reduction in maternal and perinatal morbidity and mortality. I will tell her that induction of labour is associated with certain risks which include uterine hyperstimulation, fetal distress and need for emergency caesarean section. It is also associated with the risk of uterine scar dehiscence or uterine rupture depending on parity of woman and past obstetric history. In case of induction of labour continuous CTG monitoring is done which is associated with reduced mobility of mother. Drugs used for induction of labour have certain side effects like fever, palpitations, diarrohea, need for analgesia and with oxytocin infusion, dilutional hyponatremia and hypotension. Artificial rupture of membranes is also associated with the risk of cord prolapse and amniotic fluid embolism rarely. Methods include medical and surgical methods of induction. Medical methods include prostaglandins either as pessary or gel and oxytocin infusion. Studies have shown that gel is more effective for induction as compared to pessaries. A dose of 2 mg gel is used for primiparas and 1 mg for multiparas repeated at interval of 6 to 8 houre. A CTG is done before and after giving gel. Maximum dose of gel is 5 mg for primiparas and 3 mg for multiparas however hospital protocol will be followed in deciding the doses. Surgical method of induction of labour includes artificial rupture of membranes. It also gives the opportunity to see the colour of liquor to assess fetal well being. However there are rare risks of cord prolapse and amniotic fluid embolism. If woman declines induction of labour I will tell her that as post term pregnancies are associated with high perinatal morbidity and mortality we need to monitor the baby. I will tell her that there is no proven method of surveillance under these circumstances however my suggestion would be twice weekly CTG and weekly ultrasound scan and umbilical Doppler. She should monitor fetal movements with the help of kick chart and report immediately if concerned. I will ask her if she would like induction if she does not deliver after a week or 10 days. I will document all the discussion and womans preferences in antenatal notes. I will also inform my consultant whether he wants to discuss with the woman. Written information regarding induction of labour will be given with discussion.
		Posted by Shatha A. Sun Feb 10, 2008 07:20 pm
a) around 10% of pregnancies will be prolonged pregnancies which is 42 completed weeks , prolonged pregnancy carry high risk of muconium stained liquor, high incidence of perinatal morbidity and high risk of sudden intrauterine death and latter sudden infant death , so induction of labour at 41 week is recommended as showen by randomised controlled trials that induction at 41 weeks will decrease the incidence of perinatal morbidity ,muconium stained liquor and decrease incidence of caesarean section(CS) in comparission to expectant management & it will not increase the incidence of operative vaginal delivery .written information about prolonged pregnancy should be given b) risks with induction of labour will depend on the previous obstetrical history ,and the method used. IOL associated with increase incidence of operative delivery ,there is risk of failed induction that will lead to delivery by CS , there is a risk of hyperstimulation of the uterus which will increase the risk of fetal distress that may necessitate delivery by emergency CS and this risk is higher with the use of prostaglandin E2 (PGE2) and less with the use of oxytocic drugs as it can be titrated according to uterine contractions, continuous fetal monitoring is indicated with effective analgesia .In presence of previous CS there is a risk of 0.7% rupture uterus , and this risk increases with use of PG . prolonged induction will carry a risk PPH c) methods used for induction of labour should be decided after assessment of fetal presentation , size & Bishop score of the cervix , also depend on previous obstetrical history .sweeping of membranes although its uncomfortable to patient it may be effective it will not carry any risk of infection and spontaneous labour may be started within 48 hr to 7 days, aminiotomy with or with out oxytocic drugs may be used if Bishop score more than 5, with titration of oxytocic drugs according to the labour room protocole so that contraction will not exceed 3-4 per 10 min. , induction with prostaglandin E2 preferably using vaginal route is another option which is preferable method especially if her previous deliveries were vaginal and in case of lower Bishop score. d) I will respect her decision , documentation of consultation and the patient?s wish in her file notes .close fetal surveillance twice weekly should be carried out by BPP (biophysical profile) which will include assessment of liquor volume and CTG ,with Doppler study of the umbilical artery once weekly to detect compromised fetus.
		Posted by Anna A. Sun Feb 10, 2008 07:35 pm
(a) Justify the recommendation to induce her labour [5 marks] Routine induction of labour (IOL) at 41 weeks is associated with reduced risk of caesarean section rate but she is not exposed to increased risk of instrumental delivery. The requirement of analgesia or abnormal pattern of fetal heart rate is not increased with routine IOL at 41 weeks. Instead, IOL at 41 weeks is associated with reduction of meonium staining of the amniotic fluid. IOL at 41 weeks also associated with reduction risk in perinatal mortality. (b) What will you tell her about the risks associated with induction of labour? [5 marks] She should know that IOL is associated with uterine hyperstimulation which lead to fetal heart rate abnormality. She should be fully informed that IOL is associated with increased risk of operative delivery in a form of instrumental delivery or caesarean section (CS). Risk of infection is also increased in IOL patient as compared to spontaneous labour. Risk of post partum haemorrhage and uterine ruptured (especially in grandmultip) is also increased in IOL patient. She should be told about the risk of failed IOL, thus SC should be anticipated. If rupture of membrane is done with high presenting part, it may be associated with cord prolapse. If oxytocin is used , care should be taken for risk of hyponatremia. Risk of neonatal jaundice should be explained to her. Written information should be provided to her. (c) What will you tell her about the methods used to induce labour? [5 marks] There is medical, mechanical and surgical of IOL. Prostglandin E2 (PGE2) tablet 3milligram or gel of 2milligram can be used in a patient with intact membrane or unfavorable cervix. Maximum use is 6miligrams in tablet PGE and 4milligram in PGE2 gel. Artificial of membrane followed with oxytocine infusion (start dose of 1-2milliunit per minute with maximum dose of 32milliunit perminute) is alternative agent for IOL in the presence rupture of membrane or favorable cervix. Sweep and stretch can be initiated at 40 weeks and it is associated with reduced risk of post date and increased the change of spontaneous labour. The use of Misoprostol (50microgram 4hly, maximum dose of five doses) has been used and associated with promising outcome but it is not licensed for IOL. Foley catheter or dilapan is the other mechanical method of IOL, but the success rate varies. Written information should be given to her. (d) Induction of labour is declined. How would you manage the rest of her pregnancy? [5 marks] If she decline IOL, a close fetal surveillance should taken place at 42 weeks onward. Biweekly CTG should be arranged. Ultrasound for deepest pool should be done weekly. BPP (biophysical profile) should be undertaken weekly. BPP is time consuming and consist of fetal movement, breathing pattern, fetal tone, AFI and CTG. She should be informed that the values of fetal surveillance are not clear and the risk of intrauterine death should be stress on her. Sweep and stretch should be offered to her as it can increase the chance of spontaneous labour. IOL should be strongly recommended if her pregnancy is beyond to 43 weeks as the perinatal mortality is increased to 6 in 1000.
		Posted by Sahathevan S. Sun Feb 10, 2008 07:53 pm
(a) Justify the recommendation to induce her labour [5 marks]. Induction of labour (IOL) recommended 41-42 weeks of pregnancy. This is because there is no proven benefit to health of the mother and /or baby to be gained by continuing the pregnancy after 41-42 weeks.This recommended clinical practice derived from a Canadian multi centre RCT and it also supported by . NICE and RCOG guidelines..IOL (41-42weeks) reduce the incidence of Caesarian section, Operative vaginal delivery. It has also shown the benefit of reduction of complications of fetal distress and meconium staining liquor.. As mechanism of fetal death in late term pregnancy is poorly understood it is not possible to offer complete reassurance(even after range of tests for fetal well-being) to the expectant mother who continue await sportaneous onset of labour. (b) What will you tell her about the risks associated with induction of labour? [5 marks] I will tell her that Induction of labour is associated with intrapartum and postpartum complications.Uterine hypertoninia and fetal distress are increased risk in induced labour.Increaded requirement of analgesia and prolongation of labour also recognized complications with IOL. Also induced labour is risk for operative interventions such as operative vaginal deliveries, Caesarian sections and fetal blood sampling. PPH is a recognized complication with IOL. Psycological morbidity is also a problem associated with failed induction or complications with IOL. (c) What will you tell her about the methods used to induce labour? [5 marks] Vaginal prostaglandin is given for ripening of the cervix and IOL. Amniotomy with or without oxytocin infusion is also a method of IOL. The choice of the method depends on individual patient. Previous vaginal deliveries and favorability of cervix for amniotomy play a role in choice of method. There is advantage s to use of prostaglandin for ripening the cervix compared with oxytocin alone. Increase successful vaginal delivery within 24 hrs and decreased incidence of C-section and reduced epidural usage are the benefit. Traditional methods of castor oil, acupuncture, and herbal remedies have not been recommended as they have no proven benefit. I Will provide Written information. (d) Induction of labour is declined. How would you manage the rest of her pregnancy? [5 marks] Successful management of these pregnancies depends upon effective counseling of the women and their full participation in the discoing making. She should understand. The implications of and conservative management of post maturity is associated with increased risk of perinatal mortality and morbidity. Women should Close fetal surveillance should be carried out. At least twice weekly CTG and USS for amniotic fluid volume (RCOG guideline recommendation) however none of these methods offering complete reassurance. However different investigations are carried out in practice. Indication for delivery with these investigations are an amniotic fluid index of <5cm or maximum pool depth <2cm, Biophysical score of 6/10 or less or abnormal umbilical artery Dopplers. Counseling should be backed up with written information.
		Posted by M M A. Mon Feb 11, 2008 06:12 am
a)Induction of labour is offered because there is an increased risk of antenatal and intrapartum still birth with progression of pregnancy beyond 41 weeks gestation. There is also increase incidence of meconium stained liquor with more incidence of operative delivery if induction done in later stage in pregnancy. Also it is associated with increase risk of neonatal mortality. Therefore; induction of labour at 41 weeks gestation is justified. b)We tell her generally the risk is small and she and her baby will be kept under close observation and monitoring so if any complication occur, it can be detected and dealt with as early as possible. Uterine stimulant drugs can lead to uterine hyperstimulation with subsequent fetal distress and she may need urgent delivery which carries risk of anaesthesia. Artificial rupture of membrane [ARM] can lead to cord compression when there will be reduction of liquor volumes also it can lead to cord prolapse but this is rare and occur when Arm is done while the presenting part is high. Incidence of cord prolapse increases also if there is polyhydramnios. In such cases placental abruption can occur also as a result of sudden release of liquor by ARM. Excessive use of oxytocin can lead to water retention with dilutional hyponatreamia and patient may develop confusion, convulsion or even coma and death. This risk can be decrease by using isotonic solutions like normal saline. She may got failure of induction with the need for caesarean delivery, more often if she didn\'t give vaginal birth before. Also there is increase risk of post partum haemorrhage because of long labour and exhausted uterus that result in uterine atony. c)We tell her that selection of the method used will be affected by her bishop score. Oxytocin intravenous infusion can be started with low or high dose regimens according to unit protocols until the contraction reach 3-4 per 10 minutes, each lasting for 30-40 seconds, continuous fetal monitoring will be required. If she has unfavorable cervix, prostaglandin is more preferable, it can be taken orally or as vaginal tables or gel, vaginal route is more successful in ripening the cervix. The dose can be repeated after 6 -8 hours. If taken orally it can cause side effects like nausea, vomiting, diarrhoea and abdominal pain. ARM can assist induction of labour, it shorten duration of labour without affecting mode of delivery. There are other mechanical methods like sweeping of membranes, it can lead to spontaneous labour within one week, it also reduce frequency of using other methods of induction and it is not associated with increase maternal or fetal infection. Other mechanical methods of dilating the cervix using intracervical folly\'s catheter or intracervical osmotic dilators can be used also and according to unit protocol. d)We advise her to do daily kick count. Also we advise for non stress test using CTG, twice per week, if there is 2 or more accelerations over 20 minutes, this can be considered reassuring. We do further ultrasound examination after one week to assess amount of liquor as reduced liquor can be a sign of placental insufficiency. Doppler Us of umbilical artery is done also to detect absent or reversed end diastolic flow, this may indicated fetal compromise and urgent delivery will be required, usually by caesarean section. We should inform the patient that there is no single fetal surveillance test that can assure fetal wellbeing and there is no test has been proven to be superior to other tests. If she doesn\'t have a spontaneous delivery within one week, the decision of induction of labour should be re-considered at 42 weeks gestation. The woman given patient information leaflet . If she still decline induction, we continue monitoring and we should document clearly the information given to her and her preferences to avoid future litigation.
		Posted by Reiaz M. Mon Feb 11, 2008 11:51 am
Induction of labour (IOL) for post term pregnancy is done in an attempt to decrese the perinatal morbidity and mortality associated with it. Pregnancy that continues beyond 42 completed weeks is associated with a 2 fold increase in the perinatal morbidity and mortality rate compared to those that deliver <42 weeks. Post term pregnancy is associated with an increased risk of meconium staining of liquor which can lead to meconium aspiration in the neonate. As pregnancy proceeds beyond 42 weeks placental functon becomes compromised which can lead to intrauterine demise. The risks of IOL are outweighed by the benefits and is thus justified. b) IOL is associated with both maternal and fetal risks. The risks vary depending on the method of induction used. Risks to the mother include an increased risk of operative vaginal delivery and its sequelae. There is also an increased risk of post partum haemorrhage as a result of uterine atony. IOL is associated with an increased risk of uterine hyperstimulation which can lead to fetal hypoxia and acidosis. IOL is also associated with an increased rate of caesarean section. Failed IOL is a risk that must be emphasised, but this is highly dependednt on the method of induction. There is a 5% failure rate when prostaglandins are used compared to a 25-30% failure rate with oxytocin alone. The patient should be supplied with information leaflets on IOL. c) Different methods have different success rates and risks associated with them. IOL can be performed using mechanical or hormonal methods. Mechanical methods include use of a Foleys catheter or laminaria. These are inserted into the vagina via a speculum examination. These are used to dilate the cervix. Amniotomy +/- oxytocin may be needed. Extraamniotic saline infusion is another method that can be used. Prostaglandins are the recommended agent for IOL in this patient. PGE2 is inserted into the vagina usually at night. The fetal heart rate is monitored for 20 minutes before and 1 hour following insertion. More than one dose may be needed. The interval between doses vary according to local protocols. She can be administered an epidural if she so desires. Oxytocin infusion may be needed. This will involve placement of a venous access. d) She is counseled to return to hospital if she notes any decrease in fetal movements, green vaginal discharge, vaginal bleeding or signs of labour. This patient requires regular monitoring from 42 weeks. An ultrasound scan is done to assess liquor volume. Decreased liquor volume is an indication for delivery. CTG is done twice weekly. The patient is advised not to use herbal medications to induce labour because of their unknown safety profile. She is advised that if she changes her mind IOL can still be performed.
		Posted by Shankaralingaia N. Mon Feb 11, 2008 10:21 pm
a)Induction after 14 days over her due date should be advised because of the increased risk of stillbirth.There is also increased perinatal morbidity after 42 weeks of gestation.Studies have shown the risk increases mainly due to placental insufficency.There is also risk of meconium aspiration on prolonged pregnancy.If there is rupture membranes and not in labour within 24 hrs there is increased risk of chorioamnionitis. Induction of labour reduces the risk of caesarean section and instrumental deliveries. b)Induction of labour can fail,due to failure to dilate after prostaglandins administration and thus needing caesarean section.Other risks are fetal distress and uterine rupture associated with overstimualtion. Artificial rupture of membranes can sometime cause cord prolapse in case of high head. Oxytocin may cause neonatal hyperbilirubinaemia. c)Methods used are membrane sweep,prostaglandins,artificial rupture of membrane(ARM) and syntocinon. Women can be offered membrane sweep and reassure there is no increased risk of maternal or fetal infection.Studies have shown that this could induce labour within 48 hrs to 7 days and reduce the chance of prolonged pregnancy. Secondly,intravaginal prosaglandins(PGE2) tablets or gels(dose depending on the local protocol)should be administered after assessing fetal condition and favourability of the cervix. Once dialation is achieved by the prostaglandins ARM is done. If no adequate contractions then start syntocinon as per the protocol.Continuos monitoring of the fetus is mandatory d)We should understand and alleviate her anxiety and understand the reasons for not wanting an induction.We should respect her views after understanding the risk and benefits and has made informed choice should be offered antenatal care in terms of CTG twice weekly and ultra sound scan for the liquor volume and biophysical profile. Advice her to monitor fetal movements and report if any reduced movements. See her in clinic more often and reiterate the risks and benefits. Documentation in the notes is important.
		Posted by Farina A. Tue Feb 12, 2008 03:51 am
Induction of labour in otherwise normal pregnancy is recommended after 41 completed weeks, as prolonged pregnancy is associated with increased incidence of oligohydramnios, meconium staining, fetal distress and still birth due to placental insufficiency. Before embarking upon induction of labour her dates should be reconfirmed. The regularity of menstrual cycle and surety of her dates is very important for revising her EDD. Early pregnancy dating scan should also be revised before a decision for inducing a labour. Decreased fetal movements is a subjective finding, however if present is an important consideration. Clinically apparent oligohydramnios is one of the finding adding to adverse outcome. Sonographic evidence of oligohydramnios and placental calcification adds to the risk of adverse pregnancy outcome. Antenatal wards are appropriate place of induction for an uncomplicated post dated pregnancy. Ensuring fetal wellbeing before and after induction is essential. Intermittent fetal monitoring before active labour is justified in these pregnancies. Failed induction with failure to progress and emergency CS is one of the most important risks that should be discussed with the patient in advance. Post dated pregnancy is at a higher risk of fetal distress during labour. Incidence of dysfunctional and prolonged labour is increased with induction of labour, however that of emergency CS and instrumental delivery is not. Increased. Uterine hypercontractility is common and may require higher doses of analgesia and subcutaneous terbutalin respectively. Sweeping of membranes is one of the methods with successful outcome, but requires a mutiparous os and a cooperative patient. Risk of PROM is increased however this method is associated with minimum adverse effects. Prostaglandin induction of labour is recommended for intact membranes . Dose of prostaglandin is determined according to parity and Bishop?s score. Oxytocin induction of labour is used for higher Bishop?s score and ruptured membranes however is associated with higher but reversible incidence of fetal distress. Amniotomy needs some dilatation of cervix and is effective method of induction. After appropriate counseling patient is advised to have a record of her fetal kick counts, although it is a subjective analysis but reduced fetal movements are important to take action. It is advised to attend the day care assessment unit to have a CTG on daily bases. Biweekly biophysical profile may be cost effective and umbilical artery Doppler studies gives an idea about uteroplacental circulation. Waiting for a spontaneous onset of labour beyond 42 weeks is not wise and patient should be told about the risks associated. Patient wishes should be respected.
		Posted by S M. Tue Feb 12, 2008 04:21 am
A healthy 32 year old woman has been referred to the antenatal clinic at 41 weeks gestation because she does not want her labour to be induced. Her pregnancy is otherwise normal. (a) Justify the recommendation to induce her labour [5 marks]. (b) What will you tell her about the risks associated with induction of labour? [5 marks](c) What will you tell her about the methods used to induce labour? [5 marks] (d) Induction of labour is declined. How would you manage the rest of her pregnancy? [5 marks] a) The labour should be induced at 41 weeks because this reduces the perinatal mortality rate. The risk of caesarean section is reduced by 13% and the incidence of meconium stained liquor is less. After 42 weeks gstation there is an increased risk of uteroplacental insufficiency. The risk of stillbirth increases to 1:1000 at 42 weeks and 1:500 at 43 weeks. Therefore by inducing labour, the mother is more likely to have a birth of a live infant. b) The maternal risks include anxiety and frustration since the process of induction may sometimes be slow. The rate of epidural analgesia is higher among women with induced labours. There is a greater chance of her having an instrumental delivery or caesarean section. The fetal risks include fetal distress and the inherent risks from instrumental deliveries. I will provide her with written information. c) A vaginal examination is done to assess the cervix. If the cervix is unfavourable, then the method of induction of labour is with a prostaglandin tablet or gel which is inserted vaginally and functions to ripen the cervix. This is done every 6 to 8 hours. The fetal heart is monitored intermittently. When the cervix is favourable, an artificial rupture of membranes is performed and an oxytocin infusion is commenced. During the oxytocin infusion there is continuous electronic fetal monitoring. I will provide written information. d) This can be a stressful time for both the obstetrician and the mother. This should be managed jointly with the general practitioner and her midwife. I would explain to the mother that their is no effective method of monitoring the fetus. However it would be advisable for her to attend the fetal assessment unit twice weekly for cardiotocography to be done to assess fetal wellbeing. Weekly ultrasound measurement of the deepest amniotic pool and dopplers of the umbilical artery for idenification of placental insufficiency. There should be at least 10 fetal movements in 12 hours. This is not a very effective method of monitoring fetal wellbeing. However, the mother should come in to hospital for monitoring if she observes less movements. I would offer to do a membrane sweep to stimulate natural hormones which has a 50% chance of starting spontaneous labour. Information on the risks shall be given and maternal wishes shall be followed.
		Posted by Hala T. Tue Feb 12, 2008 05:47 am
a)She should be offered induction of labour because it reduces perinatal mortality without an increase in caesarean section rates. The risk of stillbirth per thousand increases three fold in the continuing pregnancies at 42 weeks, and increases to six fold in the continuing pregnancies at 43 weeks , if compared to that at 37 weeks gestation. The progression of pregnancy beyond 42 weeks is associated with increased of meconium stained liquor , meconium aspiration , fetal distress in labour and the need for emergency caesarean section due to fetal distress and failure to progress . Postneonatal deaths are significantly increased in infants delivered at gestations greater than 41 weeks. There is no evidence that induction of labour ( IOL) increases the operative vaginal delivery , use of epidural or FHR abnormalities during labour. IOL is a cost-effective intervention. b) I will tell her that there is a possible increased risk of uterine hyperstimulation ,and hypertonic contractions which may result in a uterine rupture in multiparous women. I will tell her also, about the increased requirement of analgesia , prolongation of labour and increased risk of postpartum haemorrhage . She should also be explained that there is also, a possibility of failed induction of labour. c)I will tell her that ,membrane sweeping has been shown to increase the chances of labour starting naturally within 48 hours and can reduce the need for other methods of induction IOL . Membrane sweeping can be performed through a circular movement of the mid-wife\'s finger just inside the cervix. If she had agreed for IOL ,she should be offered membrane sweeping before other methods are used. It may cause some discomfort or bleeding , but it will not cause any harm to her fetus and it will not increase the chance of infection. She should know that it is not recommended if her membranes had ruptured. The second option is using prostaglandins which are drugs that help to induce labour by encouraging the cervix to soften and shorten(ripen). PGE2 are normally given as tablet or gel that is inserted into the vagina . This is to be done in hospital on an antenatal ward. More than one dose may be needed . Doses should only be given every 6-8 hrs.If the membranes have not yet ruptured PGE2 are the recommended method of induction. This is the case whether this is the first pregnancy or not ,and whether the cervix is ripe or not. Before induction with PGE2 , the FHR should be checked . After being given PGE2 ,she should lie down for at least 30 min. Once uterine contractions started , the mid-wife should monitor FHR using CTG cardiotocography. Once uterine contractions established ,the CTG shpuld be discontinued and she can move around. PGE2 can cause the uterus to contract too much which may affect the pattern FHR . If this happens she should be asked to lie on her left side. She may be given subcutaneous terbutaline drug to help relax the uterus. Another method is using Oxytocin which should be given in the hospital in the labour ward.This drug encourages contractions,and it given through a drip IV infusion.Once a regular contractions is established ( 3-4 in 10 min.), the rate of infusion can often be adjusted until the baby is delivered. If membranes had ruptured PGE2 and oxytocin are shown to be equally effective methods of IOL. While oxytocin is given, FHR should be monitored continuously.If membranes are intact amniotomy may done through a hole to break the membranme( forewater ). IOL involves assessment of the cervix ( Bishop\'s score).An epidural may be inserted to relief pain. If PGE2 had already been given per vaginum, oxytocin should not be given at least for 6 hours. d)Expectant management may be undertaken if IOL is declined.Serial fetal surveillance should be initiated which include twice weekly CTG, and measurement of single deepest pool of liquor ( NICE guideline recommendation).Although such tests have the advantage of taking less time than other tests, there is no evidence for improved perinatal outcome. The woman\'s wishes should be taken into account in reaching a final decision. Written information should be provided.
		Posted by Azza S. Tue Feb 12, 2008 09:08 pm
To induce labour the gestation age should be corrected according to earliest dating scan, as this is significantly reduces the number of induction for prolonged pregnancies. There is significant evidence to show that induction of labour at 41+6 gestation age associated with less perinatal death [ante/ intra-partum,& neonatal], operative delivery [ caesarean section-C/S-, instrumental vaginal delivery], and meconium stained liquor. Induction of labour [IOL] is a medication of labour which may not be acceptable by some women. There is an indication for continuous monitoring when establish in labour so restricting mobility. IOL especially with prostaglandin is associated with increased risk of uterine hyper stimulation leading to fetal distress and necessitating more interventions. IOL especially with synticinon is associated with increased pain. Iatrogenic preterm labour- if gestational age not correctly calculated- leading to increase risk of respiratory morbidity in the new-born. Failure of IOL will necessitate an emergency C/S. Emergency C/S carries increased risks of morbidity and mortality to both mother and fetus compared to an elective C/S. Prostaglandin is available in different preparation, forms and route of administration. It is effective with favorable or unfavorable cervical finding according to Bishop score. It is associated with high success rate , less pain , less need for analgesia and more maternal satisfaction. Artificial rupture of the membranes [ARM] when the cervix is favorable is another method of IOL. Especially in multiparous it is likely to be effective without the need to add synticinon. If contraction failed to occur after ARM, synticinon will be added. Synticinon is another way of IOL. It is preferred to be through an infusion pump to minimize fluid over load as it has an anti-diuretic effect. The rate titrated against uterine contraction aiming for 3-4 contractions per 10 minutes. Synticinon is associated with increased pain, and need of analgesia and decreased in maternal satisfaction. Mechanical methods of IOL like sweeping/striping of the membranes or inflated catheter balloons. Sweeping/striping of the membranes is associated with decrease number of women undelivered at 42GA, decrease number of formal induction of labour without an increase in infection rate. It is associated with discomfort, vaginal bleeding and irregular contractions. The patient should be informed that most of pregnancies will not be complicated and 40-50% will delivered before 42+6 GA but there is increased risks of stillbirth, perinatal death, meconium stain liquor &meconium aspiration, increased risks of dystocia and operative delivery. As fetal risks are increased probably due to placental insufficiency, increased fetal surveillance is needed. There is no superior way and no one method is effective, so it is reasonable to adopt multiple methods. Fetal heart monitoring [CTG] twice per week, ultrasound for amniotic fluid & umbilical artery Doppler and biophysical profile. Follow-up appointments weekly. If she agreed for sweeping/striping of the membranes it should be offered. When presented in labour continuous monitoring is advised as it is high risk . There is increased risk of intrapartum asphyxia, acidosis and perinatal mortality. Monitoring the progress of labour and fetal wellbeing epically if meconium stain liquor or no liquor.
		Posted by Idris O. Wed Feb 13, 2008 12:59 am
a) I would confirm the gestational age with an early ultrasound scan done before 20weeks to prevent iatrogenic prematurity. I would inform her the benefit of induction of labour. Induction of labour is associated with stimulation of uterine contractions and save delivery of the baby. It is highly recommended after 41 weeks to reduce the risk of perinatal mortality and morbidity which increases after 42weeks.The risk of perinatal mortality increases from 1/3000 at 37weeks to 3/3000 at 42weeks. This increases 6x at 43weeks. This increase is due to reduced placental function which reduces the oxygen delivery from the placenta. This is associated with an increased risk of oligohydramnios, meconium staining of the liquor and meconium aspiration. b)The maternal risks include increased uterine contractions with increased need for analgesia. This is associated with the risk of hyperstimulation and risk of uterine rupture. There is a risk of failed induction of labour with an increased likelihood of c-section. The fetal risks include fetal distress from hyperstimulation. The prostaglandin may cause pyrexia in labour. The oxytocin may cause fluid retention if hypotonic fluid is used in labour and NNJ in the baby after birth.I would offer her information leaflet on induction of labour. c)There are medical and surgical methods of induction of labour. Membrane sweeping is usually offered at 41weeks. This mimics spontaneous labour by release of endogenous prostaglandin which causes cervical effacement and uterine contractions. Usually effective within 48-72h. It is associated with mild discomfort and bleeding. Amniotomy is a surgical method of induction of labour. It allows access to the colour of the liquor. It promotes good application of the head on the cervix and increases the efficiency of uterine contractions. It shortens the duration of labour without affecting the outcome. Prostaglandins is usually administered intravaginally though can be given intacervical every 6h. It causes cervical softening and increased sensitivity of the uterus to oxytocin. It may cause fever and diarrhoea in labour. Oxytocin is usually titrated to achieve 3-4 uterine contractions in 10minutes. It improves the efficiency of uterine contractions but may cause hyperstimulation and uterine rupture. I would offer her information leaflet on induction of labour. d) I would ask her the reason she?s declining induction of labour and address the issues. I would inform her pregnancy beyond 42 weeks is associated with an increased risk of perinatal mortality and morbidity including stillbirth. I would offer her twice weekly CTG and liquor volume assessment. She should be aware of the limitations of this tests in predicting fetal wellbeing. An abnormal CTG or oligohydramnios would be an indication for delivery. If all is well she would be offered induction of labour after 43weeks.
		Posted by a P. Wed Feb 13, 2008 03:09 am
a.Induction of labour is the intiation of uterine contactions to produce cervical effacement and dilatation resulting in vaginal delivery; average rate in the UK is 20%. Prolonged pregnancy (>41 weeks) is the most common indication. The post-term trial in 1992 indicated a small significant reduction of perinatal mortality and less obstetric intervention with routine induction offered after 41 weeks. Written information is given to the patient outlining the reasons for induction. b. Failure of induction may occur if no progress occurs following attempted ripening of the cervix. The situation is reviewed with the patient and a decision made for a further attempt at induction the following day or days later punctuated by fetal surveillance. Uterine hyperstimulation may occur leading to fetal hypoxia and death. This may be minimised by performing a cardiotocograph before induction and proceeding only if it is normal. Uterine hyperstimulation may be treated by placing the patient on her side, administering oxygen and tocolysis with subcutaneous terbutaline. Fetal immaturity may occur if an accurate dating ultrasound is unavailable or the dates are miscalculated. This is reduced by reviewing the notes carefully prior to arrangement and admission for the procedure. Amniotomy may result in a small risk of chorioamnionitis, kept to a minimum by commencing oxytocin at or soon after amniotomy to reduce the induction to delivery interval. Electrolyte imbalance may occur with prolonged use of high doses of oxytocin due to fluid overload and hyponatraemia. Strict adherence to local protocols should reduce this complication. The use of oxytocin places the patient at risk of uterine atony and postpartum haemmorrhage. Active management of the third stage of labour employing 6-8 hours of oxytocic infusion facilitates prevention. There is an increased incidence of neonatal jaundice with oxytocin but is not cinically significant. Written infoomation describing the risks of induction of labour is given to the patient. c. The method employed for induction of labour is dependent upon abdominal examination assessing fetal lie, presentation and engagement of the presenting part together with the status of the cervix upon vaginal assessment. This is recorded and tabulated by means of the Bishop\'s score which provides a visual assessment of progress during induction. Membrane sweeping is performed if the cervix is dilated one finger\'s breadth thereby allowing the membranes to be stripped from the internal os and part of the lower uterine segment. It reduces the numbers of women who remain undelivered within a week. Membrane sweeping releases endogenous prostaglandins to ripen the cervix, can be uncomfortable and may result in a blood-stained discharge. Amniotomy is performed if the cervix is favourable; 80-90% of women go into labour within 24 hours. Medical methods of induction as prostaglandins may be given orally, intravenously, intracervically of vaginally. The most popular method due to ease of administration, efficacy and relatively fewer side effects compared with the other routes, is prostaglandin E2 gel or tablets 1mg or 2 mg, depending on parity.Dose intervals are 6 hourly and up to 3 applications are given. A slow release preparation is available and may be removed if hyperstimulation supervenes. A cardiotocograph is performed before and after the procedure to detect signs of fetal distress. If the membranes have ruptured already, an oxytocin infusion may be commenced on labour ward. Oxytocin is diluted in either a crystalloid or 5% dextrose-saline and the dose titrate carefully via a pump to produce effective contractions and minimise hyperstimulation. Continuous fetal heart rate monitoring is employed to detect fetal distress and approprate analgesia is offered. d. If the patient is fully informed of the risks of declining induction, conservative management is possible. This may be in the form of daily CTG which is only predictive of fetal health for 24 hours, measurement of liquor volume thrice weekly or a biophysical profile which is technically demanding and may be time consuming for the sonographer and patient. The patient is given written information and advised to return if she has any concerns including reduced fetal movements (a fetal kick chart may be helpful). The patient sholud return to clinic the following week to reassess her views on induction. However, this is dependent upon patient compliance and all advice should be documented, dated and signed.
		Posted by rachael L. Wed Feb 13, 2008 10:06 am
Induction of labour in a woman who is over 41 weeks gestation is carried out to achieve delivery prior to 42 weeks gestation. This is done because there is a significant increase in perinatal mortality from 1 in 1000 ongoing pregnancies at 42 weeks gestation to 2 in1000 at 43 weeks. In addition induction carried out after 41 weeks reduces perinatal mortality without increasing the caesarean section rate. Induction of labour involves one or more of the following: membrane sweeping, cervical ripening with prostaglandin E2, artificial rupture of membranes (ARM) and oxytocin infusion. The risks associated with membrane sweeping are minimal and they are discomfort during the procedure and mild vaginal bleeding. There is no additional risk of infection to the patient or her unborn baby. The main risk associated with prostaglandin and oxytocin administration is uterine hypercontractility which can cause fetal distress. Measures can be taken to reverse this but if not effective then urgent delivery may be required. There may be failure to induce labour if cervical ripening does not occur and ARM is not possible or cervical dilatation does not occur in spite of oxytocin infusion. Delivery by caesarean section will be required. Membrane sweeping increases chance of spontaneous labour within 48 hours. It is carried out in the antenatal clinic by the midwife or obstetrician after expected date of delivery. If the cervix is unfavourable the patient will require admission for cervical ripening with prostaglandin vaginal tablets or gel to ripen usually up to 2 doses 6-8 hours apart. As this patient is low risk this can be performed the antenatal ward. Electronic fetal monitoring is carried out prior each dose and with onset of contractions. Once cervix is favourable then ARM is carried out on the labour ward. This can precipitate uterine contractions. However if this does not occur then an oxytocin infusion will be started to achieve optimal contraction i.e. 3-4 contractions every 10 minutes. Continuous fetal monitoring is carried out once an oxytocin infusion is in progress. Written information should be given regarding the induction process and contact details should be given. The patient should be advised to take note of fetal kick count and if she experiences less than 10 movements in a 12 hour period then she should contact the day assessment unit or labour ward to make arrangements for CTG monitoring and ultrasound for amniotic fluid index if required. From 42 weeks gestation fetal surveillance should be increased with regular CTG monitoring and amniotic fluid index assessment at least twice weekly. If any there are abnormalities in the investigations then delivery should be strongly advised. The patient should be reassured that she can change her mind at any time.
		Posted by Gulfreen J. Wed Feb 13, 2008 07:46 pm
a) Prolonged prgnancy is gestation beyond 42 weeks. Evidence shows that it is associated with incresed perinatal morbidity and mortality, there a policy of induction of labour at 41 - 42 weeks is recommended. Fetal risks due to decreased uteroplacental circulation include oligohydriamnios, reduced fetal growth, meconium stained liquor, meconium aspiration syndrome, axphyxia and stillbirth. Due normal placental perfusion fetal macrosomia with resultant birth trauma including shoulder dystocia and neurological damage may occur. Mother is at increased risk of caesarean section, operative vaginal delivery, prolonged labour, perineal trauma. With policy of expectant management withfetal monitorring is associated with maternal anxiety and cost travel and time off work for twice weekly check-ups. There is no evidence of the best protocol and tests for the fetal surveillence in prolonged pregnancies. Evidence has shown that there is 4 fold increased risk of stillbirth and 3 fold risk of neonatal death after 42 weeks. More babies are born with low apgar score and admission in neonatal intensive care unit is increased with its related cost and organizational implications. Therefore due fetal, maternal and neonatal risks and lack of evidence for best method of fetal surveillance induction of labour (IOL) at 41 - 42 weeks is recommended. b) IOL is an intervention carried out with pharmacological agents, surgical or mechanical methods, depending on the state of the patient\'s cervix. There are certain risks associated with each method of induction. Prostaglandin E2 vaginal pessary is the most commonly used agent because of its safety profile. Failed induction occurs in 3% of cases and generally results in delivery by caesarean section. Uterine hyperstimulation would result in fetal compromise. There is a risk of caesarean section for failed induction or fetal distress. Cord prolapse and placental abruption are rare complications which may occur after surgical IOL by amniotomy. There is also a risk of chorioamnionitis and fetal infection with prolonged rupture of membranes. Hyponatremia, fluid and electrolyte imbalance and hyperbilirubinemia in baby may occur with prolonged use of oxytocinon infusion. Generally, IOL is a safe procedure where benefits outweighs the risks. c) Method of IOl include pharmacological, surgical and mechical methods. Variety of pharmacological agents have been used for IOL orally, parentally or as vaginal pessaries. most commonly used are prostaglandin(PG) E2, PGE1 analogue -misoprostol,and oxytocinon. Mifepristone, interluekin-8, nitric oxide donors and relaxin are under trial. Agents like castor oil and herbs are also used but there is no evidence to support their use. Each drug has its own risks and benefits and their use is dependent on the bishop\'s score determined by her state of cervix. Prostaglandins are resgarded as safe method used even when bishop score is less than 5 may result in uterine hyperstimulation and fetal distress but are associated with no increase in caesarean section (C/S) or perinatal morbidity or mortality. Oxytocinon is adminstrated by infusion when bishop score is more than 5. It restricts mobility of patient and prolonged use is associated with hyponatremia, fluid and electrolyte imbalance, But is an effective method in presence of irregular contractions and a ripe cervix. Surgical method by amniotomy is used when bishop score is more than 8 with or without oxytocinon, is generally safe with a small risk of infection and rarely due to sudeen decompression placental abruption or cord prolapse. mechanical method include intracervical / extraamniotic placement of foley\'s catheter or lamineria tents etc but are not popular due to loss success rate and maternal discomfort. d) If expectant management is the option she choices, I would counsel her that she would be required to visit Day assessment unit (DAU) twice weekly for test for fetal well being. There are a number of tests that are available but none of them are associated with a significant reduction in perinatal morbidity or martality and may be associated with an increase in rate of intervention. Neither is the best frequency or timing to begin these fetal surveillance tests known but are generally started at 42 weeks onwards. Twice weekly Non stress cardiotocography (NS CTG) with assessment of liquor volume by amniotic fluid index (AFI < 5 cm) or deepest amniontic fluid volume pocket < 2 cm is regarded as helpful as more sofisticated tests in detecting compromised fetuses requiring immediate delivery by IOL or caesarean section. other tests include fetal movement charting by the patient, is a simple method but associated with false positive and false positive results. Contraction stress test is invasive and requires oxytocinon to be given to see if if fetal compromise appears with stress. Viboacoustic test is lacks evidence to supports its clinical use. Biophysical profile (BPP) includes assessment of fetal tone, breathing movements, body movements, CTG and liqour volume with total score of 10. A score of below 6 is an indication for delivery. it is done for 20-40 minutes therefore is time consuming and requires expertise to for correct interpretation. Doppler umbilical artery waveform is a good predictor of fetal distress but facility is not available in every centre. There is a good chance that with appropriate fetal monitoring she wait till she goes into spontaneous labour or in case of any sign of fetal distress deliver by IOL or C/S. Whatever the case her labour should be monitored with continous electronic fetal monitoring and delivery by a senior obstetrician to deal with any untoward event such as intrapartum fetal distress or shoulder dystocia. After delivery she will be counselled that prolonged pregnancy is associated with 20-30 % recurrebce rate.
		Posted by SUDHA N. Thu Feb 14, 2008 10:52 am
a)Prolonged pregnancy is associated with increased perinatal mortality and morbidity.Check patient\'s notes for parity and any medical problems in the antenatal period.Confirm that the EDD is according to the booking scan. The reasons for recommending induction of labour (IOL) are: 1)Stillbirth rate rises it is 1/3000 at 37 weeks, 3/3000 at 42 weeks and 6/3000 at 43weeks.This rise from 42 weeks is worrying.This is because the placental function is on the decline. 2)Trials comparing routine IOL after41 weeks with expectant management showed a decrease in perinatal mortality rate without increase in Caesarean section rate.Hence the ideal time for IOL is 41-42weeks. 3)IOL had no effect on instruemental delivery rate, use of epidural or fetal heart rate abnormalities during labour.The incidence of meconium staining of liquor was noted to be less. Patient\'s fears and concerns should be addressed. b)There are risks associated with IOL like hyperstimulation.This can occur in 1% of patients.Cord prolapse and abruption can occor after amniotomy, though the incidence of this is low.Post partum haemorrhage (PPH) has a higher incidence.About 3-5% of patients fail to respond to IOL.The fetal problems seen are hyperbilirubinaemia (mild),this is because of oxytocin or following ventouse delivery. c)There are various ways of inducing patients,it depends on the dilatation of the cervix.Sweeping of membranes this involces inserting a finger in the cervical canal and moving it along the cervix,releases natural prostaglandins.About50% patients are likely to go into spontaneous labour in the following 48hrs.Amniotomy can be performed if cervix is dilated,this is followed by augmentation using oxytocin.It is commenced in a pump at the rateof 1-2 mu/min and increased every 30 mins to maximum of 32mu/min. Oxytocin is then titrated to 3-4 contractions every 10mins. ProstaglandinE2 can be used orally but unfortunately vomiting and diarrhea limit this use.ProstaglandinE2 gel is given intravaginally,this was better accepted because the gastrointestinal side effects were minimum and plasma levels were higher.The maximum dose is 4mg (2mg,&1mg &1mg)in primigravida, and 3mg (1mg,1mg,1mg)in multiparous.This will depend according to the local policy.Dose is given according to Bishop score. Patients are reviewed 6hrs after the first dose.Prostaglandin helps to soften the cervix and dilates it.Cervix when dilated upto 2cms an amniotomy is carried out on Labour ward and augmentation is done with oxytocin..ProstaglandinE2 tablets the success rate was low.Misoprostol was tried for IOL but the incidence of uterine hypertonus was high and also of PPH. d)The mechanism by which fetal death occurs is not known.There is hence no consensus regarding monitoring of these patients.The placental function is on the decline after 42weeks and this will be reflected by liqour measurement.The vertical pool depth is measured and if <2cms will need delivery, because it will have effect on the fetal heart, which will show decelerations.After 42weeks, these patients should be monitored twice weekly for CTG and maximum pool depth.Doppler measurements of umbilical vessels if suggests compromise will need delivery.Biophysical profile is not supported by evidence.
		Posted by Maud V. Thu Feb 14, 2008 12:47 pm
a) There is an increased risk of antepartum, intrapartum and neonatal death when pregnancy proceeds beyond 42 weeks gestation. There is also an increased risk of meconium stained liquor and meconium aspiration. There is a higher risk of fetal distress, resulting in a higher risk for the need of caesaren section or instrumental delivery. There is also an increased risk of dystocia and failure to progress in labour, which also increases the risk for need of caesarean section and the risks associated with section. All these risks are lower when labour is induced at 42 weeks gestation compared with allowing the pregnancy to continue. b) Induction of labour is safe and effective, but is associated with a risk of failure. It may take several days from start of induction untill delivery. The medication used to induce labour and cause vaginal soreness, making vaginal examinations painfull. The uterus may be overstimulated, causing fetal and maternal distress. Once labour is established, continuous fetal monitoring is advised. c) A dating scan from early pregancy will be checked to ensure the gestation is correct and induction is advised at 42 weeks. A vaginal examination will be undertaken to assess favourability of the cervix. If the membranes cannot be ruptured, a prostaglandin pessary or gel will be inserted vaginally and the examination repeated 6 hours later. A second pessary or gel may be required. Once the cervix is dilated enough to rupture the membranes, the woman will go to the delivery suite to have them ruptured. this is not painfull for her nor for the fetus. She might, however, find the examination while rupturing the membranes uncomfortable. If the contraction 2 hours following rupture of membranes are not frequent and regular enough, an oxytocin drip will be started. This will be gradually titrated to give regular contraction, 4 in every 10 minutes and lasting about 45 seconds. the advantage of the drip, is that it can be reduced or stopped when the contractions become too frequent or if the fetus becomes distressed. She will have regular examinations to assess progress in labour. all in all the induction may take a couple of days, or may be a lot quicker and this depends partly on how favourable the cervix is at the start of induction. d) Information leafelts about induction of labour must be given to her to read. A biophysical profile, including AFI measurement and CTG, and also umbilical artery dopplers are performed twice a week to monitor the fetus. A membrane sweep can be offered at 41 and again at 42 weeks. This may set off labour in 1 out of 7 women who undergo this. The woman should have open access and encouraged to come in if she has reduced fetal movements, pain, bleeding or clear or green vaginal loss. She should be seen regurlary by a senior obstetrician to discuss the option of induction again. She has to be able to make an informed decision and her wishes should be taken into account.
		Posted by Dr seema jain J. Thu Feb 14, 2008 07:26 pm
a)I will tell her that there is a 3-fold increase in still birth rate and a 2-fold increase in neonatal and postneonatal mortality rates.Meconium staining of the amniotic fluid and need for intrapartum fetal blood sampling are much more common.Other fetal risks include intrapartum fetal hypoxia resulting in fetal acidosis,neonatal seizures and perinatal death .Birth trauma and shoulder dystocia also are more common.Maternal risks include increased operative delivery rate and postpartum hemorrhage.Maternal trauma to the perineum because of instrumental delivery and shoulder dystocia can occur.It is also associated with con siderable psychological morbidity. b)Induction of labour can be associated with maternal and fetal risks depending on the method that is used..Amniotomy may be associated with cord prolapse if the presenting part has not entered the pelvis and abruption placenta because of sudden drainage of liquor.Failed induction of labour can occur in 35% of cases when only oxytocin is used and in 3-5% when prostaglandins are used.Hyponatremia can occur as a consequence of prolonged intravenous oxytocin which can also lead to electrolyte disturbances in the baby.There is a risk of hyperstimulation of 1:500 inductions with use of oxytocin and prostaglandins.There is a higher risk of postpartum haemorrhage.Rarely uterine rupture can occur.Neonatal jaundice following use of oxytocin can occur. c)I will tell her that there are mechanical and biochemical methods of induction of labour.The traditionally used methods of induction of labour like castor oil, acupuncture,herbal remedies are not advocated.Membrane sweeping may be associated with little discomfort and frequent contractions following the procedure and a little vaginal bleeding but it is one of the safest methods.Upto 88% of women will go into labor following amniotomy within 24 hours.Prostaglandins can lead to increased successful vaginal delivery within 24 hours,decreased incidence of caesarean and decreased use of epidural analgesia.Misoprostol is an affective induction agent but is unlicensed for labor induction.Oxytocin infusion started after amniotomy can lead to shorter induction delivery interval.The other agents under research are nitric oxide donors,relaxin and mifepristone.I will tell her that it is not necessary that only one method is used and that different methods can be used sequentially.I will discuss with her that in event of failed induction of labour, management can be in in form of awaiting onset of spontaneous labour,further attempt at induction or caesarean section. d)I will tell counsel her that there is no single test which can offer complete reassurance and she may need to undergo a battery of tests for fetal assessment till she delivers .The commonly offered tests will include twice weekly CTG and ultrasound for amniotic fluid volume.An amniotic fluid index of less than 5 cm or maximum pool death of less than 2 cm are indications for delivery.Biophysical profile can be used for assessment of the baby and a score of 6/10 or less and an abnormal umbilical artery Doppler would be a reason for delivery.
		Posted by Shankaralingaia N. Sat Feb 16, 2008 02:17 am
Hi paul, You have not checked my answer plaese could you look into it. Nethra