Induction of labour and artificial rupture of membranes

Induction of Labour...as a treatment for 'overdue' pregnancy

Sarah Stewart 2011http://www.flickr.com/photos/31929257@N00/2067613496

Definitions Term (as in a ‘normal’ and healthy gestation

period): is from 37 weeks to 42 weeks. Post dates: the pregnancy

has continued beyond the

decided due date ie. is over

40 weeks. Post term: the pregnancy has continued

beyond term ie. 42+ weeks.

Reed, 2010

http://www.flickr.com/photos/23524220@N00/3419755539

Most women birth between 41 and 42

weeks gestation

http://www.flickr.com/photos/48819968@N00/84515824

In Australia...

26.2% women have their labour induced 50% women are first time mums No effect on stillbirth rate Only half these women had normal birth One third had c/section

Patterson et al, 2011

Clinical guidelines recommend that women should be offered induction of labour between 41 and 42 weeks gestation

NICE, 2008

http://www.flickr.com/photos/10249607@N04/3333062178

Expectant management

Thought to be increased risk of fetal death if pregnancy lasts past 42 weeks but no clear evidence

500 IOL are needed to prevent 1 perinatal death

Evidence that there is increased risk of caesarean section and meconium-stained liquor after 41 weeks, but no increase in aspiration syndrome

Tracy, 2010

Clinical guidelines recommend surveillance after 42 weeks eg ultrasound scan and CTG, but no evidence to support efficacy of this

http://www.flickr.com/photos/75062596@N00/903573472

Membrane sweep

Sweeping the membranes is effective in bringing on labour before 41 weeks

Causes discomfort, some bleeding and irregular contractions.

8 membrane sweep need to be carried out to prevent 1 medical IOL

NICE recommends membrane sweep between 40 and 41 weeks pregnancy

Homoeopathy No evidence to support its use

http://www.flickr.com/photos/22198928@N00/841883683

Not enough evidence to support acupuncture

http://www.flickr.com/photos/51035747113@N01/10920514

Risks of induction of labour

Start of the 'cascade of intervention' More likely to need epidural and have

instrumental birth Increased risk of fetal distress 50% increase risk of caesarean section in

primiparous women for non-medical IOL

Tracey, 2010

http://farm6.static.flickr.com/5110/5619333529_4ff0fd7698.jpg

Contraindications

Maternal refusal Malpresentation Previous major surgery – some would argue previous

c-section CPD Cord prolapse Active genital herpes Placenta previa Severely compromised baby Breech baby

Induction of labour should not be started if Bishop Score is less than

6. A score of 8/9 indicates a

“favourable” cervix

http://medchrome.com/major/gynaeobstr/bishop-score-and-modified-bishop-score/

Prostin

Vaginal prostagladin gel is preferred method of IOL

Regime varies from hospital to hospital May cause fetal distress, cause discomfort and

take time for labour to start Side effect may be hyper-stimulation Placed in posterior fornice of cervix

Care of woman Informed consent Assessment of woman including health, history, EDD

and abdominal palpation Assessment of baby's health – CTG Bishop score Correct administration of drug Woman to rest on side for 30 mins. CTG when contractions started until fetail health is

confirmed Documentation

Johnson and Taylor, 2010

ARM Disrupts normal progression of

labour and often leads to other interventions

Should not be used in “normal” labour

May shorten labour by 1 hour but increase labour pain leading to increased use of analgesia eg epidural

Increased risk of fetal distress, cord prolapse and c/section

http://www.flickr.com/photos/scratch/249557231/

Contraindications

High presenting head Polyhydramnios Preterm labour Known vaginal infection Positive HIV Placenta previa Vas previa

http://www.flickr.com/photos/97328945@N00/4106718

Care of the woman Informed consent Exclude contraindications Maternal and fetal

assessment VE-rupture membranes with

amnihock Check fetal heart Share findings with woman Documentation

http://www.flickr.com/photos/48819968@N00/64798520

Oxytocin

Intravenous syntoconon is not as effective as vaginal prostagladin

Used with ARM is as effective as vaginal prostagladin

http://www.flickr.com/photos/44124425616@N01/262522417

Once ARM is performed, there's no going back

IVI is very restrictive Must be constantly

monitored Continuous CTG Very careful adherence to

syntocinon protocol Very diligent

documentation http://www.flickr.com/photos/40646519@N00/2318860224

Key points

Midwife's role is to be advocate – be mindful of society's attitudes to length of pregnancy

Education during ante natal period so woman can make informed decision

Be clear about what research says and what it doesn't say

Induction of labour starts cascade of intervention

Very careful monitoring of mother and baby Contemporaneous documentation

References

Johnson, R. & Taylor, W. (2010). Skills for midwifery practice. Edinburgh: Elsevier.

NICE. (2008). Induction of labour. Retrieved from http://guidance.nice.org.uk/CG70

http://onlinelibrary.wiley.com/doi/10.1111/j.1479-828X.2011.01339.x/full

Reed, R. (2010, September 16). Induction of Labour: balancing risks [web log message]. Retrieved from http://midwifethinking.com/2010/09/16/induction-of-

labour-balancing-risks.

Reed, R. (2011, July 17). Induction: a step by step guide [web log message]. Retrieved from http://midwifethinking.com/2011/07/17/induction-a-step-by-step-guide/

Tracey, S. (2010). Interventions in pregnancy, labour and birth. In S.Pairman, S.Tracy,

C.Thorogood, & J. Pincombe (Eds.). Midwifery. Preparation for practice

(pp863-970). Edinburgh: Elsevier

http://www.flickr.com/photos/32323502@N00/428401602

Sarah Stewart: [email protected]://sarah-stewart.blogspot.com