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    Induction Lecture Fmdrl Induction Lecture Fmdrl Presentation Transcript

    • Getting Things Started… Cervical Ripening and Labor Induction Jennifer Frank MD Fox Valley FMR Program
    • The best teachers…
      • Are our patients.
        • Case 1: 36 yo G2P1 at 39 weeks for social induction.
          • VBAC
          • Cytotec for cervical ripening
        • Case 2: 29 yo G1 at 40 +2 weeks for social induction
          • Cytotec for cervical ripening
    • Take home points (or learning objectives)
      • Cervical ripening, labor induction, and labor augmentation carry risks that are potentially serious to mom and baby and must be weighed by the potential benefit.
      • There is good evidence to direct the safe use of cervical ripening agents and agents used for labor induction and labor augmentation.
      • There are clinical indications when labor induction (+/- cervical ripening) is appropriate.
    • Indications for Labor Induction
      • Maternal and fetal indications
        • Placental abruption
        • Chorioamnionitis
        • Fetal demise
        • Gestational hypertension, preeclampsia, eclampsia
        • Premature ROM
        • Postterm pregnancy
        • Maternal medical indications
        • Fetal compromise (e.g. IUGR)
    • Indications for Induction
      • Other types of indications
        • Risk of rapid labor
        • Distance from hospital
        • Psychosocial indications
      • ACOG Practice Guideline No. 10. Induction of labor.
    • Contraindications to Labor Induction
      • Vasa previa
      • Complete placenta previa
      • Transverse fetal lie
      • Umbilical cord prolapse
      • Previous transfundal uterine surgery
      • ACOG Practice Guideline No. 10. Induction of labor.
    • Additional Contraindications
      • Absolute
        • Pelvic structural abnormality
        • Active genital herpes infection
        • Invasive cervical cancer
      • Relative
        • Abnormal FHT
        • Breech presentation
        • Maternal heart disease
        • Multifetal pregnancy
        • Polyhydramnios
        • Presenting part above pelvic inlet
        • Severe maternal hypertension
      Harman JH, Kim A. Current trends in cervical ripening and labor induction. AFP 1999;60:477-84.
    • Successful Labor Induction
      • Different definitions of success
        • Achieve vaginal delivery in specified time (12-24 hours)
        • Achieve active labor within a specified time
        • Achieve active labor
    • Factors Predicting Success
      • Cervical status
        • Traditional Bishop score > 9
        • Favorable score varies from > 5 to > 8
        • Inverse relationship b/w cervical score and length of latent phase of labor
        • Increased risk of cesarean delivery with “unfavorable” cervix (generally < 5)
      • Crane JM. Factors predicting labor induction success: A critical analysis 2006;
      • Clin Obstet Gynecol 49;573-84.
    • Maternal Factors
      • Maternal characteristics
        • Parity
          • Variable evidence for the weight this has on predicting delivery within 24 hours
        • Height
          • Association between taller women and increased chance of vaginal delivery within 12-24 hours of starting labor induction
        • Weight
          • Lower weight – more likely to be successful
        • Age
          • Younger women are more likely to be successful
    • Fetal Factors
      • Higher birth weights (>3.5 kg) associated with increased risk for failed induction (lower rate of vaginal delivery within 24 hours)
      • Increasing gestational age associate with increased likelihood of labor induction success
    • Fetal maturity
      • Criteria for establishing fetal maturity
        •   Fetal heart tones documented for at least 20 weeks by nonelectronic fetoscope or for 30 weeks by Doppler
        • At least 36 weeks since a positive HCG (serum or urine)
        • At least 39 weeks' gestation based on crown-rump length performed at 6–11 weeks' gestation
        • At least 39 weeks' gestation based on ultrasound measurement at 12–20 weeks' gestation
      • Sanchez-Ramos L. Induction of labor. Obstet Gynecol Clin North Am - 01-JUN-2005; 32(2): 181-200, viii
    • Cervical Ripening
      • Softening, effacement, dilation preceding active labor
      • Prostaglandins play an unknown role in mediating cervical ripening
      • When is it needed?
        • “Unripe cervix” based on cervical score (usually < 6 on Bishop score)
    • Bishop score ___ Soft Med Firm Consistency ___ Anter Mid Post Position +1 to +2 -1 or 0 -2 -3 Station 80 60-70 40-50 0-30 Effacement (%) 5-6 3-4 1-2 0 Dilation 3 2 1 0 Factor
    • Assessing Cervix
      • TVUS
        • More objective
        • Not superior to Bishop score in meta-analysis
      • Fetal fibronectin
        • May bind placenta and membranes to decidua
        • Presence associated with preterm birth
        • Not superior to Bishop score
      • Insulin-like growth factor binding protein-1
        • Synthesized by maternal decidua, may be released with cervical ripening and fetal membrane separating from decidua
        • May indicate cervical “ripeness”
    • Methods of cervical ripening
      • Low dose oxytocin
        • < 4 mU/minute
      • Dinoprostone (PGE 2 )
        • Intravaginal or intracervical
        • FDA approved for cervical ripening
        • Pt needs to be recumbent for 30 minutes and should be monitored for 1-4 hours
        • Onset of contractions usu. within 1 st hour, peak at 4 hours
    • Methods of cervical ripening continued
      • Misoprostol: PGE 1
        • Not FDA approved for this indication
        • Oral or vaginal administration*
        • 3x systemic bioavailability of vaginal vs. oral
        • As or more effective than other methods
        • Increased risk of tachysystole
          • Has not equated with worse overall outcomes
        • Hyperstimulation occurs in 1-10% of patients
        • Cheaper and more convenient
        • Recommend informed consent
    • Nonpharmacologic methods for cervical ripening
      • Stripping or sweeping the membranes
        • Causes an increase in prostaglandins
        • Insert finger through internal cervical os and move in a circular direction to detach the inferior part of the membranes from the lower uterine segment
        • Risks: infection, bleeding, accidental amniotomy, discomfort
        • Alone is not effective but may reduce dose of oxytocin needed
        • Important note: Strippingmembranes.com is for sale
    • Nonpharmacologic methods for cervical ripening continued
      • Mechanical dilators – local pressure stimulating release of prostaglandins and dilating cervix
        • Hygroscopic (osmotic) dilators
        • Balloon devices (Foley bulb)
          • Method & materials
        • Effective for cervical ripening (compared to misoprostol, PGE 2 )
      • Amniotomy
        • Increases production/release of prostaglandins
        • Evidence does not support use for labor induction
    • Alternative methods for cervical ripening
      • Evening primrose oil, Black Haw, Black and blue cohosh, red raspberry leaves
        • All have uncertain role
      • Castor oil, hot baths, enemas
        • No evidence to support use
      • Sexual intercourse – stimulation of oxytocin release and prostaglandins
        • Uncertain role, but fun to try.
      • Breast stimulation
        • May be helpful but no good evidence
      • Acupuncture/transcutaneous nerve stimulation
        • May have benefit, need better studies
      • Tenore, JL. Methods for cervical ripening and induction of labor. AFP 2003.
    • Labor Induction
      • Stimulating uterine contractions to promote delivery prior to the onset of spontaneous active labor
      • Rate is > 20% and increasing
      • Most common indication is postterm pregnancy
    • Risks of Labor Induction
      • Operative vaginal delivery
      • Cesarean delivery
      • Excessive uterine activity with abnormal FHR patterns (uterine hyperstimulation)
      • Delivery of preterm infant
    • Labor Induction - ACOG
      • PGE analogues are effective for both cervical ripening and labor induction (Level A)
      • Cytotec at doses of 25 micrograms every 3-6 hours are effective for cervical ripening and labor induction (Level A)
      • With term PROM, may induce labor with prostaglandins (Level A)
      • Increased complications with doses of cytotec > 50 mcg (Level B)
      • Avoid cytotec in VBAC (Level B)
    • Methods of Labor Induction
      • Oxytocin
        • Oxytocin receptors in the uterus increase starting at 32 weeks
        • IV administration of solution of 10 Units to 1 Liter of isotonic solution = 10 mU/1mL
        • Continuous infusion vs. pulsed dosing
          • Continuous usually start at 0.5 to 2.5 mU/min increased by same increment every 15-60 minutes
          • Effect within 3-5 minutes, steady state by 15-30 min.
          • No clearly superior regimen – great variability in response
    • Methods of Labor Induction
      • PGE 1
      • PGE 2
      • Oxytocin
    • Oxytocin continued
      • Oxytocin is good…
        • It is potent
        • May titrate
        • Short half-life
        • Well tolerated
    • Oxytocin for labor induction
      • Low-dose
        • Start at 0.5-2 mU/min
        • Increase by 1-2 mU/min every 15-40 minutes
      • High-dose
        • Start at 6-8 mU/min
        • Increase by 6 mU/min every 15-40 minutes
      • High-dose results in shorter labor, decreased intra-amniotic infections, and decreased rates of c/section for dystocia but higher risk of hyperstimulation
      • Sanchez-Ramos L. Induction of labor. Obstet Gynecol Clin North Am - 01-JUN-2005; 32(2): 181-200, viii
    • Dosing of Oxytocin
      • Commonly accepted practice is to increase by 1-2 mU/min every 40 minutes
        • May optimize pharmacokinetics by not increasing dose before steady-state is reached
        • Lower risk of hyperstimulation
        • May result in longer labor for oxytocin-insensitive women
        • May result in lower overall dose of oxytocin required
      • Usual dose
        • More than 90% of women will respond to 16 mU/min or less
        • Rare for women to require 20-40 mU/min
    • Potential Risks
      • Stripping membranes
        • Bleeding from undiagnosed placenta previa or low-lying placenta
        • Accidental amniotomy
      • Nipple stimulation
        • Uterine hyperactivity
        • FHR decels
      • Amniotomy
        • Unpredictable length of time until onset of contractions
        • Cord prolapse
        • Chorioamnionitis
        • Cord compression
        • Vasa previa rupture
      • Laminaria
        • Increased maternal/fetal infections
      • ACOG Practice Guideline No. 10. Induction of labor.
    • Potential Risks cont’d
      • Misoprostol (cytotec)
        • Tachysystole, hyperstimulation
        • Uterine rupture
        • Increase in meconium staining of AF
        • Abnl FHR tracing
        • Likely dose and route dependent
      • Intravaginal/intracervical PGE 2
        • 1-5% rate of uterine hyperstimulation
        • Fever, vomiting, diarrhea
        • Uterine rupture secondary to hyperstimulation
      • Oxytocin
        • Dose related
        • Hyperstimulation
        • FHR decels
        • Placental abruption/uterine rupture secondary to hyperstim
        • Water intoxication
        • Antidiuretic effect and hypotension with large/rapid IV administration
      • ACOG Practice Guideline No. 10. Induction of labor.
    • Questions & Comments
    • References
      • ACOG Practice Bulletin No 10 Induction of Labor, 1999.
      • Crane JM. Factors predicting labor induction success: A critical analysis 2006; Clin Obstet Gynecol 49;573-84.
      • Harman JH, Kim A. Current trends in cervical ripening and labor induction. AFP 1999;60:477-84.
      • Tenore JL. Methods for cervical ripening and induction of labor. AFP 2003;67:2123-8.
      • Weeks A. Oral misoprostol administration for labor induction. Clin Obstet Gynecol 2006;49:658-71.