Transcript of "When to schedule posterm induction"
Postterm Induction Guidelines USE 1) THE BISHOP SCORE 2) CERVICAL DILATION 3) PARITY 4) EGA TO MAKE DECISONS WHEN TO SCHEDULE THER IS A RANGE FROM 41W 0d – 41 6d TO CONSIDER
What are the Changes ARRIVE EARLIER <ul><li>Out Patient CYTOTEC INDUCTIONS all scheduled to ARRIVE staggered 1 st @ 7:30 then // 8:00 then // 8:30 PM </li></ul><ul><li>This will facilitate a decision re Admission/Discharge prior to 8:30 AM the following morning </li></ul><ul><li>This will provide the opportunity for an Induction admitted the night before for Cytotec the opportunity for additional Cytotec dosing if appropriate AND more time for cervical ripening </li></ul><ul><li>During board rounds @ 5:30 PM a discussion between the OB 1 & 2, CNM and Charge Nurse regarding the status of L&D and whether or not the inductions ( 2 max of 3) start to arrive @ 7:30 PM OR if the Patients are to call back later @ a time To Be Determined by the TEAM for arrival as early as it appears reasonable. The decision made by the team by 6 PM prior to the patient calling @ 6 PM to have their scheduled 7:30 PM arrival time approved. </li></ul><ul><li>2) In Patient Pitocin only induction staggered 1 st to ARRIVE @ 0600 then @ 0530 . </li></ul>
DILATION SCORE 0 0 cm 2 1-2 cm 4 3-4 cm 6 >4 cm CERVICAL LENGTH SCORE By digital PALPATION 0 3 cm 1 2 cm 2 1 cm 3 0 cm STATION SCORE In relation to spines 0 -3 1 -2 2 -1/O 3 + 1/+2
Favorable Cervix is Bishop Score of 6 The success of induction is most dependent on the amount of cervical dilatation Consider induction as early as 41w 0d IF: For a MULTIP if cervix is dilated 2 cm For a NULLIP if cervix is dilated 3-4 cm <ul><li>Bishop Score of < 5 is associated with an increased risk </li></ul><ul><li>-- 2 day induction </li></ul><ul><li>--Doubles the Risk of Cesarean Section </li></ul><ul><li>41 weeks 3 days is early if score is < than 6 </li></ul><ul><li>All patients delivered by 42 weeks 0 day </li></ul>Am J Obstet Gynecol 2003 Jun;188(6):1565-9
PARITY <ul><li>Multiparous patients who are induced are more likely to experience an induction resulting in vaginal delivery than Nulliparous patients. </li></ul><ul><li>A Multiparous patient with a Bishop Score of 6 and cervix dilated to 2 cm is very likely to deliver within 12 hours of induction start. </li></ul><ul><li>A Nulliparous patient with an unfavorable cervix Bishop Score of < 5 has an increased risk for a </li></ul><ul><li>-- 2 day induction </li></ul><ul><li>--Double the Risk of Cesarean Section </li></ul>
SCHEDULING for OUTPATIENT CYTOTEC INDUCTION with CONSIDERATION of PARITY <ul><li>For Nulliparous with Bishop score < 6 AND a cervix </= to 1 cm The closer to 41w6d ( ie 41 weeks 4- 6 day) the induction is scheduled the more likely a vaginal delivery. CONSIDER THIS WHEN SCHEDULING INDUCTIONS IN Nulliparous patients. </li></ul><ul><li>- Nulliparous Patient with Bishop Score < 6 is most likely to fail induction and Require Re-scheduling @ 42 weeks. Prepare the patient for this possibility. 41 weeks 3 days is early. Goal is for All patients to be delivered by 42 weeks 0 days . </li></ul><ul><li>- Multiparous Patients Are more likely to respond to Cytotec induction and have a vaginal delivery within 12 hours after start of induction. Especially if the cervix is dilated ; even if only 1-2 cm. </li></ul>
Use Bishop Score for Decision Making <ul><li>All patients delivered by 42W 0D </li></ul><ul><li>May Induce Postterm as early as 41w0d ONLY for patients with a Modified Bishop Score of 6 AND Cervix is dilated </li></ul><ul><li>( Nulliparous 3-4cm dilated / Multiparous 2cm dilated ) </li></ul><ul><li>For Nulliparous with Bishop score < 6 AND a cervix </= to 1 cm ;The closer to 41w6d the induction is scheduled the more likely a vaginal delivery. </li></ul><ul><li>May consider to induce Postterm as early as 41w3d and no later than 41w6d as an Outpatient ie (PM Cytotec) if the Bishop Score is 5 or less. </li></ul><ul><li>The Bishop Score will ALSO help you decide which protocol to utilize </li></ul><ul><li>(ie Cytotec Start vs Pitocin Start) </li></ul><ul><li>For Multiparous Bishop Score of 6 is favorable. MAYCONSIDER scheduling as early as 41w 0d. OK for AM Pitocin Induction patients. It is still Ok to wait until 41weeks 3-4 days. </li></ul><ul><li>For Nulliparous patients a Bishop Score of 6 is favorable; therefore you MAY CONSIDER an induction as early as 41 w 0 days. It is still Ok to wait until 41weeks 3-4 days. However a cervical dilation of 3-4 cm is a prerequisite for Pitocin only AM induction. </li></ul><ul><li>For Nulliparous with a Bishop score of 6; WITH cervical dilation of 2 cm MAY CONSIDER scheduling Cytotec induction as early as 41w 0d . It is still Ok to wait until 41weeks 3-4 days. </li></ul>
MEDICAL INDICATIONS FOR INDUCTION <ul><li>Medical Indications for induction have the flexibility of a delivery “week “ with reassuring FHR and stable maternal condition. Arbitrary cut-offs ie “39 w 0d” are unnecessary </li></ul><ul><li>If NST/AFI is Reassuring and Medical Condition is stable it is Ok to follow most medical patients to be scheduled during the 39 th week up to 40w 0d and for many more up to 41w0d. Therfore there will be an entire week or more to attempt to schedule an induction when the primary doctor is on call on L&D. ie from 39w 0d to 40w 0days </li></ul><ul><li>Cytotec protocol vs Pitocin protocol as described previously. Schedule Cytotec induction the evening before the Primary OB Dr is on L&D the next day . </li></ul><ul><li>Spontaneous labor is more likely to result in NSVD than Induction unless the patient is multiparous with a favorable cervix . Waiting a few days ie 40 weeks 3-4 days id also OK. </li></ul>
INDICATIONS for INPATIENT INDUCTION (ie AM scheduling) <ul><li>Postterm inductions @ 41 weeks (41w0d-41w6d) </li></ul><ul><li>ONLY With a favorable cervix is Early AM Pitocin Induction protocol an option (ie Bishop Score of 6) that must include cervical dilation of 3-4 cm in a Nulliparous patient and 2 cm for a Multiparous patient </li></ul><ul><li>Medical Indications (In control with Reassuring NST) no later than 41w 0d for any patient with a medical indication. </li></ul><ul><li>GDM with a favorable cervix as early as the 39w 0d up to 41w 0d </li></ul><ul><li>Pre Gestational Diabetes as early as 39w 0d no later than 40w0d </li></ul><ul><li>Gestational HTN / Preeclampsia “37 th week – 38 th week” </li></ul><ul><li>CHTN without superimposed Preeclampsia 39w 0d – 40w +/-2days </li></ul><ul><li>SOCIAL INDICATIONS: Provider’s presence for delivery AND a Favorable Cervix are Prerequisites (Score of 6 as discussed for Nulliparous vs Multiparous as early @ 39w 0d up to 42w 0d) </li></ul>
Indications for a CST Prior to Induction <ul><li>CONSIDER CST PRIOR TO INDUCTION IF: </li></ul><ul><li>Equivocal FHR or Unstable Medical Condition or IUGR or AFI < 5 </li></ul><ul><li>May be a Candidate for Cytotec Induction if CST Negative Reactive </li></ul><ul><li>BEST OPTION IS A FOLEY BULB INDUCTION or Pitocin Only Induction </li></ul><ul><li>CERVIDIL NOT RECOMMENDED. </li></ul><ul><li>STRONGLY RECOMMEND Foley bulb induction which HAS BEEN DEMONSTARTED TO DECREASE THE RISK FOR CESAREAN SECTION compared to CERVIDIL </li></ul><ul><li>IUGR with an EFW </= 10 % tile may be a relative contraindication for induction dependent on the clinical situation ie consider: Modified Bishop Score, Parity, Estimated time to Delivery, Maternal Medical condition, Degree of IUGR ) STRONGLY CONSIDER Foley bulb induction which may decrease the risk for C/S for fetal Indications. </li></ul><ul><li>AFI < / = 5 cm is not a contraindication for Induction; However STRONGLY CONSIDER Foley bulb induction which may decrease the risk for C/S for fetal Indications. </li></ul>
RIVERSIDE OP CYTOTEC GUIDELINES <ul><li>Patients are to have an NST @ 41 0/7 +/- 1 day. Subsequent NST should be performed every 3-4 days until delivery. If the patient has an outpatient failed attempt a follow up NST is not required for 3-4 days after the induction attempt. </li></ul><ul><li>If THERE IS CONCERN regarding any clinical information that became apparent during the outpatient induction ; ADMIT THE PATIENT and continue with 2 day induction or C/S. A FOLLOW UP NST IS NOT APPROPRIATE for equivocal FHR during Induction. </li></ul><ul><li>N0 interval NST is indicated if a " reassuring FHT tracing " is present during a failed attempt at outpatient induction if the patient is scheduled to return for Induction within 3-4 days of previous induction attempt. </li></ul><ul><li>A history of Previous postpartum hemorrhage , current EFW =/>4000 grams, Grand Multiparity ( 5 previous deliveries), and history of previous difficult delivery may all increase the risk associated with induction. </li></ul>
Do the Math Think About In Patient Cytotec Night Start @ 41w 4-6 d <ul><li>CYTOTEC INDUCTION WITH UNFAVORABLE CERVIX </li></ul><ul><li>When 41 w 6 d or 42w 0d falls on a Saturday or Sunday. Consider the option for a 41w 4d-6d with Thursday or Friday night Cytotec start. They will not be sent home as all patients are delivered by 42 week 0 days. </li></ul><ul><li>NST @ 41 WEEKS +/- 1 DAY on all patients. </li></ul><ul><li>Outpatient postterm induction scheduled @ 41 weeks 4-5 days and fails induction attempt. NO follow up NST required because all patients delivered by 42 weeks ( ie they are back for their Induction on L&D within 3-4 days). If the FHR tracing is equivocal during the induction attempt they are TO BE ADMITTED. </li></ul>
INPATIENT INDUCTION Etiquette & Wisdom <ul><li>A note describing the Risk / Benefit / Indications for Medical Induction Should be placed under the Clinician Notes on the Patients Chart. Physicians who you discussed the case with and whether or not consultation with MFM was obtained should be included. </li></ul><ul><li>Patients who want amniotomy first without Pitocin and / or request to walk first without Pitocin in the hopes that the normal contractions that are invariably present @ term will result in " natural labor " without immediate Pitocin start require further counseling & Documentation re IUFD / C/S risk </li></ul><ul><li>NOT CANDIDATES FOR A 41 WEEK POSTTERM INDUCTION. Schedule @ 42w0d +/- 1 day </li></ul><ul><li>IF MEDICAL INDUCTION IS INDICATED THIS IS NOT ACCEPTABLE </li></ul>
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