Induction of labour and artificial rupture of membranes


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Induction of labour and artificial rupture of membranes

  1. 1. Induction of a treatment for 'overdue' pregnancy Sarah Stewart 2011
  2. 2. Definitions <ul><li>Term (as in a ‘normal’ and healthy gestation period): is from 37 weeks to 42 weeks. </li></ul><ul><li>Post dates: the pregnancy </li></ul><ul><li>has continued beyond the </li></ul><ul><li>decided due date ie. is over </li></ul><ul><li>40 weeks. </li></ul><ul><li>Post term: the pregnancy has continued beyond term ie. 42+ weeks. </li></ul><ul><li>Reed, 2010 </li></ul>
  3. 3. Most women birth between 41 and 42 weeks gestation
  4. 4. In Australia... <ul><li>26.2% women have their labour induced </li></ul><ul><li>50% women are first time mums </li></ul><ul><li>No effect on stillbirth rate </li></ul><ul><li>Only half these women had normal birth </li></ul><ul><li>One third had c/section </li></ul><ul><li>Patterson et al, 2011 </li></ul>
  5. 5. Clinical guidelines recommend that women should be offered induction of labour between 41 and 42 weeks gestation NICE, 2008
  6. 6. Expectant management <ul><li>Thought to be increased risk of fetal death if pregnancy lasts past 42 weeks but no clear evidence </li></ul><ul><li>500 IOL are needed to prevent 1 perinatal death </li></ul><ul><li>Evidence that there is increased risk of caesarean section and meconium-stained liquor after 41 weeks, but no increase in aspiration syndrome </li></ul><ul><li>Tracy, 2010 </li></ul>
  7. 7. Clinical guidelines recommend surveillance after 42 weeks eg ultrasound scan and CTG, but no evidence to support efficacy of this
  8. 8. Membrane sweep <ul><li>Sweeping the membranes is effective in bringing on labour before 41 weeks </li></ul><ul><li>Causes discomfort, some bleeding and irregular contractions. </li></ul><ul><li>8 membrane sweep need to be carried out to prevent 1 medical IOL </li></ul><ul><li>NICE recommends membrane sweep between 40 and 41 weeks pregnancy </li></ul>
  9. 9. Homoeopathy No evidence to support its use
  10. 10. Not enough evidence to support acupuncture
  11. 11. Risks of induction of labour <ul><li>Start of the 'cascade of intervention' </li></ul><ul><li>More likely to need epidural and have instrumental birth </li></ul><ul><li>Increased risk of fetal distress </li></ul><ul><li>50% increase risk of caesarean section in primiparous women for non-medical IOL </li></ul><ul><li>Tracey, 2010 </li></ul>
  12. 12. Contraindications <ul><li>Maternal refusal </li></ul><ul><li>Malpresentation </li></ul><ul><li>Previous major surgery – some would argue previous c-section </li></ul><ul><li>CPD </li></ul><ul><li>Cord prolapse </li></ul><ul><li>Active genital herpes </li></ul><ul><li>Placenta previa </li></ul><ul><li>Severely compromised baby </li></ul><ul><li>Breech baby </li></ul>
  13. 13. Induction of labour should not be started if Bishop Score is less than 6. A score of 8/9 indicates a “favourable” cervix
  14. 14.
  15. 15. Prostin <ul><li>Vaginal prostagladin gel is preferred method of IOL </li></ul><ul><li>Regime varies from hospital to hospital </li></ul><ul><li>May cause fetal distress, cause discomfort and take time for labour to start </li></ul><ul><li>Side effect may be hyper-stimulation </li></ul><ul><li>Placed in posterior fornice of cervix </li></ul>
  16. 16. Care of woman <ul><li>Informed consent </li></ul><ul><li>Assessment of woman including health, history, EDD and abdominal palpation </li></ul><ul><li>Assessment of baby's health – CTG </li></ul><ul><li>Bishop score </li></ul><ul><li>Correct administration of drug </li></ul><ul><li>Woman to rest on side for 30 mins. </li></ul><ul><li>CTG when contractions started until fetail health is confirmed </li></ul><ul><li>Documentation </li></ul><ul><li>Johnson and Taylor, 2010 </li></ul>
  17. 17. ARM <ul><li>Disrupts normal progression of labour and often leads to other interventions </li></ul><ul><li>Should not be used in “normal” labour </li></ul><ul><li>May shorten labour by 1 hour but increase labour pain leading to increased use of analgesia eg epidural </li></ul><ul><li>Increased risk of fetal distress, cord prolapse and c/section </li></ul>
  18. 18. Contraindications <ul><li>High presenting head </li></ul><ul><li>Polyhydramnios </li></ul><ul><li>Preterm labour </li></ul><ul><li>Known vaginal infection </li></ul><ul><li>Positive HIV </li></ul><ul><li>Placenta previa </li></ul><ul><li>Vas previa </li></ul>
  19. 19. Care of the woman <ul><li>Informed consent </li></ul><ul><li>Exclude contraindications </li></ul><ul><li>Maternal and fetal assessment </li></ul><ul><li>VE-rupture membranes with amnihock </li></ul><ul><li>Check fetal heart </li></ul><ul><li>Share findings with woman </li></ul><ul><li>Documentation </li></ul>
  20. 20. Oxytocin <ul><li>Intravenous syntoconon is not as effective as vaginal prostagladin </li></ul><ul><li>Used with ARM is as effective as vaginal prostagladin </li></ul>
  21. 21. <ul><li>Once ARM is performed, there's no going back </li></ul><ul><li>IVI is very restrictive </li></ul><ul><li>Must be constantly monitored </li></ul><ul><li>Continuous CTG </li></ul><ul><li>Very careful adherence to syntocinon protocol </li></ul><ul><li>Very diligent documentation </li></ul>
  22. 22. Key points <ul><li>Midwife's role is to be advocate – be mindful of society's attitudes to length of pregnancy </li></ul><ul><li>Education during ante natal period so woman can make informed decision </li></ul><ul><li>Be clear about what research says and what it doesn't say </li></ul><ul><li>Induction of labour starts cascade of intervention </li></ul><ul><li>Very careful monitoring of mother and baby </li></ul><ul><li>Contemporaneous documentation </li></ul>
  23. 23. References <ul><li>Johnson, R. & Taylor, W. (2010). Skills for midwifery practice. Edinburgh: Elsevier. </li></ul><ul><li>NICE. (2008). Induction of labour . Retrieved from </li></ul><ul><ul><li> </li></ul></ul><ul><li>Reed, R. (2010, September 16). Induction of Labour: balancing risks [web log message]. Retrieved from labour-balancing-risks. </li></ul><ul><li>Reed, R. (2011, July 17). Induction: a step by step guide [web log message]. Retrieved from </li></ul><ul><li>Tracey, S. (2010). Interventions in pregnancy, labour and birth. In S.Pairman, S.Tracy, </li></ul><ul><ul><li>C.Thorogood, & J. Pincombe (Eds.). Midwifery. Preparation for practice </li></ul></ul><ul><ul><li>(pp863-970). Edinburgh: Elsevier </li></ul></ul>
  24. 24. Sarah Stewart: [email_address]