LABOR INDUCTI0N GUIDELINES

1. LABORINDUCTI0NGUIDELINES Oguchi Andrew Nwosu MD, FAAFP Asst. Prof. Emory Family Medicine January 28th 2010

2. Introduction • ACOG practice bulletin #107, August 2009 • Up To Date September 9, 2009 • Def: IOL refers to iatrogenic stimulation of uterine contractions to accomplish delivery prior to the onset of spontaneous labor • Benefits of expeditious delivery should outweigh risks of preg. continuation • Rate doubled from 9.5% to 22.5% b/w 1990 & 2006. Why?

3. Objectives • Classify indications & contraindications • Review current methods of cervical ripening and IOL • Summarize effectiveness of these approaches based on research • Describe the agents used for cervical ripening • Cite methods used for IOL • Outline requirements for the safe clinical use of the methods for IOL

4. What are the indications and contradindications to induction of labor?

5. Indicationsx and Contraindications • Abruptioplacentae • Chorioamnionitis • Fetal Demise • Gestational Hypertension • Preeclampsia, eclampsia • PROM • Postterm Pregnancy • Maternal medical conditions • Fetal compromise eg IUGR • Logistics • Vasaprevia • Complete placenta previa • Umbilical cord prolapse • Previous classical C/S • Active genital herpes • Previous myomectomy entering endo. cavity

6. What criteria should be met before the cervix is ripened or labor is induced?

7. Criteria • Assessment of gestational age, how? • Consideration of potential risks to mother or fetus • Appropriate counseling including C/S risk • Plan on allowing 12 to 18 hours for latent labor b/4 diagnosing failed induction • Assess cervix, pelvis, fetal size and presentation • Monitor FHR and uterine contractions • Have physician capable of C/S readily available

8. Bishops scoring system

9. Methods for cervical ripening and IOL?

10. Methods Cervical ripening Induction of Labor • Foley catheters • Hygroscopic dilators • Osmotic dilators (Laminaria) • Double balloon devices • Extraamniotic saline infusion • Misoprostol (i/vg,po,s/l) • Dinoprostone insert (cervidil) • Dinoprostone gel (prepidil) • Misoprostol • Oxytocin • Membrane stripping • Amniotomy • Nipple stimulation

11. Relative effectiveness • Systematic review- foley decreased duration of labor if used prior to oxytocin • SR: No difference in duration of induction to del. or C/S with foley or PGE2 gel. PGE2 - more tachysystole • Intravaginal misoprostol reported as either superior to or as efficacious as PGE2 gel. Less epidurals, more del. within 24hrs, more tachysystole • Pharmacological methods for cervical ripening do not decrease the likelihood of C/S

12. What are the potential complications with each method of cervical ripening and IOL and how should the be managed?

13. Complications of cervical ripening

14. Complications of IOL

15. Management of complications Complications of prostaglandins and oxytocin tend to be dose dependent • Remove cervidil • Discontinue or decrease oxytocin dose • Turning patient to her side • Oxygen administration • I/V fluid administration • Terbutaline (0.25mg s/c) or other tocolytic • C/S

16. Are there special considerations that apply for induction in a woman with ruptured membranes?

17. PROM Large randomized study found that oxytocin Reduced • Interval between PROM and delivery • Frequency of chorioamnionitis • Postpartum febrile morbidity • Neonatal antibiotic treatments No increase • C/S deliveries These data suggests that for women with PROM at term, labor should be induced at the time of presentation , generally with oxytocin infusion, to reduce the risk of chorioamnionitis Adequate time for latent phase progress should be allowed

18. PROM • Intravaginal prostaglandins for IOL in women with PROM appears safe and effective • No evidence that increases risk of infection • Insufficient evidence for use of mechanical dilators • IOL in PROM vs. expectant mx. – significant reduction in chorioamnionitis, endometritis and neonates admitted to NICU

19. What methods can be used for induction of labor with intrauterine fetal demise in the late 2nd or 3rd trimester?

20. Intrauterine fetal demise Method depends on gestational age, presence of a uterine scar and maternal preference • In 2nd trimester, D/C can be offered • Labor induction is appropriate for later gestations • B/4 28weeks gest., vagmisoprostol appears to be most efficient regardless of Bishop’s score. • After 28 weeks, usual protocols. Avoid misoprostol with scar • Avoid C/S if possible, maternal morbidity, no fetal benefit

21. Summary of Recommendations & Conclusions

22. Level A R & C • PGE analogues are effective for cervical ripening & IOL • Low or high dose oxytocin regimens are appropriate for women that IOL is indicated • B/4 28W gest., vag. misoprostol most efficient method of IOL regardless of Bishop’s score. High dose oxytocin also acceptable choice • Consider 25mcg of misoprostol initial dose for cx ripening and IOL. Administer Q 3-6 hours

23. Level A R & C continued • Intravaginal PGE2 for IOL in PROM appears to be safe and effective • Misoprostol use in women with prior C/S or major uterine rupture associated with uterine rupture. Avoid in 3rd trimester • The Foley catheter is a reasonable & effective alternative for cervical ripening and IOL

24. Level B R & C • Misoprostol (50mcg Q 6hours) to induce labor may be appropriate in some situations, although higher doses are associated with increased risk of complications including uterine tachysystole +/- FHR decelerations

25. Elective induction That is induction with no medical/obs. Indication • Increased C/S rates • Iatrogenic prematurity • Higher health care costs • No proven medical/obs. benefit

26. Questions?