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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