Oli and Poly

• Induction of labour


  The process of artificially stimulating the uterus to start labour, usually by administering oxytocin or prostaglandins or manually rupturing the amniotic membranes
• Induction of labour is usually performed by administering oxytocin or prostaglandins to the pregnant woman or by manually rupturing the amniotic membranes
• Indications for IOL


  Reasons seen in practice for Induction of Labour
• There has been constant deliberation over the last decade about when the optimum time is for good outcomes in pregnancy
• Post-dates


  When a pregnancy exceeds 42 weeks
• Recent evidence and guidance has suggested "post-dates" induction should happen sooner to reduce risk
• Some researchers/midwives have raised concerns of the one size fits all approach to post-dates induction
• It is important that correct dating is established in order to minimise the risks that might be associated with induction and ensuring women are able to make fully informed choices
• Estimated Due Date


  A guess with quite a wide timespan, as only 5% of babies are born on their due date
• Normal is a range and not just one fixed point, as bodies, babies and pregnancy lengths vary
• Women's experiences of IOL

  • Some felt relieved to know when labour would start, some felt it difficult to deal with the shift from expecting spontaneous labour to a new plan, IOL caused feelings of disappointment, resignation and passivity, some described it as a "nondecision" as they felt unable to intervene in the protocol or request anything other than what the medical staff suggested, IOL was experienced as a sequential set of steps where the women were expected to fit into the existing hospital organization, negative experiences with IOL delays and long waits, lack of information
• Women's experiences of IOL can likely be improved by a communicative and patient centred approach
• Information women need to make an informed choice about IOL

  • Risks to mother: shoulder dystocia, genital tract trauma, operative birth, postpartum haemorrhage
  • Risks to fetus/neonate: placental dysfunction, oligohydramnios, fetal growth restriction, meconium aspiration, stillbirth, macrosomia associated risks
• Primiparous women with IOL vs. spontaneous onset differed significantly for: spontaneous vaginal birth, instrumental birth, intrapartum caesarean section, epidural, postpartum haemorrhage
• Following induction, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years
• Induction was associated with fewer (all‐cause) perinatal deaths and fewer stillbirths compared to expectant management
• For women in the policy of induction arms of trials, there were probably fewer caesarean sections compared with expectant management and probably little or no difference in operative vaginal births with induction
• Induction may make little or difference to perineal trauma and probably makes little or no difference to postpartum haemorrhage
• Rates of neonatal intensive care unit (NICU) admission were lower, and probably fewer babies had Apgar scores less than seven at five minutes in the induction groups compared with expectant management
• Membrane sweeping


  A procedure that might make it more likely that labour will start without the need for additional pharmacological or mechanical methods of induction, but can cause pain, discomfort and vaginal bleeding
• Membrane sweeping is used to promote the normal physiological onset of labour by releasing localised prostaglandins F2α, phospholipase A2 and cytokines from the intrauterine tissues, which act on the cervix to augment cervical ripening and potentially instigate uterine contractions
• The evidence for membrane sweeping being effective in achieving a spontaneous onset of labour was of low certainty, but it potentially reduces the incidence of formal induction of labour
• There is a lack of evidence around women's information needs, decision-making and experiences of membrane sweeping, and informed consent may not always be obtained
• Bishop's score


  A scoring system that assesses four features of the cervix and the relationship of the presenting part to the ischial spines, with a score of ≥8 suggesting a greater probability of a vaginal birth, similar to that when the onset of labour is spontaneous
• Favourable cervix


  A cervix that is more compliant, offering less resistance as the contraction and retraction of the myometrium forces the presenting part down
• Dinoprostone


  The active substance in PROPESS and Prostin E2, which softens the collagen of the cervical connective tissue and acts on the smooth muscle of the cervix to efface
• Use of PROPESS


  PROPESS can remain in situ for 24 hours but must be removed at least 30 minutes before oxytocin infusion, woman to remain semi recumbent for 20-30 mins, periodic CTGs until in established labour
• Use of Prostin E2

  Prostin E2 can be given to a maximum dose of 4mg with AT LEAST 6 hour between doses, periodic CTGs until in established labour
• For VBAC, the aim is to induce labour by applying pressure to the cervix and therefore indirectly increasing local secretion of prostaglandin
• Bishops Score


  A score of ≤6 is considered to be unfavourable, a score of ≥8 suggests a greater probability of a vaginal birth, similar to that when the onset of labour is spontaneous
• Ripe or favourable cervix


  One that for the purpose of IOL is more compliant, offering less resistance as the contraction and retraction of the myometrium forces the presenting part down
• PROPESS


  Contains the active substance dinoprostone 10 mg, used to help start the birth process >37 weeks
• Dinoprostone


  • Softens the collagen of the cervical connective tissue and acts on the smooth muscle of the cervix to efface
• PROPESS


  1. Can remain in situ for 24 hours but must be removed at least 30 minutes before oxytocin infusion

  2. To remain semi recumbent for 20-30 mins

  3. Periodic CTGs until in established labour
• Prostin E2


  Vaginal gel contains the active substance dinoprostone 1mg/2mg, used to help start the birth process >37 weeks
• Prostin


  1. Can be given to a maximum dose of 4mg with AT LEAST 6 hour between doses

  2. Periodic CTGs until in established labour
• Balloon Catheter


  1. Aim to induce labour by applying pressure to the cervix and therefore indirectly increasing local secretion of prostaglandin and oxytocin, or both

  2. A standard Foley urinary catheter is commonly used, with the balloon inflated in the extra‑amniotic space. The catheter is then put under tension to pull back against the cervical os

  3. Sometimes saline solution is infused into the extra‑amniotic space as an adjunct
• Balloon Catheter


  Some studies have shown increased vaginal birth rates compared to prostaglandins, but other have shown no difference in rates, but a reduced risk of hyperstimulation
• Contraindications to IOL include: Placenta praevia, Transverse/oblique lie or compound presentation, HIV-positive women not receiving any antiretroviral therapy or women on any antiretroviral therapy with a viral load of ≥400 copies/mL, Active genital herpes, Cord presentation or cord prolapse when vaginal birth is not imminent, Known cephalo–pelvic disproportion (CPD), Severe acute fetal compromise
• Alternatives to IOL include: Artificial Rupture of Membranes, Oxytocin as Uterotonic Agent