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+ Ways to induce labor Julie Springer. + Induction An estimated 22% of all gravid women undergo induction Done when benefits of expeditious delivery outweigh.

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Presentation on theme: "+ Ways to induce labor Julie Springer. + Induction An estimated 22% of all gravid women undergo induction Done when benefits of expeditious delivery outweigh."— Presentation transcript:

1 + Ways to induce labor Julie Springer

2 + Induction An estimated 22% of all gravid women undergo induction Done when benefits of expeditious delivery outweigh the risks of continuing pregnancy Fetal or maternal indications

3 + Induction Cervical changes that occur in normal pregnancy include: Thinning, softening, dilating Collagen breakdown & rearrangement, inc cytokines, inc WBCs, and change in glycosaminoglycans (1)

4 + Induction The cervix is assessed using Bishop’s score Unfavorable <6 >8 has same probability of vaginal delivery compared to spontaneous labor (1) If induction of labor is attempted in a nulliparous woman with an unfavorable cervix  it doubles her baseline risk of cesarean

5 + Methods of induction of labor Non-pharmacologic methods Membranes stripping, nipple stimulation, castor oil Pharmacologic methods Misoprostol, dinosprostone, oxytocin Mechanical methods Foley, Cook Catheter, EASI Special Populations Prior Cesarean PROM

6 + Nonpharmacologic methods Induction of labor

7 + Membrane Stripping Membrane stripping During cervical exam, disconnect membranes from lower uterine segment Increases in phospholipase A2 activity and prostaglandin F2a (1) Can be done outpatient (at clinic visit)

8 + Membrane Stripping Cont’d Cochrane Review in trials Membrane stripping results in spontaneous labor 3 days sooner than if membranes were not stripped It reduces need for other methods for induction of labor It causes maternal discomfort, but no major maternal or fetal adverse effects Results are less predictable(3)

9 + Nipple Stimulation Stimulating nipple w/ manual massage or pumping Increases oxytocin release Cochrane Review studies Nipple stimulation decreased the number of patients “not in labor” within 72 hours--62.7% vs 93.6% Should be used with caution for high risk population Decreases postpartum hemorrhage 0.7% vs 6% (4) Safe for women attempting a vaginal trial of labor after a c-section

10 + Castor Oil Vegetable oil Used as laxative- works on small intestines Cochrane Review 3 studies all with single dose of castor oil No difference in cesarean section rates Maternal side effects were high (6) Castor Oil is NOT generally used for induction

11 + Pharmacologic methods Induction of labor

12 + Dinoprostone PGE2 Forms Gel-0.5mg Tablet Vaginal insert (“cervidil”) Cochrane review showed similar cesarean rates and outcomes among the three types Risk of uterine tachysystole 5% for PGE2 inserts and vaginal gel, 1% for intracervical gel Rinsing vagina does not help to alleviate tachysystole(1)

13 + Dinoprostone Cont’d Cochrane Review studies reviewed, 10,441 women Compared to placebo, dinoprostone increases the rate of cervical favorability and successful vaginal delivery in 24 hours PGE2 has no effect on rate of cesarean section It results in increased rates of hyperstimulation and FHR changes 4.4% vs 0.49% incidence (8)

14 + Misoprostol Synthetic PGE1 (“cytotec”) Oral, vaginal, sublingual administration First marketed for peptic ulcer disease Often used in 25mcg or 50mcg doses, q3-6 hours Associated w/ less use of epidural analgesia, more vaginal deliveries within 24 hours compared with dinoprostone and oxytocin (1) Cochrane Review Found to be more effective than dinoprostone, oxytocin, and placebo (9) The major side effect is tachysystole or hyperstimulation No increase in poor fetal outcomes

15 + Dosage of misoprostol Cochrane Review No advantage of higher doses to lower doses Lower doses result in less hyperstimulation but more need for oxytocin The majority of studies used 25mcg vs 50mcg (9)

16 + Oral vs Vaginal Misoprostol Cochrane Review Oral dose has been shown to result in fewer cases of low apgars and hyperstimulation w/ FHR abnormalities Oral dose can be titrated more Vaginal shows less need for oxytocin afterwards (9) Jindal et al Study of 101 women at term 50ug oral vs vaginal Vaginal dose resulted in less time to delivery than oral- 9.79hr vs 16.47hr Decrease number of doses were required in vaginal- 2 vs 6 (15)

17 + Misoprostol vs Dinoprostone Cochrane Review Misoprostol results in: less need for oxytocin, less analgesia than dinoprostone more uterine hyperstimulation then dinoprostone(9)

18 + Oxytocin (“Pitocin”) One of most common medications used in the US Uterine response depends on gestational age Gradual increase 20-30wks Plateau from 34 wks-term Predictors of response Increased parity, cervical dilation, gestational age Lower BMI Low and high dose regimens exist Low- start at 0.5-1, increase by 1-2mU/min, q15-40min High- start at 6, increase by 3-6 mU/min, q15-40min (1)

19 + Mechanical methods Induction of labor

20 + Mechanical Methods of Induction Foley Catheter Double Balloon Catheter Laminaria

21 + Mechanical vs Pharmacologic Cochrane Review 27 studies reviewed Comparison of any mechanical method vs vaginal prostaglandins Mechanical methods resulted in fewer deliveries within 24 hrs 29% versus 7% Mechanical methods caused less hyperstimulation w/ FHR changes 0 vs 5% Comparable cesarean rates- 26 vs 23% (23)

22 + Balloon/ Foley Catheter Advantages Low cost Stable at room temperature Decrease incidence of tachysystole Decreased cesarean section rate Foley balloon is inflated INSIDE internal os. When contractions occur, baby’s head puts downward pressure on the balloon. This dilates the cervix as the balloon is pushed out of the cervical canal.

23 + Extraamniotic saline infusion Sterile saline infused into the catheter.

24 + Foley + EASI Adding saline infusion (EASI) Karjane et al- 140 women Foley +EASI led to shorter induction time hrs vs 21.47hrs No difference in chorio, cesarean section rates, or apgars (19) Guinn et al- 100 women Foley+ EASI vs Foley alone- both with concurrent oxytocin No difference in induction time hrs vs 17.4hrs (20)

25 + Double balloon foley

26 + Induction after cesarean section Cochrane Review Reviewed 2 studies Lydon-Rochelle study- compared induction to repeat c-section, evaluated risk for uterine rupture Spontaneous labor 3.3 x risk, induction with non- prostaglandins 5 x risk, and prostaglandins 15.5x risk Wing et all- misoprostol vs oxytocin in 38 women Studied stopped due to 2 uterine ruptures in misoprostol group (10) Should avoid misoprostol in 3 rd trimester with prior c/s Use of oxytocin also increases risk of rupture, but only by a small amount (from 36/10,000 to 87/10,000) (1)

27 + Induction after PROM Induction of labor on presentation decreases risk of chorioamnionitis and endometritis (26) Oxytocin Decreases risk of chorioamnionitis, postpartum febrile morbidity, and neonatal antibiotic treatments No increase in cesarean deliveries or neonatal infections Prostaglandins No evidence that they increase risk of infection Up to 86% can have successful induction of labor after PROM with misoprostol (24) Misoprostol is more effective than dinoprostone (25)

28 +

29 + Citations 1. Mildred, Ramirez, MD, and Ramin Susan, MD. "ACOG Practice Bulletin No. 107: Induction of Labor." Obstetrics & Gynecology 114.2, Part 1 (2009): Print. 2. Yildirim, Gokhan, Kemal Güngördük, Özge İ dem Karada ğ, Hal İ l Aslan, Erdem Turhan, and Yavuz Ceylan. "Membrane Sweeping to Induce Labor in Low-risk Patients at Term Pregnancy: A Randomised Controlled Trial." Journal of Maternal- Fetal and Neonatal Medicine 23.7 (2010): PubMed. Web. 14 Jan Michel, Boulvain, Stan Catalin, and Irion Olivier. "Membrane Sweeping for Induction of Labor." Cochrane Database of Systemic Reviews 4 (2009): n. pag. Web. 14 Jan Josephine, Kavangh, MD, Kelly Anthony, and Thomas Jane. "Breast Stimulation for Cervical Ripening or Induction of Labor." Cochrane Database of Systemic Reviews 4 (2009): n. pag. Web. 14 Jan EO, Ugwu, Iferikigwe ES, Dim CC, and Ezugwu FO. "Membrane Stripping to Prevent Post-term Pregnancy in Enugu, Nigeria: A Randomized Controlled Trial." Arch Gynecology Obstetrics (2014): Web. 14 Jan Anthony, Kelly, Kavanagh Josephine, and Thomas Jane. "Castor Oil, Bath And/or Enema for Cervical Priming and Induction of Labor." Cochrane Database of Systemic Reviews 7 (2013): n. pag. Wolters Kluwer. Web. 14 Jan Boel, Macteld Elisabeth, Sue Jean Lee, Marcus Johannes Rijken, Moo Koo Paw, Mupawjay Pimanpanarak, Saw Oo Tan Singhasivanon, Francois Nosten, and Rose McGready. "Castor Oil for Induction of Labour: Not Harmful, Not Helpful." The Australian and New Zealand Journal of Obstetrics and Gynaecology 49.5 (2009): Wiley. Web. 14 Jan Kelly, Anthony, Sidra Malik, Lee Smith, Josephine Kavanagh, and Jane Thomas. "Vaginal Prostaglandin for Induction of Labour at Term." Cochrane Database of Systemic Reviews 5 (2012): n. pag. Wolters Kluwer. Web. 14 Jan Hofmeyr, Justus, A. Metin, and Cynthia Pileggi. "Vaginal Misoprostol for Cervical Ripening and Induction of Labour." Cochrane Database of Systemic Reviews 1 (2013): n. pag. Wolters Kluwer. Web. 14 Jan

30 + Citations Satin, AJ, KJ Leveno, ML Sherman, DS Brewster, and FG Cunningham. "High versus Low Dose Oxytocin for Labor Stimulation." Obstetrics and Gynecology 80.1 (1992): PubMed. Web. 14 Jan Pettker, CM, SB Pocock, DP Smok, SM Lee, and PC Devine. "Transcervical Foley Catheter with and without Oxytocin for Cervical Ripening: A Randomized Controlled Trial." Obstetrics and Gynecology (2008): PubMed. Web. 14 Jan Rahman, H., A. Pradhan, L. Kharka, S. Kar, and S. Dutta. "Comparative Evaluation of 50 Microgram Oral Misoprostol and 25 Microgram Intravaginal Misoprostol for Induction of Labour at Term: A Randomized Trial." Journal of Obstetrics and Gynaecology Canada 35.5 (2013): Web. 14 Jan Loto, OM, AA Ikuomola, II Ayuba, and U. Onwudiegwu. "Comparative Study of the Outcome of Induction of Labor Using 25 µg and 50 µg of Vaginal Misoprostol." Journal of Maternal Fetal Neonatal Medicine (2012): Web. 14 Jan Jindal, Promila, Kumkum Avasthi, and Maninder Kaur. "A Comparison of Vaginal vs. Oral Misoprostol for Induction of Labor-Double Blind Randomized Trial." Journal of Obstetrics and Gynaecology India 61.5 (2011): Springer Link. Web. 14 Jan Garry D, Figueroa R, Kalish RB, Catalano CJ, Maulik D. Randomized controlled trial of vaginal misoprostol versus dinoprostone vaginal insert for labor induction. J Matern Fetal Neonatal Med 2003;13:254– Carbone, Jeanine, MD, Methodius G. Tuuli, MD, Patricia Fogertey, RN, Kimberly Roehl, MPH, and George Macones, MD. "Combination of Foley Bulb and Vaginal Misoprostol Compared With Vaginal Misoprostol Alone for Cervical Ripening and Labor Induction: A Randomized Controlled Tria." Obstetrics and Gynecology (2013): Obstetrics and Gynecology. Web. 20 Jan Karjane NW, Brock EL, Walsh SW. Induction of labor using a Foley balloon, with and without extra-amniotic saline infusion. Obstet Gynecol 2006;107:234– Labor induction in women with an unfavorable Bishop score: randomize controlled trial of intrauterine Foley catheter with concurrent oxytocin infusion versus Foley catheter with extra-amniotic saline infusion with concurrent oxytocin infusion. Am J Obstet Gynecol 2004;191: 225–9. (Level I)

31 + Citations Suffecool, K., BM Rosenn, S. Kam, J. Mushi, J. Foroutan, and K. Herrera. "Labor Induction in Nulliparous Women with an Unfavorable Cervix: Double Balloon Catheter versus Dinoprostonea." Journal Perinatology Medicine (2013): n. pag. PubMed. Web 23. Jozwiak, Marta, WM Kitty Bloemenkamp, Anthony Kelly, Willem Ben Mol, Olivier Irion, and Michel Boulvain. "Mechanical Methods for Induction of Labor." Cochrane Database of Systemic Reviews 3 (2012): n. pag. Wolters Kluwer. Web. 14 Jan Sanchez-Ramos L, Chen AH, Kaunitz AM, Gaudier FL, Delke I. Labor induction with intravaginal misoprostol in term premature rupture of membranes: a randomized study. Obstet Gynecol 1997;89:909– Am J Perinatol Apr 16. [Epub ahead of print] Labor Induction for Premature Rupture of Membranes Using Vaginal Misoprostol versus Dinoprostone Vaginal Insert.Abraham C, Meirowitz N, Kohn N.Abraham C, Meirowitz N, Kohn N. 26. Dare MR, Middleton P, Crowther CA, Flenady VJ, Varatharaju B. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD DOI: / CD pub2. (Level III) 26.


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