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RECENT GUIDELINES ON INDUCTION OF LABOUR.

Royal College of Obstetricians & Gynaecologists. ngg-gs.

PREREQUISITES FOR INUCTION OF LABOUR. FOGSI-ICOG(2018) WHO ACOG NICE QUEENSLAND NHS Consent Baseline estimationn of GA,EFW,CTG for FHR patterns Maternal pelvis assessment Assess the Cx IOL-clear medical indications Consider woman”s wishes,preferences Cervical status,method of induction. Ensure availability of CTG Maternal H/ O,Baseline inv. Nad abdominal examination and consent. Antenatal fetal surviellance reports Abdominal examination Assess the readiness of cx (Bishop’s score) Antenatal CTG to confirm FHR patterns and Ut contractions before IOL Maternal H/ O,GA,baseline inv.,Abdominal palpation,assess membrane status,VE Informed consent,Assess fetal well being. Check GA,,Abdominal examination,USG,CTG,Basic investigations..

P OSTDATED OR PROLONGED PREGNANCY. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS IOL at 41 weeks for uncomplicated pregnancies. IOL at 39 weeks for low risk pregnancies. IOL at >40 +7 weeks (In whom who are known with certainty) Sonographic measurements taken before 20 wks of GA support GA of >39 weeks or FH documented for 30 weeks by doppler usg.or A Positive serum or urine B-HCG result has been documented for >36 weeks. IOL after 42 weeks is recommended.41-42 weeks can be considered. ILO at 41 completed weeks If the woman does not want their labor induced at 42 weeks-weekly twice CTG,USS ILO at 41 completed weeks for uncomplicated cases. Waiting after 42 weeks is not recommended. IOL at 41 -42 weeks especially 41+5 weeks.

PROM. FOGSI-ICOG WHO ACOG NICE NHS At term (>37 weeks)IOL is recommended. IOL at term , oxytocin as 1 st option Immediate IOL at diagnosis With vaginal PGE2 PROM at term-Expectant Mx till 24 hours in the absence of infection . Immediate IOL/CS if >48 hrs or GBS + ve . No GBS/MSL-IOL after 24 Hrs. GBS +VE- Imm . IOL MSL(thick)-IOL with Oxytocin MSL(thin)-IOL with PGE2.

PPROM. FOGSI-ICOG ACOG NICE NHS 34-37 weeks-Expectant Mx upto 37 weeks in the absence of sepsis. <34 (IOL not Recommended)Weeks-AN steroids,MGSO4,IV antibiotics. Delivery is recommended for all women with >34 weeks of GA with Ruptured membranes. <34 weeks-No IOL 34-37 weeks-Expectant MX upto 37 weeks. If GBS + ve -Immediate IOL with PGE2/ Oxytocin or CS Expectant management upto 37 weeks in the absence of infection..

GESTATIONAL DIABETES. FOGSI-ICOG WHO ACOG NICE NHS GDM on MNT-IOL at 39 -39+6 weeks Well controlled with insulin/OHA-38 weeks Un controlled DM- Mx should be individualised If GDM is the only abnormality,IOL before 41 weeks is not recommended. IOL if there is placental insufficiency/uncontrolled DM Pre GDM-well controlled-39-40 weeks PreGDM with vascular complications-36-39 weeks On MNT-39-41 WEEKS. Well controlled on drugs-39-40 weeks Type 1 and 2 with no complications-37-38+6 weeks. With Complications-before 37 weeks. GDM with maternal and fetal complications-before 40+6 weeks GDM without complications-after 40+6 weeks GDM with macrosomia-37 weeks. Well controlled with insulin with normal fetal growth-38 weeks. Well controlled with MNT-40+6 WEEKS.

FGR. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS IOL at term is advisable at term to prevent stillbirth None Uncomplicated-38-39 weeks. EFW<3 RD % and abnormal umblical A Doppler-37 weeks Absent end diastolic flow-IOL not recommended If there is severe FGR with fetal compromise IOL is not recommended. Timing of birth depend s on GA,severity of concern,and results of fetal well being IOL at term is appropriate FGR with Normal doppler-37 weeks. Abnormal doppler-Mx should be individualised ..

FETAL MACROSOMIA. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS None IOL not recommended for suspected macrosomia Suspected fetal macrosomia is not an indication for IOL. IOL not recommended in the absence of other indications IOL on the basis of fetal macrosomia alone is not recommended IOL recommended at 38+ weeks if EFW->3500g at 36 weeks >3700g at 37 weeks >3900g at 38 weeks GDM with macrosomia -IOL at 37 weeks. And CS if EFW>4500G CS if EFW >5Kg in Non Diabetics.

ON MATERNAL REQUEST. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS Not routinely practised for non medical reasons. - - Not routinely offered on maternal request except under exceptional circumstances. Consider IOL at term based on exceptional circumstances of the women and her family. IOL at 40 weeks if favourable ..

IUD. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS In 90% SP.labour starts in 3 weeks.If IOL is delayed for 48 hrs-weekly twice testing for DIC. PGE2 AND oxytocin can be used for IOL In 3 rd trimester for dead and anamolous fetus oral or vaginal misoporostol can be used <28weeks-vaginal misoporostol (200 to 400 mcg every 4 -12 hrs)or high dose oxytocin . >28 weeks-usual obstetric protocol. Oral mifepristone 200mg followed by vaginal PGE2 or Misoprostol aftre 36 to 48 hrs. - Same as NICE guidelines.oxytocin is not routinely recommended..

PREVIOUS CS. FOGSI-ICOG WHO ACOG NICE NHS Ensure availability of Emergency caesarean and fetal well being services. Favorable Cx -AMNIOTOMY +OXYTOCIN Unfavorable Cx -Mechanical methods. - Mechanical method can be used.PGs should be avoided IOL in scarred uterus increases the risk of uterine rupture and Em.lscs rate PGs should be avoided. Not an indication for IOL. Cervical ripening with balloon catheter is preferrable ..

TWIN PREGNANCY. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS IOL at 37 weeks is recommended for uncomplicated twin pregnancies. None MCDA-with fetal growth restriction-32 -35 weeks DCDA-37-38 Weeks MCDA-36 WEEKS,DCDA-37 weeks In uncomplicated twin pregnancies (MCDA/DCDA)-Plan birth after 37 weeks MCDA-36 weeks DCDA-37 weeks.

OBSTETRIC CHOLESTASIS. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS IOL at 37 to 38 weeks IOL before 36 weeks in case of biochemical abnormalities None When total bile acid level<100-IOL at 37 to 39 weeks Bile acid>100-36=7 weeks or at diagnosis if diagnosed later. IOL at 37 weeks to reduce stillbirth rate. IOL at 37 to 37+6 weeks to reduce still birth rate. Cosider IOL before 36 weeks for patient with severe jaundice and biochemical abnormalities. IOL at 37 weeks.

OUTPATIENT INDUCTION. FOGSI-ICOG WHO ACOG NICE Not recommended Not recommended. None Consider outpatient induction with vaginal PGE2 or mechanical methods in women who wish to return home.

M ETHOD S O F I NDUCTIO N.

MECHANICAL METHODS. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS Causes similar effects like vaginal PGE2. Duration 24 hrs. Less chances of Ut.hyperstimulation Contraindicated in PROM and vaginal bleeding. Balloon catheter alone. Or Balloon catheter with Oxytocin when PGs are not available or contraindicated Foley is reasonable and cost effective alternative Foley catheter and laminaria should not be used routinely Balloon catheter-single(capacity 30-80 ml) or double balloon(30 ml) Balloon cathter is used in cases of previous LSCS,PARITY>4 and failed induction with PGs.

MEMBRANE SWEEPING. FOGSI-ICOG WHO ACOG NICE QUEENSLAND It is suitable for non urgent conditions.It can be repeated at regular intervals Recommended for reducing formal induction of labour Effective method in inducing spontaneous labour within 48 hrs. Offered at 40 weeks in nulliparous and 41 weeks in multiparous women It reduces the need for additional pharmacological IOL Decreses the need for IOL by encouraging spontaneous labour . Serial membrane stripping on alternate days reduces the no.of pregnancies reaching 42 weeks..

PHARMACOLOGICAL METHODS. FOGSI-ICOG WHO ACOG NICE QUEENSLAND NHS PGE2-Vaginal gel(3mg),pessary10mg,or tape. Oxytocin start at low dose1-2 mu /min to high dose 40 mu /min. Miso not yet approved. Oral miso (25mcg-2 nd hrly )Vaginal miso (25mcg 6 th hrly ) Low dose PGE2. Amniotomy +low dose oxytocin if PG is not available. Amniotomy alone is not recommended. PGE2 gel0.5 MG 3 doses at 6 hr interval. Vag.miso at 3 to 6 hr interval Oral 50 to 100mcg at 3 to 6 hr interval. Oxytocin (1 to 6 mu)infusion. Vaginal PGE2 /gel 6 th hrly (max 2 doses) Pessary one dose over 24 hrs. Low dose(25mcg)miso for induction Miso and mifepristone only in IUD.oxytocin (max 32 mu) PGE2 and oxytocin.Misoprostol isnot used for Induction. IF Bishops score is < 6-PGE2 gel or tablet/Mechanical. If bishops score is >6-Amniotomy + oxytocin.

O XYTOCIN INFUSION CALCULATION. NICE GUIDELINES 1.30 U IN 500ML RL 2.30000 MU IN 500 ML 3.60mU IN 1 ML 4.Stat dose is 1MU/min 5.so,start at a rate of 1ml/hr and dose can be increased upto 32 mU /min..

FOGSI GUIDELINES. 1ml of oxytocin is added to 4ml of NS to make it as 1U /ml Add 1ml of this mixture in 500ml of isotonic solution.i.e.1000mu in 500ml 1ml =2mu=16 drops O.5ml /min=1mu/min=8 drops /min(low dose oxytocin)-30ml/hr in infusion pump. High dose of 40 m. units/min is allowed as per FOGSI guidelines.

Appendix D Good Clinical Practice Guidelines FOGSI- ICOG 2018 Induction Of Labor: G C PR Check List Age ( Date Of birth ) : —years; p ( peri ) ; Gestational age by first ultrasound done before 20 &veeks Of gestation ) : History Of any allergies. rnedical condition . special need: Yes/ No High Risk Review: Yes,'No for Yes/ No Consent signed by the patient and her attendant : Rate t Yes/ No Of the t : Signature of the Doctor: of the IDO,ctor: Yes/ No • Date and tirne:.

IMPORTANT TERMINOLOGIES. Induction of labour Membrane sweeping(separatechorionic membranefrom deidua,cervical massage if the os is closed) Cervical ripening(use of pharmacological/other methods to soften,efface,or dilate the cervix to increase the likelihood of normal delivery) Successful induction-A vaginal delivery within 24 to 48 hours of induction of labour..

iv.Uterine tachysystole(more than 5 contractionsin 10 min for atleast 20 min without FHR changes)) v.Uterine hyper stimulation(a contraction lasting atleast 2 min) associated with FHR changes. vi.Unsuccessful induction/Failed induction-(labour not starting after one cycle of treatment-insertion of 3 doses of PGE2 gel and 12-24 hours of oxytocin administration. Or one PGE2 pessary within 24 hrs)..

TAKE HOME MESSAGES. Informed consent Mechanical methods are reasonable and cost effective alternative. PGE analogues are effective for cervical ripening.(Misoprostol is used offlabel after28 Weeks of gestation) Intravaginal PGE2 in PPROM appears to be safe and effective. The use of Misoprostolshould be avoided in women with previous uterine scar. If primary methods fails, other methods can be tried...