INDUCTION OF LABOUR - RECOMMENDATIONS

Dr Narimah Awin

Regional Adviser (MRH)

SEARO

Asian Conference on Maternal and Newborn Health, Dhaka, 4th-6th 2012

INDUCTION OF LABOUR

WHAT?

HOW?

WHY?

WHY NOT?

WHAT TO RECOMMEND?
WHO Recommendations for IOL

WHAT IS IOL ?
The process of artificially stimulating the uterus to start labour

HOW is IOL done?

Oxytocin or prostaglandin Manual rupture of amniotic membrane (ARM)

WHY ?
post-mature , 41 weeks gestation or more
prelabour rupture of membranes

fetal death
ecclampsia and severe pre ecclampsia (separate recommendations) maternal medical conditions (GDM)

WHY?
vaginal bleeding
chorioamnionities

twin pregnancy
request - not willing to wait
- convenience, choice of date

WHY NOT ?
- not risk free
- discomfort, reduced mobility

- close monitoring required, implication on resources, LSCS - complications can occur

- bleeding

- hyperstimulation of uterus --- rupture

Recommendations

Recommendations
General principles
IOL in specific circumstances

Methods of cervical ripening & IOL

Management of complications Setting for IOL

General principles
Only when indicated, benefits vs risks
Consider wishes of woman, status of cervix, methods and associated conds Caution risk and complications Monitor; if oxytocin/prostaglandin never to leave unattended Failed IOL not always indicate Cs, but if possible only in facilities with CS

Recommendations
(1) Specific circumstances
- prelabour rupture of mebrane - GDM - macrosomia - uncomplicated twin
- post-term

(2) Methods
- oxytocin
- misoprostol - other prostaglandin - balloon catheter

(3) Managing uterine hyperstimulation (4) IOL in outpatient setting

GRADE
Grading of
Recommendations Assessment and

Development of
Evidence

GRADE
1) Quality of evidence
- evaluate quality

- prepare GRADE tables

2) Strength of recommendation
- strong (desirable effect of the recommendation
outweighs the undesirable effects)

- weak (desirable effects probably outweighs

undesirable effects but expert panel is not confident about these trade-offs)

(1) Specific Circumstances

Recommendation Quality Strength

1. Post-term, 41 weeks (YES) 2. GDM beofre 41 week (NO)

3. Fetal macrosomia (NO) 4. Pre Labour membrane rupture (YES) 5. Un complicated twin (NONE) 6. Dead fetus (YES)

Low Low
Very Low High Low

Weak Weak
Weak Strong Strong

HDP ECCLAMPSIA &PRE-ECCLAMPSIA

- The only definitive treatment of ecclampsia and pre-ecclampsia is delivery of the baby and placenta
- Separate guidelines developed - Timing of delivery depends on severity of disease, term or preterm

Expectant management or IOL for mild PET? IOL is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks of gestation
Koopmans et al, Lancet 2009, 374:979-988

HDP-TIMING BASED ON SEVERITY OF DISEASE

"Severe pre-eclampsia and eclampsia are managed similarly with the exception that delivery must occur within 12 hours of onset of convulsions in eclampsia. ALL cases of severe preeclampsia should be managed actively"
Managing Complications in Pregnancy and Childbirth, 2000

HDP -TIMING BASED ON SEVERITY OF DISEASE

"In severe pre-eclampsia, delivery should occur within 24 hours of the onset of symptoms"
Managing Complications in Pregnancy and Childbirth, 2000

HDP - CURRENT RECOMMENDATIONS

Deliver within 24 h for severe preeclampsia Expectant management with monitoring for mild preeclampsia until 36 wk; induce labour after 37 wk

Induction methods include amniotomy, oxytocin, prostaglandins including misoprostol and balloon catheter
Managing Complications in Pregnancy and Childbirth, 2000

(2) Methods of iOL

Recommendation 1. Oxytocin alone, prosta not available (YES) 2. Oral misoprostal 2ug, 2hrly (YES) 3. Vaginal misoprostal 2ug, 6hrly (YES) 4. Previous caesarian (NO) 5. Balloon Catheter with oxytocin prostaglandin not available (YES) 6. Sweeping membrane (YES) Quality Mod Moderate Moderate Low Low Moderate Strength Weak Strong Strong Strong Weak Strong

(3) Management of uterine hyperstimulation betamimetics are recommended (low quality, weak rec) (4) IOL in outpatient setting is NOT recommended (low quality, weak rec)

THANK YOU