Induction of Labor

Joseph Breuner, MD Obstetrics Fellowship Director Swedish Family Medicine Residency April 10, 2007

Why is induction important?

40 to 60 % of pts at first hill get pitocin Labor is terrifying Transition from passive to active medical role

Teaching points

Stillbirth rate Foley bulb Doubles c-section rate for any indication

Stillbirth

Devastating event Defined as death before delivery after 20 wks Collective incidence 6 per 1000 Fear of this motivates ob decisions, often irrationally

Silver, ob/gyn 2007

Stillbirth by gestational age

0.003

0.002

0.001

0 40 wks 41 wks 42 wks 43 wks

Gabbe 2002

ACOG recommends

Consider induction in pts >41 wks with a favorable cervix If cx unfavorable, semiweekly testing or induction are equally reasonable options

Gabbe 2002

dating

1. 1st tri scan 2. 2nd tri scan 3. good LMP 4. 3rd tri scan

When do I get NST/AFI?

NST at 41 and 41 3 or 4/7 AFI at 41 Induce at 42

Joe, today

Never Induce Before

39 wks without
Amnio for fetal lung maturity Strong medical indication both

Mechanical induction methods

Foley bulb

Induction doubles section rate

First hill and ballard campuses 1999 and 2000 Luthy et al

Risk factor Nullip/ multip Chronic HTN fibroids Birth wt>4k GA>42w ks

Section Section rate with rate without 18% 3%

24% 17% 20% 35% 11% 11% 10% 11%

Odds ratio 6
2 1.5 2 3

Risk factor

Section Section rate with rate without

30% 32% 11% 8%

Odds ratio
3 4

abruption Abnl position

induction 19% Primip 18% induction Multip 3% induction

11% 35% 6%

1.8 2 2

Teaching points

Stillbirth rate 1 per 1000, 1.5, 1.8, 2.9 at 40, 41, 42, 43 wks Foley bulb Induction doubles section rate

Case 1

28 yr old primip at 40 1/7 wks Prodroming for 4d, in triage every 12 hours why cant you induce my labor?

Case 1

Cervix bishop score 3 Nst ok Afi fluid ok

Case 2

Multip 35 yrs old somali woman 42 3/7 Only 2 pn visits in last month Now in yr exam room No antenatal testing God will take care of me

Case 3

41 3/7 wk primip Bishop score 2 NST non reactive with variable to 80s AFI 10