Induction of Labor, Labor after Induction - PowerPoint Presentation

Slide1

Induction of Labor, Labor after Induction

W. Spencer McClelland, MD

Physician Lead, Women’s Care Clinic, Denver Health

Assistant Professor, Obstetrics and Gynecology, CU Anschutz

Co-Chair, SOAR Steering Committee, Colorado Perinatal Care Quality Collaborative

My disclosures

None

My bona fides

Six years in practice

Now at Denver Health, but previously in private practice in NYC

Three different hospitals, two different states, private and public

Trained in a mixed setting, alongside CNMs

About 800 babies, Personal NTSV rate: 11%

Outline

Cervical ripening agents

Pharmacologic

Mechanical

Artificial rupture of membranes (AROM)

Oxytocin

Multimodal induction

Diagnosing failed induction of labor

Digressions and big picture thoughts along the way

A warning, to start

Be skeptical about the data

There is at least one study to prove each side of an issue

The less evidence there is on a topic, the more strongly people hold their particular beliefs

Evidence, opinion, evidence-based opinion

E

O

O

E

Cervical ripening

How much does the Bishop score matter?

Conventional wisdom

Bishop score helps predict “success” of induction as compared to spontaneous labor

By extension, has been used to guide the need for cervical ripening prior to initiation of Oxytocin

Gibson et al, AJOG 2014

Comparison of elective induction vs expectant management

Risk of Cesarean delivery (CD) lower at each week of gestational age (GA)

True

regardless of Bishop score!

BTW, similar finding in the ARRIVE trial, as well

O

E

Wormer et al. Bishop Score.

StatPearls

.

Gibson et al. Am J

Obstet

Gynecol

214;211:249.e1-16.

Prostaglandin (analogs)

Variety of acceptable agents, routes and doses

Effective at reducing CD rate and failure to deliver vaginally within 24 hours, but can cause tachysystole (usually without FHR changes)

Misoprostol, PGE1 (Cytotec)

Routes: vaginal, oral

Pros: inexpensive, easy to administer

Cons: repeated doses

Dinoprostone

, PGE2 (

Cervidil

)

Pros: set it and forget it

Cons: higher rates of tachysystole, expensive

E

Chen at al.

BJOG. 2016 Feb;123(3):346-54.

Foley

Single vs double

No difference in CD rate or other outcomes

Single more cost-effective (Foley vs Cook)

Single may be safer, too?

Tension vs no tension

Consistent evidence that time to expulsion is shorter with tension

Time to delivery is not, but hold that thought for a couple slides…

Also, probably safer when using single balloon?

With rupture of membranes?

May not improve time to delivery, but also unclear re infection risk

Liu et al. BMC Pregnancy Childbirth. 2019 Oct 16;19(1):358.

Salim R et al.

Obstet

Gynecol. 2011 Jul;111(1):79-86.Fruhman et al. Am J Obstet Gynecol. 2017 Jan;216(1):67.e1-67.e9.Amorosa et al. Am J Obstet Gynecol. 2017 Sep;217(3):360.e1-360.e7.

O

E

AROM

Multiple trials show the same thing re early amniotomy (≤ 4 cm)

Shortened time to delivery

Increased proportion delivered within 24 hours

No increase in infectious morbidity or other complications

** All of the above is true in nulliparous patients

What about after a cervical Foley?

The sooner the better: all the same findings are true as above

Getting back to the Foley tension question, this argues for placing Foleys on tension, in order to get to AROM sooner

No difference in patient satisfaction with “early” AROM

The evidence is clear, so let’s not treat this as a matter of opinion

E

Macones et al. Am J Obstet Gynecol 2012;207:403.e1-5.

Kim et al. Am J Obstet Gynecol MFM. 2019 Nov;1(4):100052.

Gomez Slagle et al. Am J Obstet Gynecol. Presented at SMFM, Feb 4, 2022.

Am J Obstet Gynecol. 2019 Apr;220(4):387.e1-387.e12.

Oxytocin (Pitocin)

High- vs low-dose regimens

No evidence of increased success of vaginal birth vs CD, or vaginal birth within 24 hours

Conflicting data on whether time to delivery is shorter with high-dose

No difference in other outcomes, particularly complications

E

Cochrane Databse Syst Rev. 2014 Oct 9;2014(10):CD009701.

Multimodal induction

Misoprostol + Foley, vs miso alone

Shorter time to delivery

Lower incidence of tachysystole and meconium staining

No difference in CD rate or clinical chorioamnionitis

Foley + Oxytocin, vs Foley followed by Oxytocin

Conflicting data, but most recent meta-analysis shows increase in delivery within 24 hours

E

Lee et al. Int J Environ Res Public Health. 2020 Mar 11;17(6):1825.

Liu et al. J Matern Fetal Neonatal Med. 2019 Oct;32(19):3168-3175.

Putting it together

If you’re going to Cytotec, Cytotec until you can’t

Foley as soon as you can

Tension recommended, for efficiency and also safety

Oxytocin should overlap with Foley

AROM immediately after Foley

O

E

Guidelines: when to call it

Failed induction of labor is a

latent phase problem

Once a patient reaches 6 cm or beyond, they are in beholden to active phase standards

So please

please

please

keep the two groups distinct

How do you decide 12 hours vs 18… vs 24?

There’s more to a cervical exam than just dilation!

Do the effacement and station give you hope, or not?

O

E

ACOG Obstetric Care Consensus No. 1. March 2014.

Active phase considerations

Transition

Friedman: 4 cm vs Zhang: 6 cm

Patients haven’t read the textbook, so don’t get hung up on numbers (particularly just dilation)

It is uncommon for patients to sustain their own labor without intervention once they enter the active phase

More likely if they were more favorable to start

Tachysystole

Are we too obsessed, in the absence of FHR changes?

If we are going to be obsessed, then let’s be diligent about the definitions

O

Different flavors of inductions

Medical vs elective

Patient preference: natural childbirth vs not

Time-sensitive vs not

Is anything not time-sensitive?

Prolonged labor/induction is associated with…

Increased risks to patient and fetus/neonate

Decreased patient satisfaction

O

McKinney et al. Am J Obstet Gynecol MFM 2019; 1:100032.

Kempe et al. Eur J Obstet Gynecol Reprod Biol. 2020 Mar;426:156-159.

Dupont et al. Midwifery. 2020 May;84:102663.

The Great Dance

Expectations are everything!

Do your counseling ahead of time; that’s what prenatal care is for

There is no such thing as physiologic induction, but that doesn’t mean everything goes out the window in terms of birth preferences

Don’t make assumptions about a patient’s wishes

Don’t be monolithic in your approach

Birth preferences and interventions both exist along a spectrum, and there are ways to live in the middle comfortably

We all strive to be patient-centered, so remember to

care for the patient in front of you

, not the

type

of patient, not the

medical scenario

, not the day or time of day

O

The View from 30,000 Feet

Each patient with a long induction impacts another patient, whether we see it directly or not

ARRIVE trial

Early naysayers said ARRIVE inductions would overwhelm hospital resources, but maybe the opposite is true?

We are approaching a moment of reckoning where earlier induction may progressively be seen as the standard of care, not just for preference, but because of medical benefits

“Risk-reducing” inductions, not “elective”

When that time comes, “elective” inductions may not be so elective, and we will have to refine our system to accommodate patients

Efficient, safe, and patient-centered inductions will be a key part of our path forward

Opipari et al. Presented at SMFM 42nd Annual Meeting, Jan, 2022. Vol. 26, Issue 1, Supp. 1.

O

E

Summary

Set expectations: what can be adjusted/avoided, what cannot

Bishop score and cervical ripening may matter less than we thought

It may take longer to get to active labor, but so be it

AROM is key: the earlier the better, from every standpoint

Worry about getting to AROM more than improving the Bishop score!

So think of your Foley as a way to get to AROM sooner

Multimodal induction techniques are more effective

Don’t rush diagnosing failed induction of labor

Keep the 30,000-foot perspective in mind!