Induction of labor A case and evidence based

Induction of labor A case and evidence based approach Maria Pia Castillo, MD

Goals of lecture ● Learn evidence-based facts about IOL and improve management for IOL ● Practice quick reading and summarizing of journal articles ● Work in teams to answer clinical questions

Case #1 ● 37 yo Latina G 1 at 39+3 w today who you are seeing in clinic. She has had an uncomplicated pregnancy thus far, normal vitals today, normal fundal height and would really like to avoid induction. ● She’s been going to ANT as you recommended, but feels like it’s a hassle, asking if she can stop ● Your SVE today: closed/thick/high ● What are your plans for surveillance? For delivery?

Reddy et al paper Answer the following questions: 1. 2. 3. 4. 5. 6. 7. What is the study design? What were the objectives of the study? What was their data set? What were the medical conditions they accounted for? What did they find? What were some useful figures? Does it matter if multiparous or nulliparous? Does it matter what her race is?

So. . . what will you offer her?

Sorry - no consensus ● Data definitely supportive of doing SOMETHING ○ ○ ANT? ■ Offer to women AMA and explain risks of stillbirth, can start at 34 -36 w ■ Women closer to 40 yo you might encourage more strongly to get ANT IOL? ■ Recommend against going >41 w for all AMA women ■ Offer IOL at 39 -40 for women closer to 40 yo

Back to case #1 Your pt open to ANT, will have weekly NST, but she’s not totally sure about IOL, ok with membrane sweeping if the evidence supports that. Wants to know what else is natural.

Membrane sweeping: Cochrane from 2010 ● Potential mechanism: initiates labor by increasing production of local phospholipase A 2 and Protaglandin F 2 alpha ● 2797 women included ● Risk of cesarean, maternal/neonatal infection similar with no intervention ● Beyond 38 w: reduced the duration of pregnancy and reduced the likelihood that the pregnancy would continue beyond 41 w (RR. 59 with 95% CI) and 42 w (RR=. 28, 95% CI) ● NNT to avoid IOL =8

Nipple Stim Cochrane 2010 ● Proposed mechanism: oxytocin release with nipple stimulation ● 719 women included, only one study had women use pump, otherwise massage (1 hr either a couple times a day or once a day for 3 days) ● Reduction in the women not in labor in 72 hrs RR=. 67 95% CI ● No reduction in women with unfavorable cervix ● Reduction in postpartum hemorrhage RR=. 16 95% CI ● No significant difference in cesarean rates RR=. 90

So. . . what will you tell her?

Won’t induction of labor increase my chances of CS? ● Baseline risk for CS the same for AMA women with IOL or with expectant management ● Risk of stillborn higher, per prior paper ● Aggressively strip membranes, and consider setting up IOL as soon as pt amenable

Case #1 continued ● After 2 days of nipple stim and mineral oil, pt comes in to OBT for evaluation and is 1/25/-3 ● Pt having rare contractions, but definitely done being pregnant ● How will you augment her?

Conclusion of Case #1 ● ● ● After one dose of miso pt enters a good contraction pattern Contractions space out at 4, you start pitocin, she gets to complete After 2. 5 hrs pushing, pitocin at 2, a healthy girl is delivered. Pt has EBL of 250 cc, you gave pit bolus, bleeding resolved yay

Case #2 ● 23 yo white G 3 P 10011 at 40+3 with hx of cs for stage I arrest in setting of chorio and NRFHT in clinic for prenatal visit. Really would like to TOLAC. Her pressure in clinic was 154/90 and in OBT 147/94. She’s had some contractions, but doesn’t think much is going on. ● SVE: 1/50/-1, attempted to strip membranes ● How will you manage her?

TOLAC and IOL - Bujold et al Answer the following questions: 1. 2. 3. 4. 5. 6. 7. 8. What is the study design? What were outcomes measured? Inclusions and exclusions? What were some of the variables looked at? Which did they consider about confounders? How were inductions done in the study? What tables are helpful for seeing who was included/sample size/characteristics? What did they find? What were some useful figures? What are some limitations of this study?

Case #2 continued ● Explain that with TOLAC, better outcomes if not needing IOL/augmentation ● Very important to re-counsel about TOLAC if needing IOL, as per our lit review ● Shared decision making on following factors: ○ ○ Successful VBAC Risk of uterine rupture

Case #3 ● 29 yo G 1 at 38+5, has had an uncomplicated pregnancy other than horrible pubic symphysis pain ● She really wants to be done with this pregnancy ● Her friend told her that if she gets induced she’ll end up with a cs

ARRIVE trial Answer the following questions: 1. 2. 3. 4. 5. 6. 7. 8. What is the study design? What was the hypothesis? What were outcomes measured? Inclusions and exclusions? What were some of the variables looked at? Which did they consider about confounders? How were inductions done in the study? What tables are helpful for seeing who was included? What did they find? What were some useful figures? What are some limitations of this study? Strengths?

What do you tell her regarding her risk of CS? ● It’s actually lower if she decides to go for IOL ● If her cervix is favorable, she can consider it ● Her baby’s outcomes are unlikely to be affected by IOL

Case #4 ● 28 yo G 3 P 2 at 39+5 with no complications, but can’t manage kids, summer time, being pregnant ● She read the ARRIVE trial and she’s convinced -- she wants an induction ● She wants something that will get her into labor, for her first 2 pregnancies she didn’t start labor until 41+4 and she’s really not feeling that ● Also tells you she has minimal childcare so needs to be a “quick induction” ● SVE: 2/25/-3

Leopold and Sciscione 1. 2. 3. 4. 5. What kind of article is this? What are the methods they looked at? What aspects of induction did they look at? What were some of the more interesting results? Anything you learned? What was their conclusion about what should be done for IOL outpatient?

Back to case #4 ● ● ● Sorry, we can’t do outpatient IOL in UNM -- maybe someday! She opts for inpatient IOL 40+1 SVE on arrival 3/50/-1 Gets started on pitocin and gets to complete in 4 hrs, pushes baby out in 1 Very pleased with outcome, she recommends you to all her pregnant friends.