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Induction of Labor

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					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       Section Section     Odds
factor     rate with rate      ratio
                     without
Nullip/    18%       3%        6
multip
Chronic    24%       11%       2
HTN
fibroids   17%       11%       1.5
Birth      20%       10%       2
wt>4k
GA>42w     35%       11%       3
ks
Risk factor   Section Section     Odds
              rate with rate      ratio
                        without

abruption     30%       11%       3
Abnl          32%       8%        4
position
induction 19%           11%       1.8
Primip    18%           35%       2
induction
Multip    3%            6%        2
induction
                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 can‟t 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 80‟s
   AFI 10

				
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