NICE GUIDELINES - IOL

Question 1

What are the risks associated with a pregnancy continuing over 41:0?

Answer 1

• increased likelihood of Caesarean section
• increased likelihood of baby being admitted to a NICU
• increased likelihood of stillbirth and neonatal death

Question 2

What are the steps to take if a woman declines IOL?

Answer 2

• discuss additional fetal monitoring
• advise that additional monitoring only gives a snapshot in time
• adverse events cannot be predicted reliably using extra monitoring
• fetal monitoring could include twice weekly CTG and amniotic fluid assessment
• rediscuss and return precautions must be discussed

Question 3

If a woman has PPROM when should IOL be offered?

Answer 3

Can offer IOL from 34/40 onward (not done in Auckland)

• immediate IOL vs C/S
• expectant management until 37/40

Question 4

How to manage a woman with prelabour rupture of membranes at term?

Answer 4

• offer immediate IOL vs expectant management at 24hrs

- immediate IOL recommended for GBS +ve women with PROM

Question 5

IOL in context of previous C/S

- management?

Answer 5

• IOL can lead to increased risk of Em CS
• IOL can lead to increased risk of uterine rupture
• mechanical method of IOL preferred over Prostin
• dinoprstone and misoprostol contraindicated with women with previous scar

Question 6

If birth needs to be expedited in context of woman with previous CS you can offer:

Answer 6

• IOL
• repeat CS
  record in notes maternal wishes and discussion
  respect a women’s decision

Question 7

maternal request IOL management

Answer 7

• Consider this option following comprehensive discussion about risks and benefits

Question 8

In which scenario could you consider offering an IOL for a breech

Answer 8

birth needs to be expedited, and

external cephalic version is unsuccessful, declined or contraindicated, and

the woman chooses not to have a planned caesarean birth

Question 9

In which scenario could you consider offering an IOL for a breech

Answer 9

birth needs to be expedited, and

external cephalic version is unsuccessful, declined or contraindicated, and

the woman chooses not to have a planned caesarean birth

Question 10

what are the 5 steps you need to carry out before IOL commences?

Answer 10

• abdominally palpate - ?high presenting part >cephalic
• bedside USS for presentation if required
• assess and record bishop score
• confirm normal CTG
• confirm absence of significant uterine contractions

Question 11

what are the 5 steps you need to carry out before IOL commences?

Answer 11

• abdominally palpate - ?high presenting part >cephalic
• bedside USS for presentation if required
• assess and record bishop score
• confirm normal CTG
• confirm absence of significant uterine contractions

Question 12

How would you counsel a woman with a macrosomic baby regarding IOL?

Answer 12

There is uncertainty about the benefits and the risks of IOL cf to expectant management however:

• Shoulder dystocia incidence is reduced in IOL cf expectant management
• The risk of 3&4 degree tears increase with IOL vs expectant management
• There is evidence that the risk of perinatal death, brachial plexus injury and the need for an Em CS is the same for both

Question 13

How would you counsel a woman regarding mode of delivery following confirmation of intrauterine fetal demise?

Answer 13

• If membranes are intact
• No evidence of infection or bleeding
• Can offer IOL, expectant management or CS
  RESPECT the womens decision

Question 14

If a woman has a diagnosed IUD and chooses to opt for an IOL AND has a non scarred uterus how would you proceed?

Answer 14

• Offer mifepristone 200mg

- Prostaglandin or balloon

Question 15

If a woman has a diagnosed IUD and has had a previous C/S how would you counsel her?

Answer 15

• IOL can increase risk of uterine scar rupture

- IOL method should be guided by risk – mechanical advised over prostaglandins

Question 16

What would you counsel a woman regarding membrane sweeping

Answer 16

• Membrane sweeping is a technique that may make it more likely that a formal IOL with either balloon or gel not be required
• Pain, discomfort and vaginal bleeding are possible from the procedure
• Offer membrane sweeping from 39/40

Question 17

What did the boulvain trial assess and conclude?

Answer 17

multicentre non blinded RCT
randomly assigned non diabetic women with macrocosmic babies to either IOL vs expectant management
Found a statistically significant reduction in shoulder dystocia and fracture in IOL group

Question 18

What would you advise a woman asking about hyperstimulation and IOL?

Answer 18

• Prostaglandins associated with risk of hyperstimulation
• Hyperstimulation can be treated with tocolysis
• Misoprostol more strongly associated with hyperstimulation and more difficult to resolve with tocolysis
• Mechanical methods (balloon) less likely to result in hyperstimulation