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How to Schedule an Induction:
Call L&D Triage (for Meriter 608-417-7688, for St Mary's 608-258-6820) and discuss with HUC
Be prepared with patient name, DOB, GA, GP, conditions complicating pregnancy, and indication for induction (Survival Guide - indications for induction or see below)
Identify the attending on call (generally that day and the following day) and send EPIC inbasket message with pt chart and details of induction
Literature:
AFP Cervical Ripening and Labor Induction 2022
ACOG Committee Opinion IOL 2009 (seriously, that looks like the last update)
ACOG Com Opin on Late Preterm/Early Term delivery indications
Powerpoint from fac development 2024 on outpatient cervical ripening
General Information:
DFMCH Survival Guide - Induction of Labor
Pictocin Protocol for Meriter (from 9/19/21)
Cervical Ripening Protocol for Meriter
PROMMO Study - DON'T FORGET for Meriter pts with PROM
Video of cooks catheter placement
ObG Project Summary - Induction of Labor
Information on early amniotomy after cervical ripening:
Am J of OBGYN - Early amniotomy 2020
JABFM - "Just Pop It: Early AROM after cervical ripening" 2024
Bottom line for early amniotomy: Does not decrease risk of c-section but reduces interval from induction to delivery
**Not recommended for pt with active Hep B, Hep C, or HIV**
Dilation.pdfCooks Catheter Best Practices
Cooks Catheter Best Practices
All first year residents should have an experienced guide when placing a cooks catheter (senior resident or faculty)
For patients with very little dilation consider using a speculum and ring forceps to aid in insertion
May want to consider using dilaudid or other pain control method with insertion to ease patient experience
Consider checking the cooks catheter at 2 hr by deflating the vaginal balloon and assuring that the uterine balloon is appropriately positioned.
Misoprostol Reminders
Misoprostol Reminders
Misoprostol is absolutely contraindicated for patients who are induced and have a prior uterine scar (i.e., TOLAC), as there is an association with its use and uterine rupture (6% rupture rate in some studies!).
Misoprostol should also not be administered in the context of concerning EFM tracing given its potency and inability to stop the medication quickly
Reevaluate contraction pattern and EFM prior to administering subsequent doses of misoprostol. If you’re concerned about fetal status or uterine tachysystole, misoprostol is probably not the best choice.
Pitocin Info
Pitocin Info
Pitocin (oxytocin) is used for labor augmentation to enhance uterine contractions when labor is not progressing adequately or for induction with an adequate bishops score.
Initial dose for labor augmentation is 0.5–1 mU/min, which can be increased by 1–2 mU/min at intervals of 30–60 minutes. Goal is to achieve a contraction pattern that mimics natural labor, with contractions occurring every 2-3 minutes, lasting 60-90 seconds, and of sufficient intensity to promote cervical dilation and fetal descent (200 mVU)
The maximum dose typically does not exceed 9–10 mU/min at term (but we do sometimes go up to 20 mU/min, seriously consider an IUPC in that case)
Continuous electronic monitoring of uterine activity and fetal heart rate is essential during administration to detect any potential complications, such as hypertonic contractions or fetal distress. If you are having decelerations first turn off the pitocin! Can restart at lower dose to see if baby tolerates
Nipple Stimulation for Labor Induction
Nipple Stimulation for Labor Induction
Nipple stimulation is a way to cause endogenous oxytocin release, and may be favored by some patients for home “induction start” or cervical ripening.
It has only been studied in low-risk pregnancies, and generally seems to work better in patients with a favorable Bishop score already. In a small randomized controlled trial, bilateral breast massage for 15 to 20 minutes three times daily starting at 38 weeks' gestation increased the chance of vaginal delivery, with an NNT of 8
Nipple stimulation has also been associated with an increased trend in perinatal death, so ACOG does not recommend its use in an unmonitored setting until there is further study.
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