INFORMATION FOR CANDIDATE:

Your next patient, new to you in general practice, is a

35 weeks pregnant primigravida, Cheryl Ford, who
wants to be induced at 37 weeks for family reasons,
actually her grandmother has been diagnosed with
terminal liver cancer and liver failure and has been
given 2 months to live. She would like to make sure
that her grandmother can enjoy the birth of her first
grandchild before her certain death. Cheryl had all her
antenatal care at the general practice you work at.
YOUR TASK IS TO:
Take a history
Perform a physical examination
Explain the procedure and complications of
induction of labour
Give the most suitable advice to the patient

HOPC: Your next patient, new to you in general practice, is a 35 weeks pregnant
primigravida, Cheryl Ford, who wants to be induced at 37 weeks for family reasons,
actually her grandmother has been diagnosed with terminal liver cancer and liver failure
and has been given 2 months to live. Both, her husband and Cheryl, would like to make
sure that her grandmother can enjoy the birth of her first grandchild before her grandmas
death. It was a planned pregnancy and Cheryl had all her antenatal care at the general
practice you work at and everything has been normal including U/S etc. and the
pregnancy has been uncomplicated. Her blood group is A Rh +.
PHx. + FHx.: unremarkable
SHx: married pharmacist, non smoker, non drinker, NKA, no medication.
EXAMINATION:
Well looking pregnant women with all findings consistent with a 35 week pregnancy with
the fundus just below the xiphisternum, the foetus in a longitudinal lie and cephalic
presentation, not engaged. Normal fetal movement and fetal heart sounds.
No oedema and otherwise normal physical examination.
INVESTIGATIONS:
Urine dip-stix (normal)
DIAGNOSIS: REQUEST FOR ELECTIVE INDUCTION OF LABOUR
Induction of labour is stimulation of uterine contractions before spontaneous labour to
achieve vaginal delivery.
It can be medically indicated (eg, for preeclampsia or fetal compromise) or elective (to
control when delivery occurs). Before elective induction, gestational age and fetal lung
maturity must be assessed; if gestational age is < 39 wk by best obstetric estimates,
amniocentesis is done to determine lecithin/sphingomyelin ratio.
Contraindications to induction include the following:
Fundal uterine surgery
Prior classic or vertical cesarean incision in the thickened, muscular portion of the
uterus
Active genital herpes
Placenta or vasa previa
Abnormal fetal presentation (eg, transverse lie, umbilical cord presentation, certain
types of fetopelvic disproportion)
Multiple prior uterine scars and breech presentation are relative contraindications.
Technique: If the cervix is closed, long, and firm (unfavorable), the goal is to cause the
cervix to open and become effaced (favorable). Various pharmacologic or mechanical
methods can be used:

Medical:
Misoprostol, a synthetic prostaglandin (PGE1) analogue, 25 g vaginally every 3
hours up to 8 doses is effective and helps to ripen the cervix. It softens the cervical
connective tissue and relaxes cervical muscle fibres. Misoprostol has a lesser risk
of excessive uterine activity than prostaglandins!
Prostaglandin E2 (gemprost / Cervagem) given intracervically (0.5 mg) or as an
intravaginal pessary (10 mg). Prostaglandins are contraindicated in women with
prior caesarean delivery or uterine surgery because these drugs increase the risk of
uterine rupture. PGE2 has a lesser risk of producing uterine hypertonicity than
PGE1!
Oxytocin (Syntocinon) in low or high doses by i.v. infusion can also be given and
is most effective if preceded by PGE2 vaginal pessaries or following amniotomy.
Mechanical:
Effective mechanical methods include use of single (e.g. Foley) or double (Atad)
balloon passed aseptically through the cervix and then inflated with sterile saline.
Or the hydrophilic laminaria tent. These may be useful when other methods are
ineffective or contraindications exist.
Surgical:
Amniotomy or artificial rupture of the membranes (ARM!) is the deliberate rupture of the
membranes, more effective if the cervix is favourable (Bishop score 5+).
The major concerns associated with pre-term elective induction of labor are:
MATERNAL: - prolonged labour
- the potential for increased rates of cesarean delivery
- Infection
FETUS:
- iatrogenic prematurity
- Higher risk of neonatal intensive care unit admission
COST.
MANAGEMENT:
1. This scenario requires an objective discussion of the INDUCTION OF
LABOUR with indications, contraindications and complications.
2. Referral to or conference with obstetrician!
3. Prematurity of the baby needs to be taken into consideration, especially the lung
maturity. Prophylactic corticosteroids should be considered for improving lung
maturity.
4. GBS screening at 36 weeks!
5. Medically it would be better to aim for natural birth on term!!!