DISCLOSURES NONE Felicia Lester, MD MS MPH OUTPATIENT INDUCTION OF - - PowerPoint PPT Presentation

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DISCLOSURES NONE Felicia Lester, MD MS MPH OUTPATIENT INDUCTION OF - - PowerPoint PPT Presentation

Jun 10, 2023 374 likes •456 views

DISCLOSURES NONE Felicia Lester, MD MS MPH OUTPATIENT INDUCTION OF LABOR Associate Professor Obstetrics, Gynecology and Gynecologic Surgery Dept of Ob/Gyn & RS, UCSF 1 2 INDUCTION OF LABOR CERVICAL RIPENING Takes 12- 24 hours

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SLIDE 1

OUTPATIENT INDUCTION OF LABOR

Felicia Lester, MD MS MPH Associate Professor Obstetrics, Gynecology and Gynecologic Surgery Dept of Ob/Gyn & RS, UCSF

DISCLOSURES

NONE

INDUCTION OF LABOR

  • 25% of women currently undergo labor induction

Many anticipate this will increase with ARRIVE

  • Implications for:
  • Patient satisfaction
  • Length of stay
  • Healthcare costs
  • Facility capacity

CERVICAL RIPENING

  • Takes 12- 24 hours
  • Initial stage of IOL for patient with low Bishop score

(<6)

  • Traditionally takes place in hospital
  • Many institutions have moved to outpatient

1 2 3 4

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SLIDE 2

MECHANICAL VS PHARMACOLOGIC RIPENING

Mechanical

Pharmacologic

OUTPATIENT FOLEY BALLOON: SAFETY

  • Not associated with tachysystole, fetal intolerance
  • f labor or meconium staining (Cochrane, 2009)
  • Inpatient cohort nearly 2,000 women (Sciscione, 2014)
  • No c/s for distress, vaginal bleeding, abruption,
  • r stillbirth
  • Few outpatient studies
  • No increased maternal or neonatal

complications (McKenna, 2004; Kuper, 2018; Wilkinson, 2015; Kruit, 2016)

  • No increased infectious morbidity, PPH, c/s,
  • perative delivery or fetal distress

OUTPATIENT FOLEY BALLOON: EFFICACY

  • Outpatient vs Inpatient (Policiano, 2017)
  • Similar change in bishop score
  • Outpatient
  • Less time from application to delivery (38 vs 44

hrs)

  • 10 hours less time in the hospital
  • Vaginal delivery rate 72% vs 62% (not sig)
  • Lower CD for failed IOL (3% vs 17%)

OUTPATIENT FOLEY BALLOON: SATISFACTION

  • Pilot study of inpatient vs outpatient FB (Wilkinson, 2015)
  • Equally satisfied and equally likely to

recommend

  • Outpatient: more rest, adequate privacy, less

isolated

  • Discrete choice experiment: women would be

willing to have an extra 1.4 trips and 73 minutes

  • f travel time for outpatient (Howard, 2014)
  • 85% of women having outpatient FB were

satisfied, no comparison group (Kruit, 2016)

5 6 7 8

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SLIDE 3

OUTPATIENT PROSTAGLANDIN: SAFETY

  • Compared to FB, associated with tachysystole,

fetal intolerance of labor or meconium staining

(Cochrane, 2009)

  • Outpatient studies thus far have not reported an

increase in adverse fetal outcomes or out of hospital deliveries (Lamar, 2019)

  • With rational administration and monitoring

after initial dose, should be safe

  • Misoprostol: max blood levels 30 mins after oral

and 70-80 after vaginal administration

OUTPATIENT PROSTAGLANDIN: EFFICACY

  • Administering outpatient miso may shorten time

to spontaneous labor and avoid need for formal induction

  • 100 µg PO q 24 hrs x 3 doses for PD decreased

time to delivery b 1.5 days (Gaffaney, 2009)

  • 25 µg PV x 1 with sweeping reduced time to

delivery by 2 days (PonMalar, 2017)

  • 25 µg PV q 24 hrs x 2 doses in 48 hrs before

planned PD IOL: 85% went into spontaneous labor vs 11% in control (Stitely, 2000)

  • Outpatient vs inpatient prostaglandin (miso, PGE2

gel and insert)

  • Decreased time on L&D (Chang, 2005; Biem, 2003; Wilkinson, 2015)

OUTPATIENT PROSTAGLANDIN: SATISFACTION

  • PROBAAT-II Study: FB vs miso IOL Inpatient
  • 12% vs 6% of women would have preferred

another method of IOL (Ten Eikelder, 2017)

  • Outpatient vs inpatient PGE2 insert
  • 56% vs 39% highly satisfied with first 12

hours of IOL (Biem, 2003)

RATIONAL OUTPATIENT IOL PROTOCOL WITH FOLEY BALLOON (LAMAR, 2019)

Absolute Contraindications

  • Contraindication to Vaginal Delivery
  • Nonreactive Stress Test or BPP <6
  • High-risk medical or Obstetrical Condition
  • Placental Abruption or active vaginal bleeding
  • Preterm gestation
  • Rupture of membranes
  • Fetal growth restriction
  • Oligo or Poly
  • Need for immediate neonatal resuscitation
  • Patient unable verbalize understanding of care

plan or instructions Relative Contraindications

  • Unreliable phone access or transportation
  • Demonstrated difficulty attending prenatal

appointments

  • Previous uterine scar
  • Intrahepatic cholestasis of pregnancy
  • Bishop Score >6

9 10 11 12

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SLIDE 4

RATIONAL OUTPATIENT IOL PROTOCOL WITH FOLEY BALLOON (MODIFIED FROM LAMAR, 2019)

Patient determined to be appropriate candidate for outpatient FB by clinical Patient provides informed consent

Procedure scheduled in outpatient clinic one day prior to scheduled IOL NST performed, ultrasound for fetal presentation, Bishop score determined IF NST not reactive, painful UC >3 in 10 mins or oligo/poly, malpresentation, not candidate After reactive NST, FB placed digitally or visually through uterine cervix filled with 30-60 mL NS, clamped NST performed. If reactive and patient stable, postprocedure and return precautions reviewed If amniotomy, increased VB, NST not reactive, frequent UCs or other concerns, to L&D

RATIONAL OUTPATIENT IOL PROTOCOL WITH PROSTAGLANDIN

Contraindications Use Foley Balloon criteria but with prior uterine scar as absolute contraindication

RATIONAL OUTPATIENT IOL PROTOCOL WITH PROSTAGLANDIN

Patient determined to be appropriate candidate for outpatient misoprostol by clinical Patient provides informed consent

Medication administration scheduled in outpatient clinic one day prior to scheduled IOL NST performed, ultrasound for fetal presentation, Bishop score determined IF NST not reactive, painful UC >3 in 10 mins or oligo/poly, malpresentation, not candidate After reactive NST, misoprostol 50mcg PV administered NST performed for 90 minutes. If reactive and patient stable, anticipatory guidance and return precautions reviewed If NST not reactive, frequent UCs

  • r other concerns, to L&D

IF IT WERE RECOMMENDED FOR YOU TO HAVE AN IOL WITH A FOLEY BALLOON, WOULD YOU WANT…

  • A. Inpatient Foley Balloon?
  • B. Outpatient Foley Balloon?

I n p a t i e n t F

  • l

e y B a l l

  • n

? O u t p a t i e n t F

  • l

e y B a l l

  • n

?

83% 17%

13 14 15 16

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SLIDE 5

IF IT WERE RECOMMENDED FOR YOU TO HAVE AN IOL WITH PROSTAGLANDINS, WOULD YOU WANT…

  • A. Inpatient Prostaglandin?
  • B. Outpatient Prostaglandin?

I n p a t i e n t P r

  • s

t a g l a n d i n ? O u t p a t i e n t P r

  • s

t a g l a n d i n ?

57% 43%

IF YOUR PROVIDER RECOMMENDED IT, WOULD YOU ACCEPT… OUTPATIENT FOLEY BALLOON

  • A. Yes
  • B. No

Y e s N

  • 12%

88%

IF YOUR PROVIDER RECOMMENDED IT, WOULD YOU ACCEPT… OUTPATIENT PROSTAGLANDIN

  • A. Yes
  • B. No

Y e s N

  • 33%

67%

REFERENCES

Lamar R, Mengesha B, Little S. The case for outpatient cervical ripening for IOL at term for low-risk pregnancies. OBG Management. Vol 31

  • No. 9; Sept, 2019.

Jozwiak M, Bloemenkamp KW, Kelly AJ, et al. Mechanical methods for induction of labor. Cochrane Database Syst Rev. 2012;(3):CD001233 ACOG Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 107: induction of labor. Obstet Gynecol. 2009;114(2 pt 1):386-

  • 397. Reaffirmed 2019.

Sciscione AC, Bedder CL, Hoffman MK, et al. The timing of adverse events with Foley catheter preinduction: implications for outpatient use. Am J

  • Perinatol. 2014;31:781-786.

McKenna DS, Duke JM. Effectiveness and infectious morbidity of outpatient cervical ripening with a Foley catheter. J Rerod Med. 2004;49:28- 32. Kuper SG, Jauk VX, George DM, et al. Outpatient Foley catheter for induction of labor in parous women: a randomized controlled trial. Obstet

  • Gynecol. 2018;132:94-101.

Wilkinson C, Adelson P, Turnbull D. A comparison of inpatient with outpatient balloon catheter cervical ripening; a pilot randomized controlled

  • trial. BMC Pregnancy Childbirth. 2015;15:126.

Kruit H, Heikinheimo O, Ulander VM, et al. Foley catheter induction of labor as an outpatient procedure. J Perinatal. 2016;36:618-622. Sciscione AC, Muench M, Pollock M, et al. Transcervical Foley catheter for preinduction cervical ripening in an outpatient vs inpatient setting. Obstet Gynecol. 2001;98(5 pt 1):751-756. Policiano C, Pimenta M, Martins D, et al. Outpatient versus inpatient cervix priming with Foley catheter: a randomized trial. Eur J Obstet Gynecol Reprod Biol. 2017;210:1-6.

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SLIDE 6

REFERENCES CONT../

Howard K, Gerard K, Adelson P , et al. Women’s preferences for inpatient and outpatient priming for labour induction: a discrete choice

  • experiment. BMC Health Serv Res. 2014; 14:330.

Gaffaney CA, Saul LL, Rumney PJ, et al. Outpatient oral misoprostol for prolonged pregnancies: a pilot investigation. AM J Perinatol. 2009;26:673-677. PonMalar J, Benjamin SJ, Abraham A. et al. Randomized double-blind placebo controlled study of preinduction cervical priming with 25 µg of misoprostol in the outpatient setting to prevent formal induction of labor. Arch Gynecol Obstet. 2017;295:33-38. Stitely ML, Browning J, Fowler M, et al. Outpatient cervical ripening with intravaginal misoprostol. Obstet Gynecol. 2000;96(5 pt 1):684-688. McKenna DS, Ester JB, Proffitt M, et al. Misoprostol outpatient cervical ripening without subsequent induction of labor: a randomized trial. Obstet Gynecol. 2004;104:579-584. Chang DW, Velazquez MD, Colyer M, et al. Vaginal misoprostol for cervical ripening at term: comparison of outpatient vs. inpatient

  • administration. J Reprod Med. 2005;50:735-739.

Biem SR, Turnell RW, Olatunbosum O, et al. A randomized controlled trial of outpatient versus inpatient labour induction with vaginal controlled- release prostaglandin-E2: effectiveness and satisfaction. J Obstet Gynecol Can. 2003;25:23-31.

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