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1519420: Maternal indications - hypertension, mental health reasons, poorly controlled diabetes, choliostasis, cancer, raised BP, IUD, APH, PROM.  Fetal indications for IOL: fetal distress, IUGR, previous stillbirth, multiple pregnancy, unstable lie. Contraindications for IOL: placenta previa, active herpes, cord presentation, transverse lie, breech, women is unwell, previous classical incision. METHODS: ARM, propess, prostin, syntocinin.

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1519420: Maternal indications - hypertension, mental health reasons, poorly controlled diabetes, choliostasis, cancer, raised BP, IUD, APH, PROM.  Fetal indications for IOL: fetal distress, IUGR, previous stillbirth, multiple pregnancy, unstable lie. Contraindications for IOL: placenta previa, active herpes, cord presentation, transverse lie, breech, women is unwell, previous classical incision. METHODS: ARM, propess, prostin, syntocinin.

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IOL/Augmentation
There are a variety of indications for IOL/Augmentation.
These include:
Maternal Indications - diabetes, hypertension, post-maturity, obstetric choleostasis, PROM (pre-term, SROM & prelabour), maternal age,  maternal request, poly/oligohydromnious, previous stillbirth, myomectomy
Fetal indications - macrosomia, IUGR, IUD, Breech (when ELCS is not desired by mother),  reduced movements,
Contraindications - transverse fetal lie, cord presentation, placenta previa, cephalopelvic disproportion,  active STD, previous classical incision c-section,
TIming of IOL -  this is normally governed by trust guidelines for each individual indication, however, in addition to this the specific consultant caring for each client can have specific preferences as to when certain indications require IOL
Process - IOL is different for each individual and again can be dictated by the indication for IOL or the consultant overseeing the care.
In general, at the trust I am placed, the IOL works as follows:
Propess vaginal delivery system which is inserted high into the posterior vaginal fornix following a vaginal examination to assess the cervix position, effacement, dilation.  This is then left in situ for up to 24 hours.  It is removed if labour occurs, regular strong contractions occur, or there are signs of fetal distress.  Aim of Propess is to soften the cervix.
Prostin Pessary can then be given if required.  Again this is done after an internal vaginal examination of the cervix and the Propess has been removed.  If the cervix has changed enough and there is adequate dilation (and go ahead is given from unit coordinator and Obs team) then an ARM will be attempted.  2 Prostin can be given, 6 hours apart and then a 3rd can be given after a 24 hour rest period.
After Propess and Prostins and ARM, an oxytocin drip can be commenced to aid uterine contractions.
This process can be altered in many ways to suit each individual case.

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Indications for IOL:

-Post Dates :increased risk of perternal mortality and morbitity. However the risk is small.
-Hypertension :Pre-eclampsia
-Diabetes macrosomia
-Prelabour rupture of membrains :to avoid the risk of infection.
-Fetal death or fetal anomaly not compatible with life.

Contraindications:

-Placenta Praevia
-Transverse lie/Compound presentation
-HIV Positive
-Active Genital Herpes
-Cord Presentation or
Prolapse
-Known Cephalo pelvic Disproportion
-Severe acute fetal compromise

Methods of IOL:

-Prostoglandin: pessary, gel, tablet to ripen the cervix. (Dinoprostone)
-Membrane Sweep
-ARM
-Oxytocin (Syntocinon)

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All the risks and benefits of IOL should be discussed carefully with the woman before induction is started. This will give her an informed choice of what she wants to do and if she agrees and gives consent the IOL can begin

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Maternal indications:
- Diabetes
- Prolonged pregnancy
- Hypertension-including PET.
- Obstetric Cholestasis.
- PROM
- Maternal request.
- Maternal age.

Fetal indications:
- Macrosomia
- Reduced movements
- Fetal death
- IUGR
- Health problems

Contraindications:
- Cord presentation.
- Active genital herpes
- Placenta praevia
- Transverse lie or compound presentation.
- HIV women.
- Severe acute fetal compromise.
- Known cephalo-pelvic disproportion.

Methods:
- ARM
- Oxytocin
- Prostaglandins
- Membrane sweep (additional aid rather than method).

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Maternal Indications for IOL:
1. Hypertension including pre-eclampsia
2. Prolonged Pregnancy - 42+ weeks gestation
3.  Diabetes after 38+ weeks if well controlled
4. Maternal request in very exceptional circumstances
5. PROM - usually after 24 hours of SROM due to increased risk of infection.

Fetal indications for IOL:
1: Fetal death
2: Macrosomia - large baby
3. IUGR

Methods of IOL:
Stretch and sweep, prostaglandin as a gel, pessary or tablet, ARM, Syntocinon.

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1204533  Indications for IOL: Hypertension, Diabetes, Fetal growth restriction, Macrosomia, Porlonged pregnancy (term+12), Maternal request, Prelabour repture of membranes, fetal death. Contraindications of IOL: Placenta Praevia, Transver lie/compound presentation, HIV positive women, Active genital herpes, Cord presentation, Cord Prolapse, known Cephalo pelvic disproportion, severe acute fetal compromise. Forms of IOL: Prostaglandins in the form of tablet, gel or pessaries, Misoprostol is only used if there has been an intrauterine death. Artificial rupture of membranes, Sweep, Oxytocin IV.

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1204533  Indications for IOL: Hypertension, Diabetes, Fetal growth restriction, Macrosomia, Porlonged pregnancy (term+12), Maternal request, Prelabour repture of membranes, fetal death. Contraindications of IOL: Placenta Praevia, Transver lie/compound presentation, HIV positive women, Active genital herpes, Cord presentation, Cord Prolapse, known Cephalo pelvic disproportion, severe acute fetal compromise. Forms of IOL: Prostaglandins in the form of tablet, gel or pessaries, Misoprostol is only used if there has been an intrauterine death. Artificial rupture of membranes, Sweep, Oxytocin IV.

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Maternal indications:
1. Hypertension
2.Diabetes 38 wk+
3.Macrosomia
4.Stillbirth

Fetal Indications:
1.IUGR
2.Macrosomia
3.Rhesus isoimmunization
4.Fetal anomoly

Methods:
S&S

Natural methods: sexual intercourse, nipple stimulation, eating dates, raspberry leaf tea, spicy food to irritate bowel, turmeric, etc.
Alternative therapies (not recommended, but available) such as homeopathy, reflexology, acupuncture.

Staying upright and active.

Pharmacological induction:
Propess pessary (prostoglandin)
Prostin IV infusion (oxytocin)
Amniotomy (committed to delivery of baby)
Misoprostil and Mifepristone (for IUD only)

Contraindications:
As for SVD: placenta praevia, cephalopelvic disproportion, tranverse or oblique lie, fetal compromise.

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Other Maternal Indications for IOL - (trust guidelines)
1. PROM or PPROM - over 24 hours to reduce risk of ascending infection.
2. H/O precipitate labour - to avoid labour being unattended by a healthcare professional.
3. Maternal request - under exceptional circumstances IOL may be considered at term with risks explained and understood.
4. To avoid prolonged pregnancy. Uncomplicated pregnancies IOL between 41 and 42 weeks (according to local trust policy), to avoid risks of diminishing placental function and stillbirth. Incidence 3/3000 at 42 weeks...there is still little substantial evidence about the true risks of prolonged pregnancy.

Methods of IOL - Aside from the medical methods there are also natural methods to be considered  for use after 36 weeks (although evidence on the success of these is not conclusive).

Acupuncture and homeopathy methods, nipple stimulation, raspberry leaf tea, sexual intercourse.

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Maternal Indications for IOL:
1. Hypertension- may be necessary to avoid serious maternal and fetal complications. Maternal complications include developing pre-eclampsia which can consequently cause fetal complications such as low birth weight, premature birth, placental abruption and stillbirth.
2. Diabetes- Women with diabetes may be advised to be induced due to their baby being very large, thus causing later difficulties during birth. An induction may also be advised due to concerns over the health, well-being and growth of the baby. NICE 2015 guidelines propose that uncomplicated cases of gestational diabetes may be left until 40+6 before induction is offered to reduce the risk of stillbirth.

Fetal Indications for IOL:
1. Fetal growth restriction- induction may be necessary if this instance as the well-being of the fetus is being affected due to uteroplacental insufficiency, due to intrauterine growth restriction or abnormal fetal umbilical blood flow.
2. Macrosomia- (large baby) advised due to the risk of difficulty in delivery, as well as a potential shoulder dystocia.
3. Fetal death- if cases where a fetal death has occurred without any know medical or obstetric complications. If the membranes have ruptured or there if infection or bleeding, the induction must happen immediately, otherwise, the woman should be allowed to choose what is best for her and her family.

Contraindications for IOL: Placental praevia- due to the risk of maternal and fetal haemorrhage, cord accidents and malpresentations. Oblique or transverse lie in labour- due to the risks of cord prolapse and obstruction. Fetal compromise- in instances where it is unlikely that the fetus will cope with the stress of labour.

Methods of IOL: cervical ripening, membranes sweep, prostaglandin, oxytocin, amniotomy.