OB DILEMMAS: Is this induction necessary?
3 cases, 3 evidence-based choices
Although transcervical Foley catheter induction is often begun on an outpatient basis, it should probably be limited to hospital use in a woman with a previous uterine scar.24
M.A. receives magnesium sulfate for seizure prophylaxis. Labor is successfully induced with membrane sweeping and subsequent amniotomy. Labor is augmented with oxytocin, with continuous fetal heart rate and uterine activity monitoring throughout labor. She successfully delivers a healthy female infant.
CASE 3: Preeclampsia remote from term
L.A. is a 19-year-old gravida 1 para 0 who was hospitalized with preeclampsia at 28 weeks’ gestation. At that time, she was given betamethasone and monitored on inpatient bed rest. At 30 1/7 weeks’ gestation, she begins complaining of a headache. Her blood pressure is 168/110, and she has 2+ proteinuria on a dipstick. Her platelet count is 110,000, serum creatinine is 1.0, and she has slightly elevated liver transaminases in the 40s. Her cervix is closed, long, high, firm, and posterior. What are your choices?
Critical questions
Does preeclampsia rule out induction?
No. In a woman with severe preeclampsia remote from term, labor induction is not contraindicated.25-27 In fact, it may be a particularly reasonable option in a patient who is stable. Even eclampsia is not a contraindication to labor induction. However, rapidly evolving disease may preclude a prolonged labor induction, because delivery is the key to resolution of preeclampsia.
Are any clinical features in her favor?
Yes. The best predictors of success are a favorable Bishop score and a gestational age greater than 28 weeks.25-27
Our recommendations
Although L.A.’s Bishop score is unfavorable, her relatively stable clinical status and her gestational age suggest that labor induction should not be ruled out.
Preinduction cervical ripening
If cervical ripening is necessary, the transcervical Foley catheter may be the best choice, particularly among pregnancies affected by intrauterine growth restriction, as hyperstimulation is unlikely to occur with this method.
L.A. undergoes cervical ripening with the transcervical Foley catheter and subsequent amniotomy and oxytocin infusion. She is given magnesium sulfate for seizure prophylaxis throughout the cervical ripening and induction processes, and her clinical status is closely monitored, including blood pressure, urine output, and laboratory values. Her platelet count, serum creatinine, and liver transaminases remain stable, and she has a successful vaginal delivery.
