What are the Canadian guidelines for induction of labor (IOL) for a term pregnancy at 40+6 weeks gestational age (GA) with bleeding?

Canadian Guidelines for Induction of Labor at 40+6 Weeks with Bleeding

Induction of labor should be initiated immediately for a term pregnancy at 40+6 weeks gestational age with bleeding to prevent maternal and fetal complications. 1

Assessment of Bleeding in Late-Term Pregnancy

When evaluating a pregnant patient at 40+6 weeks with bleeding, it's crucial to:

• Determine the severity and source of bleeding through careful assessment
• Rule out serious causes such as placenta previa or placental abruption before digital examination 2
• Perform transabdominal ultrasound as the initial imaging procedure to exclude pathologic etiologies 2
• Follow with transvaginal ultrasound if transabdominal imaging is inconclusive 2

Indications for Immediate Induction at 40+6 Weeks with Bleeding

The Canadian approach aligns with evidence-based guidelines that recommend:

1. Immediate induction at term with bleeding due to increased risks:

   • Expectant management beyond 40 weeks increases risks of perinatal death, stillbirth, and hypertensive disorders 1
   • Vaginal bleeding in late pregnancy can indicate placental abruption, which is associated with worse perinatal outcomes 2
   • Any bleeding at term warrants delivery to minimize maternal and fetal risks

2. Timing considerations:

   • Even without bleeding, induction should be scheduled by 41 weeks at the latest 1
   • With bleeding at 40+6 weeks, immediate induction is indicated rather than expectant management

Management Approach

1. Pre-induction assessment:

   • Confirm fetal viability and position
   • Assess cervical readiness (Bishop score)
   • Rule out contraindications to vaginal delivery

2. Induction method selection:

   • For unfavorable cervix: Mechanical methods (Foley catheter) are preferred with active bleeding
   • For favorable cervix: Amniotomy and oxytocin are appropriate 1
   • Combination methods achieve faster delivery times compared to single-agent methods 1

3. Monitoring during induction:

   • Continuous electronic fetal monitoring
   • Regular assessment of bleeding
   • Preparation for potential hemorrhage (IV access, cross-matched blood)

Important Considerations

• Maternal risks: Women with bleeding at term have increased risk of postpartum hemorrhage and should have active management of the third stage of labor
• Fetal risks: Bleeding at term may indicate placental compromise requiring close fetal monitoring during induction
• Facility requirements: Delivery should take place in a facility equipped to handle potential complications 2

Common Pitfalls to Avoid

1. Delaying induction: Waiting for spontaneous labor in a term pregnancy with bleeding increases risks of adverse outcomes
2. Inadequate monitoring: Bleeding may worsen during induction, requiring vigilant observation
3. Digital examination before ruling out placenta previa: Always perform ultrasound before vaginal examination in cases of bleeding 2
4. Underestimating blood loss: Visual estimation often underestimates actual blood loss

The evidence clearly supports immediate induction of labor for a term pregnancy at 40+6 weeks with bleeding, as this approach minimizes risks of maternal and fetal complications while optimizing outcomes for both mother and baby.