Induction of Labour .au



Canberra Hospital and Health ServicesClinical Guideline Induction of LabourContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc507505261 \h 1Guideline Statement PAGEREF _Toc507505262 \h 3Scope PAGEREF _Toc507505263 \h 3Section 1 – Introduction PAGEREF _Toc507505264 \h 4Communication and information PAGEREF _Toc507505265 \h 4IOL declined or postponed PAGEREF _Toc507505266 \h 4Clinical standards PAGEREF _Toc507505267 \h 5Section 2 – Indications for Induction of Labour PAGEREF _Toc507505268 \h 6Indications include but are not limited to: PAGEREF _Toc507505269 \h 6Concern for fetal wellbeing PAGEREF _Toc507505270 \h 6Twin pregnancy PAGEREF _Toc507505271 \h 7Fetal macrosomia PAGEREF _Toc507505272 \h 7Obstetric cholestasis (intrahepatic cholestasis of pregnancy) PAGEREF _Toc507505273 \h 8Maternal ethnicity PAGEREF _Toc507505274 \h 9Maternal request PAGEREF _Toc507505275 \h 9Assisted Pregnancy: IVF PAGEREF _Toc507505276 \h 10Section 3 – Pre induction of labour assessment PAGEREF _Toc507505277 \h 10Cervical assessment PAGEREF _Toc507505278 \h 11Modified Bishop Score PAGEREF _Toc507505279 \h 11Membrane sweeping PAGEREF _Toc507505280 \h 11Section 4 – Methods of Induction of Labour PAGEREF _Toc507505281 \h 12Balloon (transcervical) catheter PAGEREF _Toc507505282 \h 13Balloon (transcervical) catheter insertion PAGEREF _Toc507505283 \h 14Balloon (transcervical) catheter post insertion care PAGEREF _Toc507505284 \h 15Dinoprostone PAGEREF _Toc507505285 \h 16Dinoprostone administration PAGEREF _Toc507505286 \h 18Artificial rupture of membranes (Amniotomy) PAGEREF _Toc507505287 \h 19Oxytocin PAGEREF _Toc507505288 \h 20Oxytocin administration regimen PAGEREF _Toc507505289 \h 21Section 5 – Risks and benefits associated with IOL PAGEREF _Toc507505290 \h 23Implementation PAGEREF _Toc507505291 \h 24Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc507505292 \h 24References PAGEREF _Toc507505293 \h 25Definition of Terms PAGEREF _Toc507505294 \h 27Search Terms PAGEREF _Toc507505295 \h 28Guideline StatementBackgroundNote:This Clinical Guideline has been adapted for the Centenary Hospital for Women and Children from the Queensland Clinical Guidelines: Induction of Labour.Induction of labour (IOL) is the initiation of labour in a pregnant woman who is not already in labour (artificially initiated labour [WHO]). IOL is indicated when the maternal and/or fetal risks of continuing the pregnancy outweigh the risks of IOL and birth. A woman’s individual circumstances and preferences will influence the timing and method of IOL. The purpose of this guideline is to guide the IOL process. Women with uncomplicated pregnancies should be given the opportunity to go into spontaneous labour.Key ObjectiveThis document will provide clinical guidance for midwives and medical staff caring for women undergoing an induction of labour.Alerts If an induction is being considered the woman should have a complete clinical assessment to ensure the decision to induce labour is made for an appropriate reason and induction is done at an appropriate time.Induction of labour is contraindicated in the following circumstances: Placenta PraeviaVasa praeviaTransverse lie / oblique lie unless accompanied by ECVMisoprostol: Not currently recommended for IOL where a live birth is expectedBack to Table of ContentsScopeThis document applies to staff who are working within their scope of practice including:Medical OfficersMidwives Student midwives working under direct supervision.Back to Table of ContentsSection 1 – IntroductionCommunication and informationDiscuss the risks and benefits of IOL as they pertain to each individual woman. Take into account individual needs and preferences, to enable the woman to make an informed decision in consultation with her health care provider.Table 1. Communication and informationAspectGood practice pointsMaternal experienceProvide time for questions and decision makingTake into consideration the woman’s previous experiences and current preferencesProvide written information e.g. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) information leaflet on Induction of LabourIOL discussion pointsIndication for IOLMethod of IOLPotential risks and benefitsRefer to Section 5: Risks and benefits associated with IOLOptions for pain reliefOptions if unsuccessfulOptions if declinedThe possibility of an unavoidable delay in commencing IOL due to acuity in the birthing suiteWritten/online informationConsider the use of decision aids to assist the woman make informed choicesDocumentationClear and contemporaneous documentation is required in the clinical record including:The indication for IOLThe content and outcome of discussions [refer to discussion points above]Informed consent/choiceCare provided (e.g. Bishop score, observations)Clinician name, signature and designationIOL declined or postponedTable 2. IOL declined or postponedAspectGood practice pointsCommunicationIf IOL is declined, respect the woman’s decision unless any delay would result in serious concerns for the safety of the baby or the mother. In such cases every effort should be made to make the woman aware of the potential risks of refusal.Where pregnancy gestation was greater than 41 weeks gestation, women whowaited for labour to start–38% would choose to wait next timewere induced–73% would choose IOL next timeNo form of increased antenatal monitoring has been shown to reduce perinatal mortality associated with prolonged pregnancyPlan careIf IOL is declined or postponed (e.g. due to resourcing issues or as a result of maternal request), take into account the:Individual clinical circumstances and preferencesIndication for IOLLocal service capabilities and prioritiesPerform an assessment of maternal and fetal wellbeingDevelop a plan with the woman for continued care including:Arrangements for ongoing monitoringReturn for IOLFrom 42 weeks offer at least twice weekly assessment for fetal wellbeing, including:Cardiotocography (CTG)Ultrasound scan (USS) assessment of amniotic fluid volume using estimation of deepest vertical pocketRefer to Section 2.1 Prolonged pregnancy preventionAdvise the woman to contact her health care provider/facility if concerned about her wellbeing or that of her baby (including not to wait until the next day)Provide verbal and written information about fetal movementsDocument the discussion, assessment and plan in the clinical records including the Maternity Hand Held Record (MHHR) and Birthing Outcome System (BOS).Clinical standardsTable 3. Clinical standardsAspectGood practice pointsService capabilitiesProvide care in the context of the 10 National Standards and local Clinical GuidelinesEnsure availability of health care professionals appropriate to the circumstancesContinuous electronic fetal heart monitoring and uterine contraction monitoring is required for IOL with oxytocin and prostaglandinEstablish quality and safety programs and tools to monitor care (e.g. IOL safety audits and reviews)Back to Table of ContentsSection 2 – Indications for Induction of LabourIndications include but are not limited to:Prolonged pregnancy preventionTable 4. Prolonged pregnancyPrevention of prolonged pregnancyRisk/BenefitNo form of increased antenatal monitoring has been shown to reduce perinatal mortality associated with prolonged pregnancyIOL from 41+0 weeks, compared with expectant management, is associated with:Fewer perinatal deaths [0.4 versus 3.2 per 1000 women]Less meconium aspiration syndrome [40 versus 66 per 1000 newborns]No difference in neonatal intensive care (NICU) admissionsFewer caesarean sections (CS) [168 versus 225 per 1000 women]Most women prefer IOL at 41 weeks over serial antenatal monitoringClinical practice pointFor uncomplicated pregnancies, recommend IOL after 41+0 weeksExact timing depends on the specific risk of stillbirth, individual preferences and local circumstancesWaiting after 42+0 weeks is not recommendedConcern for fetal wellbeingConcern for fetal wellbeing may arise with Fetal Growth restriction (FGR)/small for gestational age [refer to Table 5], decreased fetal movements, oligohydramnios, non-reassuring fetal surveillance test, fetal abnormality, or isoimmunisation. The timing of birth may depend on gestational age, severity of concern and results of tests of fetal wellbeing. Increased fetal surveillance may be required with expectant management [refer to Section 1 IOL declined or postponed].Table 5. Fetal growth restrictionFetal growth restriction (FGR)Risk/BenefitAlthough underpowered to show differences in late pregnancy loss, for term FGR, comparing IOL with expectant monitoring, studies show no significant difference inRate of obstetric interventions (e.g. CS)Maternal or neonatal morbidity and mortalityAdmission to a neonatal unit if birth occurred after 38 weeks gestationClinical practice pointFor babies with FGR, use of umbilical artery, middle cerebral and ductus venosus doppler may assist in improving perinatal outcome through more appropriate timing of birthSeverity of FGR affects the decision concerning mode and timing of birthIf recommending expectant management, increase fetal surveillance [refer to Section 1 IOL declined or postponed]IOL at term to prevent stillbirth is appropriateTwin pregnancyTable 6. Twin pregnancyTwin pregnancyRisk/BenefitBased on data from the United States, the fetal/infant mortality per additional week of expectant management at:37 weeks is 4.39 per 1000 women 95% CI 4.07 to 4.7038 weeks is 5.92 per 1000 women 95% CI 5.40 to 6.43A Cochrane review of elective birth at 37 weeks compared to expectant management demonstrated:No statistically significant differences in CS, perinatal death or serious morbidity, maternal death or serious maternal morbiditySignificant reduction in risk of babies being born with a birth weight less than the third percentile [one study; RR 0.30; 95% CI 0.13 to 0.68]Monochorionic twins are at increased risk of stillbirth in the third trimester compared to dichorionic twinsClinical practice pointOffer women with uncomplicated:monochorionic twin pregnancies elective birth from 36+0 weeks, after a course of antenatal corticosteroids has been offereddichorionic twin pregnancies elective birth from 37+0 weeks triplet pregnancies elective birth from 35+0 weeks, after a course of antenatal corticosteroids has been offered.Fetal macrosomiaTable 7. Suspected fetal macrosomiaFetal macrosomiaConsiderationIn a Cochrane review, comparing IOL at 37–40 weeks to expectant management, there were:Lower risks of shoulder dystocia, and (any) fracture (NNT=60)Lower birth weights [178.03 g, 95% CI 40.81 to 315.26]Higher incidences of third and fourth degree perineal tears (one study) No significant differences in:CS rate or instrumental birthMeasures of neonatal asphyxiaClinical practice pointIOL on the basis of clinical suspicion of macrosomia alone is not recommendedUSS for estimated fetal weight (EFW) is advisedWith a suspected large for gestation age baby based on clinical assessment (e.g. symphysio-fundal height equals 3 cm more than expected from 36 weeks), offer an USS to measure EFWAdvanced maternal ageTable 8. Advanced maternal ageAdvanced maternal ageRisk/BenefitAdvanced maternal age is an independent risk factor for stillbirthNulliparous women may be at higher risk of stillbirth, but evidence is inconsistentIOL at 39 weeks for advanced maternal age, compared to expectant management, had no significant effect on the CS rate and no adverse short-term effects on maternal and neonatal outcomesClinical practice pointFor women aged 40 years or older, offer IOL at 39+0 – 40+0 weeks gestationObstetric cholestasis (intrahepatic cholestasis of pregnancy)Table 9. Obstetric cholestasisObstetric cholestasisRisk/BenefitAssociated with:StillbirthApproximately 1.2% after 37 weeks gestation (although this may be consistent with population stillbirth rates)Increases with increasing gestational age and bile acid levelsMeconium stained liquorPreterm birthNo quality evidence exists to guide timing of birth although IOL is often recommended between 37 to 38 weeks due to risk of stillbirthIdentified as a medical indication for late preterm (34+0 - 36+0 weeks gestational age) or early term (37+0 38+0 weeks gestational age) birth by American College of Obstetricians and Gynecologists (ACOG)Clinical practice pointConsider IOL between 37+0 and 39+0 weeks gestation as relevant to:Individual circumstances—case for intervention is stronger with more severe biochemical abnormalitiesRisk of stillbirth—cannot predict if pregnancy continuesHigher risk of neonatal respiratory morbidity from early interventionOffer continuous fetal monitoring during labourConsider IOL around 36 weeks for severe cases with jaundice,progressive elevations in serum bile acids and liver enzymes, and suspected fetal compromiseMaternal ethnicityTable 10. Maternal ethnicityMaternal ethnicityConsiderationDifferences in ethnicity have been reported in perinatal mortality data but whether this is entirely attributable to genetic factors is unclearIn one retrospective study, South-Asian born women (country of birth India, Sri Lanka, Bangladesh, Pakistan) compared to Australian-born women:Had a higher antepartum stillbirth rate [2.4 times more likely, 95% CI 1.4 to 4.0] with risk increasing progressively with gestationWere twice as likely to have a low birthweight baby (< 2500 g)Clinical practice pointInsufficient evidence to recommend IOL based on maternal ethnicity aloneConsider a woman’s ethnicity in the context of other risk factors when determining timing of IOLMaternal requestTable 11. Maternal requestMaternal requestRisk/BenefitFor low risk women elective IOL at term is not associated with an increased risk of CSThe long term population consequences of a significant proportion of low risk women receiving elective IOL are unknownIOL requires more intensive clinical resources than spontaneous onset of labour in low risk womenRetrospective and population based studies suggest a possible association between birth prior to 39 weeks and developmental / early childhood health problemsClinical practice pointConsider IOL at term based on circumstances of the woman and her family and the wellbeing of the baby (i.e. not solely because of patient or health care provider preference)Assisted Pregnancy: IVFTable 12. Assisted Pregnancy: IVFAssisted Pregnancy: IVFRisk/BenefitIt is noted that pregnancies associated with In Vitro fertilisation have poorer outcomes. However, it is thought to be multifactorial in origin as they are associated with more complicated pregnancies such as:Multiple conceptions and multiple birthsPreterm birthsLow Birth Weight (LBW) and Small for Gestational Age (SGA)Congenital anomaliesVertical transmission of genetic diseasesMaternal ageClinical practice pointThere is no strong evidence to support routine IOL for uncomplicated pregnancies and indication for IOL should be on a case by case basis, taking into account the risk factors.For additional information specific to circumstances below refer to associated CHHS Guidelines/PoliciesInsulin Infusion for Labour and birthHypertensive disorders of pregnancyObesity: pregnancy, labour, birth and postnatal careVaginal birth after caesarean (VBAC)Early onset Group B Streptococcal disease (EOGBSD)Prelabour rupture of membranes Preterm pre-labour rupture of membranes Termination of Pregnancy and Fetal LossLabour care 1st, 2nd and 3rd stage care.Prolonged pregnancyFetal surveillanceAlert: Induction of labour is contraindicated in the following circumstances: Placenta PraeviaVasa praeviaTransverse lie / oblique lie unless accompanied by ECVBack to Table of ContentsSection 3 – Pre induction of labour assessmentPrior to IOL: Review maternal history Confirm gestationPerform baseline maternal observations (e.g. temperature, pulse, SaO2 respiratory rate and blood pressure)Perform abdominal palpation to confirm uterine size, fetal lie, presentation, position, and engagementAssess fetal wellbeing:FHR Confirm CTG is normal If CTG abnormal, escalate as per CHHS Fetal Surveillance Clinical GuidelineAssess for contraindications to IOLConsider urgency for IOL Assess membrane status (ruptured or intact)Vaginal examination (VE) to assess the cervix and descent of the fetal headCervical assessmentA Modified Bishop Score (MBS) should be attended before booking induction of labourEach feature of the cervix is scored and then the scores are summed. The state of the cervix is one of the important predictors of successful IOL. The cervix is unfavourable if the MBS is 6 or less.Modified Bishop Score Cervical featurePelvic score0123Cervix dilation (cm)<11-22-4>4Length of cervix (cm)>42-41-2<1Station relative to ischial spines-3-2-1/0+1/+2ConsistencyFirmMediumSoftPositionPosteriorMidAnteriorMembrane sweepingMembrane sweeping refers to the digital separation of the fetal membranes from the lower uterine segment during VE. This movement helps to separate the cervix from the membranes and stimulate the release of prostaglandinTable 13. Membrane sweepingMembrane sweepingIndicationReduce the need for IOL by encouraging spontaneous labourContraindicationConsistent with contraindications for vaginal birthPreterm gestationRisk/BenefitReduced need for IOL, particularly in multiparous womenOptimal gestation at which to commence is controversialOptimal frequency is unknownSerial membrane sweeping (every 2 days) reduced the number of pregnancies reaching 42 weeks [NNT=6]When performed at the onset of formal induction, membrane sweeping resulted in shorter induction to birth interval, shorter duration of oxytocin infusion and improved birth process satisfactionNo evidence of increased risk of maternal or neonatal infectionIs as safe in Group B Streptococcus (GBS) positive women as for women whose GBS status is unknown or negativeNo data available on HIV or hepatitis CAssociated with discomfort, vaginal bleeding and irregular contractionsSome studies have shown no difference in cervical length, time to onset of labour, or duration of the active phase of labour, where VBAC is planned.Clinical practice pointDiscuss the benefits of membrane sweeping in the antenatal periodOffer prior to formal IOLIf the cervix is closed and membrane sweeping is not possible, cervical massage in vaginal fornices may but is unlikely to achieve similar effectBack to Table of ContentsSection 4 – Methods of Induction of LabourTable 14. Methods of IOLAspectRecommendationCervical ripening forunfavorable cervixMechanical: balloon (transcervical) catheter (e.g. Foley, Cook cervical ripening balloon catheter)Pharmacological: dinoprostone preparations (prostaglandin E2/prostin gel, cervidil [vaginal pessary])After cervical ripening/cervix favorableArtificial rupture of membranes (ARM)OxytocinIf primary cervical ripening method is unsuccessfulIf primary method was:Balloon catheterconsiderDinoprostone gel/pessaryDinoprostone gel up to 4mgconsiderBalloon catheterDinoprostone pessaryconsiderDinoprostone gel or balloon catheterInsufficient evidenceFor IOL–there is insufficient evidence to support: Laminaria tents, breast/nipple stimulation (particularly if high risk), acupuncture, sexual intercourse, evening primrose oil, homeopathy, castor oil, nitric oxide donors, hyaluronidase, oestrogen, and corticosteriodsMisoprostolCompared with placebo, misoprostol (sustained release vaginal pessary, vaginal tablet, buccal/sublingual and oral tablet) had higher odds of uterine hyperstimulation with FHR changes than 31 other active interventions (180 studies)NOTE:Not currently recommended for IOL where a live birth is expected MisodilMisodil is licenced for IOL. Studies have shown that it is more effective than PGE2 for nullipararous with an unfavourable cervix but there is a higher incidence of hyperstimulation with or without CTG abnormalitiesBalloon (transcervical) catheterBalloon catheters (e.g. Foley, Cooks) are used to ripen the cervix through applying pressure on the internal os of the cervix, thereby stretching the lower uterine segment and increasing local prostaglandin secretion.Table 15. Balloon catheter considerationsAspectClinical practice pointIndicationsUnfavourable cervix (MBS of 6 or less)May be considered with previous CSMay be used following dinoprostone when there has been no/minimal effect on cervical ripening and ARM is not technically possibleMay be preferred where a reduced risk of uterine hyperstimulation is desirable (e.g. SGA, grand multiparity, scarred uterus)ContraindicationAny contraindication to vaginal birth (e.g. malpresentation, abnormal placentation)Any contraindications to IOLRuptured membranesUndiagnosed bleedingSimultaneous use of prostaglandins and/or oxytocinLow lying placentaPolyhydramniosAbnormal FHR on CTGRelative contraindicationsAntepartum bleedingLower tract genital infectionFetal head not engaged (4/5 or 5/5 above the pelvic brim)BenefitWhen compared to vaginal prostaglandins:Less uterine hyperstimulation and tachysystoleNo difference in CS rateNo difference in overall number not achieving vaginal birth within 24 hours, although among multiparous women the risk of not birthing within 24 hours was higherLow cost and no specific storage or temperature requirementsNo evidence of an increased risk of infection although data is limitedRiskPlacental abruptionUterine ruptureDevice entrapmentMaternal discomfort during and after insertionFailed dilatation and inability to perform ARMCervical laceration or ischaemia (if prolonged use)There is limited data comparing single to double balloon catheterBalloon (transcervical) catheter insertionTable 16. Balloon catheter insertion procedureAspectClinical practice pointEquipmentSpeculumBalloon catheter, either16/18 French gauge catheter with double balloon (e.g. Cook cervical ripening balloon)26 French gauge Foley catheterSponge forcepsSterile water Syringe (20 mL)Sterile lubricating gelSwabsTapeCTG monitorBed with stirrupsChlorhexidineProcedurePrior to commencementEnsure pre IOL assessment complete including baseline observations and CTGEncourage voidingPerformed by competent medical or midwifery staffContact a more experienced clinician if there are 2 unsuccessful attemptsInsertionPerform abdominal palpationPosition the woman appropriately e.g. lithotomy positionObserve aseptic techniqueCheck integrity of the balloon by inserting a speculum and visualise the cervix. Clean the cervix with chlorhexidine/normal salinePass the balloon catheter through the internal os of the cervix using sponge forceps to assistDouble balloon inflationEnsure the catheter has traversed the cervix and the uterine balloon is above the internal osInflate the uterine balloon with 40 mL of sterile water Gently pull the catheter back until the uterine balloon is against the internal cervical osThe vaginal balloon is now visible/palpable outside the external cervical os and is inflated with 40 mL of water Once the balloons are situated on either side of the cervix, remove the speculum and add water up to a maximum of 80 ml per balloon in 20 ml increments, depending on woman’s tolerance.Document the inflation volumeSingle balloon inflationSpigot the catheterInflate the balloon with 30–80 mL sterile water Gently withdraw the catheter until the balloon rests against the internal osProximal end of the catheter is taped to the thigh to provide constant, moderate tension of the balloonDocument the inflation volumeBalloon (transcervical) catheter post insertion careTable 17. Post balloon catheter insertionAspectClinical practice pointMonitoringAssess uterine activity, engagement of the fetal head and vaginal loss:Medical review required if significant displacement of fetal presenting part out of the pelvis following procedure CTG Ongoing monitoring as per Maternity MEWS risk assessment while:Observations are normalNo contractionsNo other contraindicationsAdvise woman to inform midwife of pain, bleeding or if she feels the catheter has fallen out Medical review if reporting pain or adverse symptomsIf membranes rupture spontaneously remove catheter12 hour reassessmentMaternal observations as per Maternity MEWS CTGAssess uterine activity, vaginal loss and pain level24 hour reassessmentSchedule assessment 24 hours after insertionIf the balloon catheter has not spontaneously fallen out, deflate balloons completely using an appropriately sized syringe, with plan to ARM and commence oxytocinIndications for Obstetric reviewObservations abnormalPersistent pain and discomfortIf ARM is not able to be performed (cervical assessment unfavourable or high presenting part)Continuing IOL may involve dinoprostone or reinsertion of another balloon catheter after 24 hoursModerate or severe discomfort Assess for labourReduce balloon volume in consultation with Registrar/ Consultant as required):Foley catheter: remove maximum of 10 mLDouble balloon catheter: remove 10 mL from each vaginal and uterine balloon Reassess and repeat ensuring a minimum of 50 mL of residual volume remains in each balloonDocument the volume removedConsider analgesia if woman not in labour and continues to experience moderate to severe discomfort despite balloon deflationIf persistent pain and discomfort following oral analgesiaReview by an obstetricianIndications for early removal of balloon catheterSpontaneous rupture of membranes (SROM)Uterine hyperstimulationMaternal requestDifficulty passing urineOffer appropriate analgesia and comfort aidsIf still unable to void, consider removing 10 mL of fluid from each of the uterine and vaginal balloonsAssess that catheter is still in correct positionIf balloon catheter falls outPerform VEPlan ARM and oxytocin infusion as soon as possible (due to the temporary dilatory effect of balloon catheters)DinoprostoneProstaglandins promote cervical ripening and stimulate uterine contractions. Dinoprostone is the most commonly used prostaglandin agent in third trimester IOL. Dinoprostone preparations include:Vaginal gel (prostaglandin E2, (Prostin?) 1 mg and 2 mgControlled release vaginal tape (Cervidil?)Refer to Table 18 and Table 19Table 18. Dinoprostone considerations and doseAspectClinical practice pointIndicationUnfavourable cervixMay be used following balloon catheter when there has been no/minimal effect on cervical ripening and artificial rupture of membranes (ARM) is not technically possibleContraindicationKnown hypersensitivity to dinoprostoneRuptured membranesGrand multiparityPrevious CS or any uterine surgery where the cavity has been breachedMalpresentation/high presenting partUnexplained PV bleeding during current pregnancyAbnormal CTG/fetal compromiseCautionsMultiple pregnancyAsthma, chronic obstructive pulmonary disease – may cause bronchospasmEpilepsyCardiovascular diseaseRaised intraocular pressure, glaucomaAvoid combining with oxytocin [refer to Section 4 Oxytocin]Risk/benefitNausea, vomiting and diarrhoea may occur soon after insertionVaginal PGE2 compared to a placebo or expectant management:Increased vaginal birth within 24 hours with repeated dosesIncreased hyperstimulation with FHR changes (4.8% versus 1.0%, RR 3.16, 95%CI 1.67 to 5.98)Did not appear to reduce CS rate, NICU admission, serious maternal/newborn morbidity/mortalityBefore administrationEnsure pre IOL assessment completeEncourage to empty bladderDinoprostone gel (prostin) doseInitial dose:Nulliparous: 2 mg PVMultiparous: 1-2 mg PVRepeat dose (if clinically indicated and only after 6 hours)Nulliparous: 1-2 mgMultiparous: 1–2 mgDo not give the repeat dose within 6 hours of the initial dose (i.e. so the maximum dose of 3mg in a 6 hour period is not exceeded)Dinoprostone pessary (cervidil) dose10 mg PV (released at a rate of approximately 4 mg in 12 hours)A second dose is not recommendedThe pessary may be left in situ for 24 hoursDinoprostone administrationTable 19. Dinoprostone administrationAspectDinoprostone administrationAdministrationMaternal and fetal safety outcomes do not seem to differ whether prostaglandins are administered in the morning or evening, but women may prefer morning administrationPessary use may avoid repeated application of the gelGel may be more appropriate where cervix is favourable, i.e. often used in a multiparous women with a MBS score less than 6 pessaries in nulliparous or multiparous women with an unfavourable cervixDinoprostone gelUse water soluble lubricants (not obstetric cream)Remove from refrigeration and stand at room temperature for at least 30 minutes prior to useInsert high into the posterior fornix of the vaginaNot for intracervical administrationAdvise the woman to lie in a recumbent or left lateral position for 30 minutes after insertionDinoprostone pessaryRemove from freezer or fridge immediately prior to useCan be stored in the refrigerator for up to one month (2–8o after removal from the freezerWarming is not requiredOpen only after decision has been made to use the pessaryUse water soluble lubricant (not obstetric cream)Insert and position transversely in the posterior fornix of the vagina:To minimise potential for the pessary to fall out and subsequent insufficient dinoprostone exposureEnsure sufficient tape outside vagina to allow removalWoman to remain recumbent for 30 minutesAdvise to report if pessary falls outMonitoring post insertionObservations as per Maternity MEWS: Temperature, pulse, respiratory rate, BP, FHR, uterine activity, and vaginal lossImmediately after insertionAt 30 minutes post insertionContinue CTG immediately after insertion (minimum 30 minutes)Advise to inform staff as soon as contractions commenceOngoing monitoring as for latent first stage of labour while:Observations are normalNo contractionsNot otherwise indicatedWhen in active labour–continuous CTGAssessment of progressReassess the MBS:Gel–wait at least 6 hours after insertionPessary–wait at least 12 hours after insertionIrrespective of MBS, recommend ARM if technically possibleIf ARM not possible, repeat gel dose may be required (following reassuring CTG)Indications for removal: dinoprostone pessaryOnset of regular, painful uterine contractions, occurring every 3 minutes irrespective of any cervical changeMembranes rupture (spontaneous or ARM)Fetal distressUterine hyperstimulation or hypertonic uterine contractionsMaternal systemic adverse PGE2 effects (e.g. nausea, vomiting, hypotension, tachycardia)If starting oxytocin infusion–remove at least 30 minutes prior to startingInsufficient cervical ripening after 12 hoursArtificial rupture of membranes (Amniotomy)Table 20. Artificial rupture of membranesAspectClinical practice pointIndicationFavourable cervix (MBS of 7 or more)ARM alone is not recommended as time to onset of contractions is unpredictable, particularly in nulliparous women To observe the colour and amount of liquor when clinically indicatedRelative contraindicationPoor application of the presenting part/unstable lieFetal head not engaged (5/5 above the pelvic brim)Risk/benefitRisk of: cord prolapse or compression, rupture of vasa praevia, pain and discomfortARM and immediate oxytocin compared to ARM and delayed oxytocin (commenced 4 hours post ARM) showed shorter ARM to birth interval in nulliparous and parous womenCompared to amniotomy alone, ARM and oxytocin resulted in fewer women not birthing vaginally at 24 hoursFollowing cervical priming, early ARM (performed regardless of MBS) has been associated with a decrease in IOL to birth interval and no difference in other outcomesBefore procedureIf no other IOL procedure before ARM, perform pre IOL assessmentEncourage to empty bladderAbdominal palpation to determine fetal lie, presentation, position and engagementVE to determine stage of labour, MBS, presentation, position and descent, possible cord or malpresentation, identify membranesConsult obstetrician if:the head is not engaged, cord presentationmalpresentationunstable lie polyhydramniosProcedure (continuing on from assessment VE)Maintain digital contact with presenting partInsert amnihook/amnicot, using examining finger as guard to hookRupture forewaters–avoid ARM over fontanelle or faceRemove amnihook/amnicot, guarding it against index fingerConfirm passage of fluid and check for presence of blood or meconiumSweep membranes from presenting partEnsure good application of presenting part before completing VEApply fetal scalp electrode, only if clinically indicated- Refer to CHHS Clinical Guideline: Fetal surveillanceFollowing ARM for IOL, recommend commencement of oxytocin immediatelyDocument abdominal palpation and VE findingsPost ARM monitoringFHR, uterine activity, and vaginal loss (liquor amount, colour and consistency) immediately after ARMIf oxytocin commenced immediately after ARM, then monitor as for oxytocin [refer Table 21 Oxytocin]If oxytocin not commenced immediately after ARM (e.g. woman wishes to await onset of contractions), then ongoing monitoring as for latent first stage of labour while:Observations are normalNo contractionsNot otherwise indicatedRefer to Clinical Guideline: Labour Care 1st 2nd and 3rd stageIf FHR or liquor abnormalities (e.g. meconium/blood stained or no liquor):Perform CTGDiscuss/refer/consult as indicatedRefer to Clinical Guideline: Fetal surveillanceEncourage mobilisation to promote onset of uterine contractionsOxytocinOxytocin stimulates the smooth muscle of the uterus to produce rhythmic contractions.Table 21. OxytocinAspectClinical practice pointIndicationIOL in the setting of ruptured membranesCautionsDue to the additive uterine effects, do not commence oxytocin within:Six (6) hours of dinoprostone vaginal gel administration30 minutes of removal of dinoprostone vaginal pessaryDiscuss with an obstetrician prior to commencement with:Previous uterine surgery (e.g. CS) [refer to Clinical Guideline: Vaginal birth after caesarean section]Multiple pregnancyGreater than four previous vaginal birthsCardiovascular diseaseRisk/benefitTachysystole or hypertonus with/without signs of FHR abnormalitiesNausea and vomiting (0.1 to 1%)Rarely (less than 0.1%): arrhythmias, anaphylactoid reaction, severe (tetanic) uterine contraction leading to uterine rupture, flushing, electrocardiograph (ECG) changes (including prolonged QT interval), transient hypotension, reflex tachycardia (common with rapid IV injection)Medication safetyThe standard oxytocin preparation and administration regimen is recommended as outlined in Table 22 below Oxytocin regimen administrationIf required, the same infusion solution can be continued for PPH management and as PPH prophylaxis following CSBefore administrationVerify CTG normalIf membranes are not ruptured, perform ARM prior to oxytocin infusionIf SROM ensure forewaters are rupturedMonitoringProvide one-to-one midwifery careCommence the intrapartum record when infusion is commencedMaternal and fetal observations as per first stage of active labour [refer to CHHS Clinical Guideline: Labour Care 1st, 2nd and 3rd stage]Commence continuous CTG at the onset of first contractions Refer to CHHS Clinical Guideline: Fetal surveillanceMaternal pulse and FHR prior to any increase in the infusion rateMonitor fluid balance as water intoxication/hyponatraemia may result from prolonged infusion (rare with the use of isotonic solutions)Planned VBAC—maintain vigilance for uterine dehiscence and ruptureOxytocin administration regimenTable 22. Oxytocin administrationAspectClinical practice pointAdministrationAdd oxytocin 30 International units to a 500 mL bag of either 0.9% sodium chloride or compound sodium lactate (Hartmann’s solution)1 milliunit/minute = 1 mL/hourUse a volumetric pump to ensure an accurate rate of infusionProgram delivery pumps for correct infusion concentrationsAdminister oxytocin by sideline/secondary IV access (as oxytocin infusion initiated at low volume)Record the dose in milliunit per minuteIncrease dose at 30 minute or longer intervalsAim for 3–4 contractions in a 10 minute period with duration of 40–60 seconds and resting period not less than 60 secondsTitrate dose against uterine contractions and FHRUse the minimum dose required to establish and maintain active labourMark changes to dose clearly and contemporaneously on the intrapartum record and/or CTGDiscontinue/ recommenceAfter labour is established oxytocin infusion may be electively discontinuedReduced incidence of FHR abnormalities and uterine hyperstimulation reportedInconsistent evidence about effect on active phase duration (possibly increased)If recommencing infusion, use the following guide:If ceased for less than 30 minutes, recommence at half previous rateIf ceased for longer than 30 minutes, recommence at initial starting dose (due to short half-life)Obstetrician reviewPrior to exceeding 20 milliunit/minute (manufacturer recommended maximum)At the maximum regimen dose of 32 milliunit/minute and labour not commencedIf infusion ceased or recommencedVariation to regimenOnly vary the regimen (milliunit/minute, rate of increase and/or maximum dose) following an assessment by an obstetrician of the individual clinical circumstances and progress of labourProcesses and systems that facilitate routine variation are notrecommendedTable 23. Oxytocin regimenInfusion: oxytocin(30 International units in 500 mL)1 milliunit/minute is equal to 1 mL/hourDose (milliunit/minute)Volume mls/hour11224488121216162020Prior to exceeding 20 milliunit/minute:Obstetrician review required242428283232Back to Table of ContentsSection 5 – Risks and benefits associated with IOLTable 24. Risks and benefits associated with IOLRiskClinical practice pointUnsuccessful IOLReview the individual clinical circumstancesAssess fetal wellbeing using CTGDiscuss options for careIf appropriate consider:An alternative IOL method, and/orDischarge home for 24 hours followed by second attempt at IOLCaesarean sectionTachysystole or hypertonus (without FHR abnormalities)ORUterine hyperstimulation (with FHR abnormalities)Escalate as required to Registrar/ ConsultantContinuous CTGAttempt removal of any remaining dinoprostone gelRemove dinoprostone pessary if still in situCease/reduce rate of oxytocin infusion while reassessing labour and fetal statePosition left lateralRecord maternal observations, including BPCommence intravenous (IV) fluids via new administration setVE to assess cervical dilation and exclude cord prolapseIf persists, consider use of tocolytic:Terbutaline: 250 micrograms subcutaneously Excessive uterine activity in the absence of evidence of fetal compromise is not in itself an indication for tocolysisIf clinically indicated, prepare for instrumental birth or CS (e.g. FHR does not return to normal)Cord prolapseA potential risk at the time of membrane rupture especially when the membranes are ruptured artificiallyTo reduce the likelihood of cord prolapse:Before ARM, assess engagement of the presenting partIf the baby’s head is high, avoid ARMPalpate for umbilical cord presentation during the VEAvoid dislodging the baby’s head during the VEUterine ruptureAn uncommon event with IOLA life-threatening event for mother and babyIf suspected, prepare for an emergency CS, uterine repair or hysterectomyPPHIOL with oxytocin has been associated with an increased risk of PPHIncreased interventionCompared with spontaneous labour, IOL may be associated with a higher incidence of additional interventions (e.g. electronic fetal monitoring, analgesia usage), although there is no increase in instrumental births or CS in randomised controlled trialsCompared with expectant management, no association found between IOL and increased rates of adverse perinatal outcomes of neonatal unit admission, maternal death, or meconium stained amniotic fluidBenefitsWhen performed for a valid indication, IOL should result in a reduction in perinatal morbidity/mortalityLimited evidence suggests women may prefer IOL to expectant management (serial antenatal monitoring) beyond 41 weeksBack to Table of ContentsImplementation This Clinical Guideline will be discussed at Multidisciplinary and Maternity Education, in-services and Unit Meetings. It will be available via the ACT health Intranet in Policy/Clinical Guidance.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealth Directorate Nursing and Midwifery Continuing Competence PolicyConsent and TreatmentProceduresCHHS Healthcare Associated Infections Clinical ProcedureCHHS Patient Identification and Procedure Matching PolicyGuidelines Labour Care 1st, 2nd and 3rd Stage careFetal surveillanceInsulin Infusion for Labour and birthObesity: pregnancy labour birth and postnatal careVaginal birth after caesarean (VBAC)Early onset Group B Streptococcal disease (EOGBSD)Prelabour rupture of membranes Preterm prelabour rupture of membranes Termination of Pregnancy and Pregnancy lossLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferencesAustralian Medicines Handbook (2016). Dinoprostone. [Internet]: Australian Medicines Handbook Pty Ltd; July 2016 [cited July 2016]. Available from: J, van der Goes B, Pel M, Mol B, van der Post J (2013). Morning versus evening induction of labour for improving outcomes. [Internet]. [cited 2016 November 14]; Issue 2. Art. No.: CD007707. Available from: DOI:10.1002/14651858.CD007707.pub2.Boulvain M, Irion O, Dowswell T, Thornton J (2016). Induction of labour at or near term for suspected fetal macrosomia. Cochrane Database of Systematic Reviews. [Internet].[cited 2016 September 10]; Issue 5. Art. No.: CD000938 DOI:10.1002/14651858.CD000938.pub2.Boulvain M, Senat M-V, Perrotin F, Winer N, Beucher G, Subtil D, et al (2015). Induction of labour versus expectant management for large-for-date fetuses: a randomised controlled trial. Lancet;385(9987):2600-5.Boulvain M, Stan C, Irion O (2005). Membrane sweeping for induction of labour Cochrane Database of Systematic Reviews. [Internet]. 2005 (updated 2009) [cited 2016 September 10]; Issue 1. Art. No.: CD000451 DOI: 10.1002/14651858.CD000451.pub2.Danon D, Sekar R, Hack KE, Fisk NM (2013). Increased stillbirth in uncomplicated monochorionic twin pregnancies: a systematic review and meta- analysis. Obstet Gynecol 2013;121(6):1318-26.Gülmezoglu A, Crowther C, Middleton P (2012). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews. [Internet]. [cited 2016 October 16]; Issue 4. Art. No.: CD004945 DOI: 10.1002/14651858.CD004945.pub2.Kelly AJ, Alfirevic Z, Ghosh A (2016). Outpatient versus inpatient induction of labour for improving birth outcomes. Cochrane Database of Systematic Reviews. [Internet]. 2013 [cited 2016 September 10]; Issue 11. Art. No.: CD007372 DOI:10.1002/14651858.CD007372.pub3.National Institute for Health and Clinical Excellence (NICE) (2008). Induction of labour. Clinical Guideline 70. [Internet]. [cited 2016 October 10]. Available from: Institute for Health and Care Excellence (NICE) (2013). Induction of labour: evidence update July 2013. A summary of selected new evidence relevant to NICE clinical guideline 70 ‘Induction of labour’ (2008). Evidence Update 44. [Internet]. 2013 [cited 2016 August 16]. Available from: .uk.Page JM, Pilliod RA, Snowden JM, Caughey AB (2015). The risk of stillbirth and infant death by each additional week of expectant management in twin pregnancies. Am J Obstet Gynecol;212(5):630.e1-7.Queensland Government (2017), Clinical Guideline-Maternity and Neonatal Clinical Guideline; Induction of labour College of Obstetricians and Gynaecologists (2013). Induction of labour at term in older mothers. Scientific impact paper no. 34, 2013. College of Obstetricians and Gynaecologists (2013). The investigation and management of the small–for–gestational–age fetus. Green-top Guideline No. 31 (2nd edition). [Internet]. 2013 (minor revisions 2014) [cited 2016 October 10]. Available from: Royal College of Obstetricians and Gynaecologists (2011). Obstetric cholestasis. Guideline No. 43. [Internet]. [cited 2016 August 16]. Available from: Australian and New Zealand Stillbirth Alliance (ANZSA). Clinical practice guideline for the management of women who report decreased fetal movements. Version 1.1. [Internet]. 2010 [cited 2016 August 16]. Available from: Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Intrapartum fetal surveillance clinical guideline-third edition. [Internet]. 2014 [cited 2016 August 15]. Available from: Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) (2010). Routine intrapartum care in the absence of pregnancy complications. College statement:C-Obs 31. [Internet]. 2010 (assessed as current 2014) [cited 2016 October 10]. Available from: J, Fairclough A, Kavanagh J, Kelly AJ (2016). Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database of Systematic Reviews. [Internet]. 2014 [cited 2016 September 10]; Issue 6. Art. No.: CD003101 DOI:10.1002/14651858.CD003101.pub3.Women’s Healthcare Australasia (WHA) (2016). Consensus statement on: Best practice care for first time mothers: Induction of Labour. S, Cooper S, Ross S (2014). Does induction of labour increase the risk of caesarean section? A systematic review and meta-analysis of trials in women with intact membranes. BJOG;121(6):674-85; discussion 85.World Health Organization. WHO (2011). Recommendations for induction of labour. [Internet]. 2011 [cited 2016 October 20]. Available from: to Table of ContentsDefinition of Terms TermDefinitionAmniotomyArtificial rupture of membranes to initiate or speed up labour.Balloon catheterA flexible tube with an inflatable balloon at one end. This can be introduced through the cervix and the balloon inflated, holding the catheter in place. Also known as transcervical catheterCervical ripeningA prelude to the onset of labour whereby the cervix becomes soft and compliant. This allows its shape to change from being long and closed, to being thinned out (effaced) and starting to open (dilate). It either occurs naturally or as a result of physical or pharmacological interventions.Expectant managementAllowing labour to develop and progress under supervision without intervention, unless clinically indicated.Favourable cervixThe cervix is said to be favourable when its characteristics suggest there is a high chance of spontaneous onset of labour, or of responding to interventions made to induce labour.Fetal growth restrictionAlso known as intrauterine growth restriction (IUGR). Fetal growth restriction (FGR) indicates the presence of a pathophysiological process occurring in utero that inhibits fetal growth.Grand multiparaA woman who has given birth to five or more babies.Induction of labourThe process of artificially initiating labour.Mechanical methodNon-pharmacological method of inducing labour.ObstetricianLocal facilities may differentiate the roles and responsibilities assigned in this document to an “Obstetrician” according to their specific practitioner group requirements; for example to General Practitioner Obstetricians, Specialist Obstetricians, Consultants, Visiting Medical Officers, Senior Registrars, Obstetric Fellows or other members of the team as required.Prolonged pregnancyA pregnancy past 42 weeks gestation.Transcervical catheterRefer to the definition for balloon catheter.Uterine hyperstimulationEither uterine tachysystole or uterine hypertonus with FHR abnormalities.3Uterine hypertonusContractions lasting more than two minutes in duration or contractions occurring within 60 seconds of each other, without fetal heart rate abnormalities.Uterine tachysystoleMore than 5 contractions in 10 minutes without FHR abnormalitiesBack to Table of ContentsSearch Terms Induction, Labour, Prostin, Cervidil, Balloon catheter, Cook catheter, Transcervical catheter, Misoprostol, ARM, Artificial Rupture of membranes, Rupture of membranes, Membrane sweeping, Bishop score, OxytocinDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 14/03/2018Complete ReviewKaren Faichney, A/g ED WY&CCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS 13/467Maternity-Induction of Labour ................
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