guideline: induction of labour - syrioqueensland clinical guideline: induction of labour refer to...

Maternity and Neonatal Clinical Guideline

Department of Health

Induction of labour

Queensland Clinical Guideline: Induction of labour

Refer to online version, destroy printed copies after use of 26

Document title: Induction of labour

Publication date: September 2011

Document number: MN11.22-V4-R16

Document supplement:

The document supplement is integral to and should be read in conjunction with this guideline

Amendments Full version history is supplied in the document supplement

Amendment date April 2015

Replaces document: MN11.22-V3-R16

Author: Queensland Clinical Guidelines

Audience: Health professionals in Queensland public and private maternity services

Review date: September 2016

Endorsed by: Queensland Clinical Guidelines Steering Committee Statewide Maternity and Neonatal Clinical Network Queensland Health Patient Safety and Quality Executive Committee

Contact: Email: [email protected] URL: www.health.qld.gov.au/qcg

Disclaimer This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances may be appropriate. This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: • Providing care within the context of locally available resources, expertise, and scope of practice • Supporting consumer rights and informed decision making in partnership with healthcare practitioners

including the right to decline intervention or ongoing management • Advising consumers of their choices in an environment that is culturally appropriate and which

enables comfortable and confidential discussion. This includes the use of interpreter services where necessary

• Ensuring informed consent is obtained prior to delivering care • Meeting all legislative requirements and professional standards • Applying standard precautions, and additional precautions as necessary, when delivering care • Documenting all care in accordance with mandatory and local requirements

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Flowchart: Induction of labour: summary of recommendations

Indications• Maternal and fetal benefit• Consider individual

circumstances

Potential circumstance • Prolonged pregnancy• PPROM / PROM• Previous caesarean section• Obstetric cholestasis• Diabetes• Hypertensive disorder• Twin pregnancy• Suspected fetal macrosomia• Fetal growth restriction• IUFD• Maternal request• Other maternal conditions

Contraindications• As for vaginal birth

Communication & information for women• Maternal and fetal benefit & risk• Indications• Methods of IOL• Pain relief• Possibility of failure• Time for decision-making• Document above

Pre-induction assessment• Review history• Confirm gestation• Baseline observations

(temperature, pulse, BP)• Abdominal palpation

(presentation, engagement)• CTG• Assess membrane status (intact

or ruptured)• Vaginal examination

Cervix• Favourable:

o Bishop score > 6• Unfavourable:

o Bishop score ≤ 6

Declined induction• Offer increased antenatal

monitoring x 2/week:o CTG o Ultrasound scan:§ Amniotic fluid index§ Umbilical arterial Doppler

Postponed induction• Consider individual

circumstances• Perform maternal and fetal

assessment• Document assessment and plan

of care in the health record• Advise the woman to return if

concerned

• Continuous CTG – minimum 30 minutes

• Recumbent left lateral for 30 minutes post insertion

• Temperature, BP, pulse, monitor uterine activity and PV loss – hourly for 4 hours

• VE reassess: o Gel – after 6 hourso Controlled release – after

12 hours

Prosta-glandin

Queensland Clinical Guideline (QCG): Induction of labour. Guideline No. MN11.22-V4-R16

Indications• Favourable cervix

o If cervix unfavourable consider Dinoprostone (PGE2)

Cautions• Not within 6 hours of

Dinoprostone gel• Not within 30 minutes of

removal of Dinoprostone pessary (Cervidil)

• Previous uterine surgery• High parity (>4)

• One-to-one midwifery care• ARM prior to Oxytocin• Continuous CTG• Assess uterine contractions

for 10 minutes every 30 minutes

• Observations as per QCG Normal birth guideline and prior to IV Oxytocin rate increase

• Maintain fluid balance • Assess progress of labour

Oxytocin

Indications • Unfavourable cervix

Contraindications• Hypersensitivity to

Prostaglandin• Grandmultiparity – gel• High parity (>3) – pessary• Previous uterine surgery• High presenting part• Malpresentation

Indications• Unfavourable cervix

Contraindication• Low lying placenta

Cautions• Antepartum bleeding• Rupture of membranes• Cervicitis

• Monitor FHR appropriate to clinical circumstances

• If not spontaneously expelled within 12 hours then obstetric review

Trans-cervical Catheter

Indications• Favourable cervix

Cautions• Avoid with high head

• Monitor FHR immediately post procedure

• Document liquor colour/consistency

• Mobilise

ARM

Indications• Offer at 39 - 40 weeks

Contraindications• Low lying placenta• Elective caesarean section

is planned

• Monitor FHR appropriate to clinical circumstances

• Advise may cause discomfort, bleeding and irregular contractions

Membrane Sweep



Abbreviations

ARM Artificial rupture of membranes; amniotomy CS Caesarean section CTG Cardiotocography FGR Fetal growth restriction FHR Fetal heart rate GBS Group B streptococcus GDM Gestational Diabetes Mellitus IOL Induction of labour IUFD Intrauterine fetal death NICU Neonatal intensive care unit PGE2 Dinoprostone, Prostaglandin E2 PPROM Preterm prelabour rupture of membranes PROM Prelabour rupture of membranes PV Per vaginam RCT Randomised controlled trial TGA Therapeutic Goods Administration VBAC Vaginal birth after caesarean VE Vaginal examination

Definition of Terms

Amniotomy Artificial rupture of membranes to initiate or speed up labour.1

Cervical ripening

A 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.1

Dinoprostone Prostaglandin gel or pessary.

Expedited IOL – PROM Induction of labour (IOL) commencing between 2 and 12 hours after prelabour rupture of membranes (PROM).1

Expectant Management Non-intervention at any particular point in the pregnancy, allowing progress to a future gestational age. Intervention occurs only when clinically indicated.2

Favourable cervix The 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.1

Fetal growth restriction (FGR)

Also known as intrauterine growth restriction (IUGR). Fetal growth restriction (FGR) indicates the presence of a pathophysiological process occurring in utero that inhibits fetal growth.3

Induction of labour The process of artificial initiation of labour before its spontaneous onset.4

Mechanical method Non-pharmacological method of inducing labour.1

Uterine hypercontractility More than 5 contractions in 10 minutes for two consecutive 10 minute intervals or a contraction lasting more than 2 minutes.1

Obstetrician

Local 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, Senior Registrars, Obstetric Fellows or other members of the team as required.

Prolonged pregnancy A pregnancy past 42+0 weeks gestation.1



Table of Contents 1 Introduction ..................................................................................................................................... 6

1.1 Communication and information ............................................................................................ 6 1.2 Indications .............................................................................................................................. 6 1.3 Contraindications ................................................................................................................... 6 1.4 Care if induction of labour declined ....................................................................................... 6 1.5 Care if induction of labour postponed .................................................................................... 7 1.6 Clinical standards .................................................................................................................. 7 1.7 Membrane sweeping ............................................................................................................. 7

2 Specific circumstances ................................................................................................................... 8 2.1 Prolonged Pregnancy ............................................................................................................ 8 2.2 Preterm prelabour rupture of membranes ............................................................................. 8 2.3 Term prelabour rupture of membranes .................................................................................. 9 2.4 Previous caesarean section ................................................................................................... 9 2.5 Obstetric cholestasis ............................................................................................................ 10 2.6 Diabetes ............................................................................................................................... 10 2.7 Hypertensive disorders of pregnancy .................................................................................. 11 2.8 Twin pregnancy ................................................................................................................... 11 2.9 Suspected fetal macrosomia (> 4000 grams) ...................................................................... 11 2.10 Fetal growth restriction ........................................................................................................ 12 2.11 Intrauterine fetal death ......................................................................................................... 12 2.12 Maternal request .................................................................................................................. 12 2.13 Other maternal conditions .................................................................................................... 13

3 Pre induction of labour assessment ............................................................................................. 14 3.1 Cervical assessment ............................................................................................................ 14

4 Methods of induction of labour ..................................................................................................... 14 4.1 Dinoprostone ....................................................................................................................... 15

4.1.1 Dinoprostone dose and administration ............................................................................ 16 4.2 Oxytocin infusion ................................................................................................................. 17

4.2.1 Oxytocin administration ................................................................................................... 18 4.2.2 Oxytocin regimens ........................................................................................................... 18

4.3 Artificial rupture of membranes ............................................................................................ 19 4.4 Transcervical catheters ........................................................................................................ 20

5 Risks associated with induction of labour .................................................................................... 21

List of Tables Table 1. Membrane sweeping considerations ....................................................................................... 7 Table 2. Prolonged pregnancy .............................................................................................................. 8 Table 3. Preterm prelabour rupture of membranes ............................................................................... 8 Table 4. Term prelabour rupture of membranes ................................................................................... 9 Table 5. Previous caesarean section .................................................................................................... 9 Table 6. Obstetric cholestasis ............................................................................................................. 10 Table 7. Gestational diabetes/diabetes mellitus .................................................................................. 10 Table 8. Hypertensive disorders of pregnancy .................................................................................... 11 Table 9. Twin pregnancy ..................................................................................................................... 11 Table 10. Suspected fetal macrosomia ............................................................................................... 11 Table 11. Fetal growth restriction ........................................................................................................ 12 Table 12. Intrauterine fetal death ......................................................................................................... 12 Table 13. Maternal request .................................................................................................................. 12 Table 15. Modified Bishop score ......................................................................................................... 14 Table 16. Dinoprostone considerations ............................................................................................... 15 Table 17. Dinoprostone administration ................................................................................................ 16 Table 18. Oxytocin considerations ...................................................................................................... 17 Table 19. Oxytocin administration ....................................................................................................... 18 Table 20. Oxytocin regimen ................................................................................................................. 18 Table 21. Artificial rupture of membranes considerations ................................................................... 19 Table 22. Transcervical catheter considerations ................................................................................. 20 Table 23. Risk factors associated with IOL ......................................................................................... 21



1 Introduction Induction of labour (IOL) is a relatively common procedure. In 2009 the IOL rate in Queensland was 22.4%.5 The aim of IOL is to achieve vaginal birth before the spontaneous onset of labour. The purpose of this guideline is to guide the IOL process. Specific circumstances and methods of IOL are included in this guideline.

1.1 Communication and information Discuss the risks and benefits of IOL as they pertain to each individual woman to enable the woman to make an informed decision in consultation with her health care provider. In Queensland, only 27.1% of women who had an IOL reported having made an informed decision6:

• Provide women with information on the1,4: o Indications for IOL o Potential risks and benefits of IOL o Proposed method(s) of IOL o Options for pain relief o Options if IOL is unsuccessful o Options if IOL is declined

• Provide women with time for questions and decision making • Clear and contemporaneous documentation is required in the woman’s healthcare record • Consider the use of decision aids to assist the woman make informed choices7

1.2 Indications IOL is indicated when the maternal and/or fetal risks of ongoing pregnancy outweigh the risks of IOL and birth. Specific circumstances are considered in section 2.2.

1.3 Contraindications Contraindications to IOL are consistent with vaginal birth contraindications. Specific circumstances where IOL is to be performed with caution are described in section 2.2.

1.4 Care if induction of labour declined Women who decline IOL should have their decision respected. Usually, these are women who have been offered IOL for prolonged pregnancy. At 41 weeks or later gestation, it has been shown for those women who8:

• Waited for labour to start – 38% would choose to wait next time • Were induced – 73% would choose an IOL next time

No form of increased antenatal monitoring has been shown to reduce perinatal mortality associated with postterm pregnancy. However, it is recommended from 42 weeks, to offer increased antenatal monitoring9 consisting of twice weekly:

• Cardiotocography (CTG)10 • Ultrasound assessment of amniotic fluid volume using:

o Estimation of maximum amniotic pool depth10,11, or o Amniotic fluid index12,13

• Umbilical arterial Doppler ultrasound12



1.5 Care if induction of labour postponed Take into account the woman’s individual clinical circumstances and preferences, the indication for IOL and the local service capabilities and priorities when determining if a booked IOL can be postponed (e.g. due to resourcing issues or as a result of maternal request). When a booked induction of labour is postponed:

• Perform an assessment of maternal and fetal wellbeing • Involving the woman, develop a plan for continued care including, arrangements for

ongoing monitoring (if required) and return for IOL • Document the assessment and plan in the health record • Advise the woman to contact the facility if she has concerns about her wellbeing or that of

her baby

1.6 Clinical standards When offering IOL:

• Consider the service capabilities of the facility • Ensure availability of health care professionals appropriate to the circumstances • Continuous electronic fetal heart monitoring and uterine contraction monitoring should be

available1

1.7 Membrane sweeping Membrane sweeping refers to the digital separation of the fetal membranes from the lower uterine segment during vaginal examination. This movement helps to separate the cervix from the membranes and helps to stimulate the release of prostaglandins. Table 1 outlines considerations for membrane sweeping.

Table 1. Membrane sweeping considerations

Membrane sweeping

Indication • Is not a method of IOL • Is used to reduce the need for formal IOL by encouraging spontaneous

labour

Risk/Benefit

• From 38-40 weeks onwards, significantly reduced pregnancies beyond 41 weeks14

• Repeated membrane sweeping has been found to decrease the proportion of postterm pregnancies15

• Reduced need for formal IOL16, particularly in multiparous women15 • Limited data on risk in Group B streptococcus (GBS) carriers17 • No evidence of increased risk of maternal or neonatal infection14 • Associated with discomfort14,15, vaginal bleeding and irregular

contractions14 • Most women would choose membrane sweeping again15 • Optimal frequency unknown. Practice varies from weekly to several times a

week1,14

Recommendations

• Consider offering membrane sweep at 39-40 weeks, especially to low risk multiparous women18

• Advise of the benefits of repeated membrane sweeping • If the cervix is closed and membrane sweeping is not possible, cervical

massage in vaginal fornices may achieve similar effect1



2 Specific circumstances Considerations for specific IOL indications are outlined in the following sections.

2.1 Prolonged Pregnancy

Table 2. Prolonged pregnancy

Prolonged pregnancy

Risk/Benefit

• The risk of fetal death increases significantly with gestational age19: o At 38 weeks gestation – 0.25% o At 42 weeks gestation – 1.55%

• IOL at 41 weeks or beyond compared with awaiting spontaneous labour for at least one week is associated with13: o Fewer perinatal deaths – 1/3285 (0.03%) versus 11/3238 (0.34%) o No significant difference in the risk of caesarean section for women

induced at 41 and 42 weeks o Lower risk of meconium aspiration syndrome at 42 weeks (3.0%

versus 4.7%), and significantly lower risk at 41 weeks (0.9% versus 3.3%)

• Most women prefer IOL at 41 weeks over serial antenatal monitoring19

Recommendations

• For women with uncomplicated pregnancies, recommend IOL between 41 and 42 weeks1,20

• Waiting after 42 weeks is not recommended1,20,21 • Exact timing depends on the women’s preferences and local

circumstances

2.2 Preterm prelabour rupture of membranes

Table 3. Preterm prelabour rupture of membranes

Preterm prelabour rupture of membranes

Risk/Benefit

Gestation between 34+0–36+6 • IOL versus expectant management:

o Reduces chorioamnionitis22,23 o Reduces maternal length of stay22 o Insufficiently sized studies to determine difference in:

§ Neonatal sepsis22,23 § Respiratory distress23 § Newborn intensive care resource use23

• Decreased neonatal intensive care unit (NICU) length of stay and hyperbilirubinaemia is demonstrated if delivery occurs after, rather than before, 34 weeks24

Gestation less than 34 weeks • Birth before 34 weeks is associated with increased neonatal mortality25,

adverse neonatal outcomes25 including respiratory distress syndrome24, intraventricular haemorrhage24, necrotising enterocolitis24 and other long term complications25

• Mortality and morbidity increase with decreasing gestational age25

Recommendations

Gestation between 34+0–36+6 • Decision should be based on discussion with the woman and her partner

and on the local availability of Special Care Nursery/ NICU facilities Gestation less than 34 weeks • IOL is not recommended unless there are additional obstetric or fetal

indications1



2.3 Term prelabour rupture of membranes

Table 4. Term prelabour rupture of membranes

Term prelabour rupture of membranes (PROM)

Risk/Benefit

• Spontaneous labour commences26 o Within 24 hours in 70% of women o Within 48 hours in 85% of women o This may decrease the need for continuous fetal heart rate (FHR)

monitoring • IOL is perceived as being more painful. These women may have a greater

need for epidural analgesia27 • A policy of expedited IOL compared to expectant management

decreases28: o Admissions to the NICU from 17% to 12.6% o Chorioamnionitis from 9.9% to 6.8% o Postpartum endometritis from 8.3% to 2.3% o No differences in caesarean section (CS) rate

• Waiting greater than 96 hours is associated with higher risk of neonatal sepsis29

• Women with planned management are more likely to view their care more positively than expectantly managed women29

• When associated with GBS: o Compared to expectant management and IOL with Dinoprostone,

IOL with Oxytocin is associated with lower rate of neonatal infection – 2.5% versus greater than 8%30

Recommendations

• Refer to Guideline: Early onset Group B streptococcal disease31 • To confirm PROM, offer sterile speculum vaginal examination (VE) • Discuss expectant management (provided a digital VE has not been

performed) and expedited management • If the woman wishes to await spontaneous labour:

o Digital VE should not be performed § If a digital VE has been performed, the use of prophylactic

antibiotics while awaiting the onset of spontaneous labour is recommended

o Waiting greater than 96 hours is not recommended • In the woman known to be GBS positive advise expedited IOL with

Oxytocin30

2.4 Previous caesarean section

Table 5. Previous caesarean section

Previous caesarean section Risk/Benefit • Refer to guideline: Vaginal birth after caesarean section (VBAC)32

Recommendations

• Taking into account individual circumstances, discuss IOL, CS and expectant management1

• Inform women of the increased risk of CS and uterine rupture in IOL1,33 • Discuss decisions about care with the responsible obstetrician34 • Refer to guideline: Vaginal birth after caesarean section (VBAC)32



2.5 Obstetric cholestasis

Table 6. Obstetric cholestasis

Obstetric cholestasis

Risk/Benefit

• There is no quality evidence to recommend best management35 • Is associated with increased risk of36:

o Intrauterine fetal death (IUFD) – 2% o Preterm birth – 44% o Meconium staining of liquor – 25-45%

• 90% of fetal deaths occur after 37 weeks36 • A correlation has been shown between serum bile acid levels and fetal

complication rates36,37: o Bile acids of less than 40 micromol/L were associated with no

increase in fetal risk o Ursodeoxycholic acid has been shown to reduce serum bile acid

levels. It is uncertain if this translates to reduced perinatal risk38,39 o Poor fetal outcome is associated with40:

§ Deteriorating biochemical tests § Unresponsiveness to Ursodeoxycholic acid

• CTG and Doppler surveillance have no role in the prediction of perinatal risk37

• IOL at 37 weeks or at time of diagnosis, before or after 37 weeks, had a decreased risk of IUFD: o 0/218 (0%) compared to 14/888 (1.6%) for historical controls in the

literature41

Recommendations

• Decision to deliver should be made on an individual basis • Based on weak evidence, IOL may be recommended at 37 weeks • Consider IOL at 35-37 weeks for severe cases with jaundice36,

progressive elevations in serum bile acids36 and liver enzymes, and suspected fetal compromise36

2.6 Diabetes

Table 7. Gestational diabetes/diabetes mellitus

Gestational diabetes (GDM)/diabetes mellitus

Risk/Benefit

• 27% of non-malformed stillbirths in women with pre-existing diabetes occur after 37 completed weeks42

• In women with GDM on insulin, comparing IOL in the 38th week with expectant management,showed43: o Reduced macrosomia in the IOL group, 10% versus 23% o No difference in caesarean section rates o A non-significant increase in shoulder dystocia in the expectant

group • Diet controlled, mild GDM is associated with good pregnancy outcome44

o No data on risk of perinatal mortality after 40 weeks

Recommendations

• Until quality evidence becomes available, offer delivery at 38 weeks to women with diabetes requiring insulin43

• Advise women with well-controlled, diet controlled GDM, and no fetal macrosomia or other complications, to await spontaneous labour unless there are other indications for IOL



2.7 Hypertensive disorders of pregnancy

Table 8. Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy

Risk/Benefit

• The only cure for pre eclampsia is birth1,14,45 • In non-severe hypertension, compared to IOL, expectant management

showed increased poor maternal outcome, using a composite measure: o 44% compared to 31% in IOL group o No differences in composite neonatal outcome

Recommendations

• Consider individual circumstances when determining timing of birth • Consider delivery where hypertension initially diagnosed after 37 weeks • Consider vaginal birth unless a caesarean section is required for other

obstetric indications4,46 • Refer to Guideline: Hypertensive disorders of pregnancy47

2.8 Twin pregnancy

Table 9. Twin pregnancy

Twin pregnancy

Risk/Benefit

• Optimal timing for uncomplicated twin pregnancy is uncertain48 • Retrospective studies demonstrate:

o Perinatal mortality rate is lowest for birth at 37 weeks gestation49 o An increase in stillbirth, particularly from 38 weeks50 o An underpowered randomised controlled trial (RCT) comparing

expectant management with IOL at 37 weeks showed no statistical difference in CS, CS for fetal distress or perinatal death51

• In uncomplicated twin pregnancy there is insufficient data to support the practice of planned birth from 37 weeks48

• The main determinant of risk in a multiple pregnancy is chorionicity and this may influence decisions regarding the timing of delivery in individual cases

Recommendations

• Taking into account individual circumstances, plan birth soon after 38+0 weeks50

• Refer for specialist consultation when risk factors, such as twin-to-twin transfusion syndrome, indicate the need

2.9 Suspected fetal macrosomia (> 4000 grams)

Table 10. Suspected fetal macrosomia

Suspected fetal macrosomia

Risk/Benefit

• Accuracy of estimating fetal weight varies52: o From 15-79% using ultrasound o From 40-52% using clinical judgement

• Comparing IOL and expectant management there are no significant differences in53: o CS rate o Instrumental birth o Perinatal morbidity – although 6/189 cases of brachial plexus injury

or fractured clavicle were found in the expectant group and 0/183 in the IOL group, the difference was not statistically different

Recommendations • In the absence of other indications, IOL should not be recommended

simply on suspicion that a baby is macrosomic1,21,53 • However, it is important to discuss and consider maternal concerns



2.10 Fetal growth restriction

Table 11. Fetal growth restriction

Fetal growth restriction

Risk/Benefit

• There are no clear guidelines supported by strong evidence on timing of delivery when fetal growth restriction (FGR) has been diagnosed54

• Use of umbilical artery and ductus venosus Doppler has been shown to assist in improving perinatal outcome54

Preterm FGR • The GRIT study comparing expectant versus immediate birth (IOL and

CS) between 24-36 weeks showed: o Expectant group55

§ Prolonged pregnancy by 4 days § Decreased CS rate (79% versus 91%) § Increased stillbirth rate (3.1% versus 0.7%) § Decreased post birth death rate, prior to discharge (6.2%

versus 9.1%) o At two years56:

§ Similar rates of mortality § More severe disability noted in immediate birth group if less

than 31 weeks at birth Term FGR • Small pilot RCT, with a total of only 33 cases, comparing expectant

versus immediate birth at term, showed no significant difference in57: o Obstetric interventions, for example CS o Neonatal morbidity

Recommendations

• In term and preterm pregnancies with FGR there is little evidence to guide timing of birth1

• Timing of birth will depend on gestational age, severity of FGR and results of tests of fetal well being

• Recommend expedited birth for a woman with FGR diagnosed at term58 • Severity affects the decision of the most appropriate mode of birth55

2.11 Intrauterine fetal death

Table 12. Intrauterine fetal death

Intrauterine fetal death

Risk/Benefit • There is no evidence addressing immediate versus delayed IOL1 • Many women go into spontaneous labour within 2-3 weeks of IUFD • Risk of coagulopathy is usually only of concern after 4 weeks59

Recommendations

• Support the woman's preferences regarding timing of IOL: o Delaying IOL for a few days should be supported, if desired,

provided: § Membranes are intact § No evidence of infection1

2.12 Maternal request

Table 13. Maternal request

Maternal request

Risk/Benefit • There are no studies that address this group specifically1 • In uncomplicated pregnancies consider the risk of neonatal respiratory

distress syndrome and related adverse effects13

Recommendations • Consider IOL based on exceptional circumstances of the woman and her family



2.13 Other maternal conditions Table 14. Other maternal conditions

Anticoagulant therapy and maternal cardiac condition

Risk/Benefit

• For a woman on anticoagulant therapy, IOL is timed around the medication protocol60

• For maternal cardiac conditions, the objective of care is to minimise the additional load on the cardiovascular system, ideally through spontaneous onset of labour60

Recommendations

• A multidisciplinary team, consisting of an obstetrician, cardiologist or physician as appropriate, anaesthetist, and midwife is essential

• Involve an intensivist and neonatologist as required60 • Develop a plan for peripartum management of anticoagulant therapy

(prophylactic or therapeutic)61 • If receiving anticoagulant therapy, wean and cease prior to IOL • For a woman with a maternal cardiac condition, plan for an IOL when

required60: o Anticoagulant therapy protocol o Availability of medical staff o Deteriorating maternal cardiac function

• Refer to Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium61



3 Pre induction of labour assessment Prior to IOL an assessment of the woman should include:

• Review of maternal history • Confirmation of gestation

o Reliable menstrual dates supported by early ultrasound examination o Ultrasound scan may be more reliable even in women who are sure of last menstrual

period12 • Abdominal palpation to confirm presentation and engagement • Assessment of membrane status (ruptured or intact)4 • Vaginal examination to assess the cervix

o Refer to Section 3.1 • Assessment of fetal wellbeing

o A normal fetal heart rate pattern should be confirmed using electronic fetal monitoring1

o Consult an obstetrician if cardiotocograph (CTG) is abnormal • Assessment of contraindications • Consideration of urgency of IOL

3.1 Cervical assessment The Bishop score is commonly used to assess the cervix. Each feature of the cervix is scored and then the scores are summed. Table 15 provides an example of a modified Bishop score62.

• The state of the cervix is one of the important predictors of successful IOL4 • The cervix is unfavourable if the score is 6 or less4

Table 15. Modified Bishop score

Cervical feature Score 0 1 2 3

Dilation (cm) < 1 1-2 3-4 > 4

Length of cervix (cm) > 3 2 1 < 1

Station (relative to ischial spines) -3 -2 -1 / 0 +1 / +2

Consistency Firm Medium Soft –

Position Posterior Mid Anterior –

4 Methods of induction of labour Methods used for IOL include:

• Medical methods o Dinoprostone preparations (Prostaglandin E2, PGE2, PG gel, Prostin E2, Cervidil) o Oxytocin infusion

• Surgical methods o Artificial rupture of membranes (ARM)

• Mechanical methods o Transcervical catheter (Foley or Atad)



4.1 Dinoprostone Dinoprostone (vaginal Prostaglandin E2) promotes cervical ripening and stimulates uterine contractions. [refer to Table 16 and Table 17]. Dinoprostone preparations include:

• Vaginal gel (Prostaglandin E2, PGE2, PG gel, Prostin E2, , gel) 1mg and 2 mg • Controlled release vaginal pessary (Cervidil)

Table 16. Dinoprostone considerations

Consideration Dinoprostone Indications • Unfavourable cervix

Contraindications

• Known hypersensitivity to Dinoprostone or other constituents63,64 • Ruptured membranes – pessary contraindicated64,65 • Multiple pregnancies65 • High parity

o Gel – parity greater than 463 and o Pessary – parity greater than 364

• Previous CS or any uterine surgery63,64,65 • Malpresentation / high presenting part63 • Unexplained vaginal discharge and / or uterine bleeding during current

pregnancy63,64,65

Cautions

• Use caution in women with asthma due to potential bronchoconstriction65 • Ruptured membranes – use gel with caution65 • Oxytocin administration63,64,65 • Epilepsy65 • Cardiovascular disease65 • Raised intraocular pressure, glaucoma65

Risk/Benefit

• Nausea, vomiting and diarrhoea may occur soon after insertion65 • Increased risk of hyperstimulation with or without FHR abnormality in

approximately 4% of women66 • Incidence of CS is not increased66 • The risk of hyperstimulation is higher with the pessary than with the gel

(4.5% versus 2.4%)67 • Risk of hyperstimulation is higher if Oxytocin is also used68 • Compared to IOL with Oxytocin – refer to Table 18 • For a woman with an unfavourable cervix, the pessary may be more

appropriate as it will avoid repeated application of the gel. Conversely, the gel may be more appropriate for a woman with a favourable cervix1

Monitoring

• Prior to insertion, encourage voiding • Perform CTG to confirm fetal well being • Remain recumbent (to retain gel) left lateral (to prevent supine

hypotension) for 30 minutes after insertion • Perform CTG after insertion (minimum 30 minutes) • Temperature, BP, pulse, per vaginam (PV) loss, uterine activity – hourly

for 4 hours • Advise the woman to inform staff as soon as contractions commence • When contractions commence, confirm fetal wellbeing with continuous

CTG1 for 30 minutes: o If applicable, remove pessary o Intermittent FHR auscultation may be used as in normal

spontaneous labour unless concerns are identified1

Assessment of progress

• If contractions do not commence, reassess the modified Bishop score: o Dinoprostone gel – 6 hours after insertion65 o Dinoprostone pessary – 12 hours after insertion65



4.1.1 Dinoprostone dose and administration

Table 17. Dinoprostone administration

Aspect Dinoprostone administration

Dose

Dinoprostone gel • Initial dose:

o Nulliparous – 2 mg PV69 o Multiparous – 1 mg PV

• Repeat dose, after 6 hours: o Nulliparous – 2 mg o Multiparous – 1-2 mg

Dinoprostone pessary • 10 mg PV (released at a rate of approximately 4 mg in 12 hours)66

Maximum dose

Dinoprostone gel • Maximum – 3 mg over 6 hours65 Dinoprostone pessary • 4 mg (12 hours after insertion)64

Administration

Dinoprostone gel • Use water soluble lubricants (not obstetric cream) • Remove from refrigeration and stand at room temperature for at least 30

minutes prior to use63 • Insert into the posterior fornix of the vagina63 • Not for intracervical administration63 • Advise recumbent and left lateral position for 30 minutes after insertion63

to facilitate absorption Dinoprostone pessary • Remove from freezer or fridge immediately prior to use64 • Can be stored in the fridge for up to one month after removal from the

freezer64 • Warming is not required64 • Open the foil only after decision has been made to use it • Use water soluble lubricants (not obstetric cream) • Insert into the posterior fornix of the vagina65 in transverse position64 • Ensure sufficient tape outside vagina to allow removal64 • Remain recumbent for 30 minutes64 • Advise women to avoid inadvertent removal of pessary and to report if

pessary falls out Side effects • Uterine hypercontractility [For management: refer Section 5]

Indications for removal

Dinoprostone pessary64 • Onset of regular uterine contractions • Membranes rupture (spontaneous or ARM) • Fetal distress • Uterine hypercontractility • Insufficient cervical ripening after 12 hours

o There is minimal evidence on the administration of Dinoprostone gel if there is no cervical change 12 hours after pessary insertion. Base decision on the woman’s individual circumstances. Timing of gel administration at the obstetrician’s discretion



4.2 Oxytocin infusion Oxytocin stimulates the smooth muscle of the uterus producing rhythmic contractions. Syntocinon is synthetic Oxytocin [refer to Table 18].

Table 18. Oxytocin considerations

Consideration Clinical practice point

Indications • IOL using ARM and intravenous Oxytocin infusion is the preferred method once the cervix is favourable70

Cautions

• Should not be started within 6 hours of administration of vaginal Prostaglandin gel administration

• Should not be used with Dinoprostone pessary insitu or within 30 minutes of its removal64

• If not already ruptured, perform ARM prior to initiation of Oxytocin infusion • Oxytocin is contraindicated in women with previous uterine scar or high

parity (greater than 4).68 Discuss with an obstetrician prior to commencement

Risk/Benefit

• Compared to IOL with vaginal Prostaglandin: o Is associated with more failures to achieve vaginal birth within 24

hours71 o Shows no significant difference in caesarean birth rates71 o Increased the need for epidural71 o Mobility is restricted1 o Refer to Table 16 for Dinoprostone considerations

• Is associated with lower infection rates in both mother and baby when membranes are ruptured at the time of IOL71

• Oxytocin induced contractions may be perceived as more painful

Monitoring

• Provide one-to-one midwifery care4 • Use continuous electronic FHR monitoring once Oxytocin infusion

commenced72,68 • Titrate dose to achieve 3-4 strong regular contractions in 10 minutes • Maternal and fetal observations:

o Refer to guideline: Normal birth73 o Assess maternal observations and FHR prior to any increase in the

infusion rate • Maintain fluid balance as water intoxication may result from prolonged

infusion68 (rare with the use of isotonic solutions) • Assess pain relief requirements

Assessment of progress

• Commence the partogram or intrapartum record with the start of the infusion

• When labour established, consider the use of alert and action lines to monitor progress



4.2.1 Oxytocin administration

Table 19. Oxytocin administration

Consideration Oxytocin administration

Administration

• Use a volumetric pump to ensure an accurate rate of infusion4,68 o Consider the need for sideline/secondary IV access as per local

protocols • A standard dilution of Oxytocin should always be used • Individual protocols should specify maximum doses • The dose should be titrated against uterine contractions

o Titration should occur at 30 minute or greater intervals4 o Aim for 3-4 contractions in a 10 minute period with duration of 40-60

seconds and resting period not less than 60 seconds • Use the minimum dose required to establish and maintain active labour4 • Record the dose in milliunits per minute • Mark changes to dose clearly and contemporaneously on the CTG and / or

intrapartum record

Maximum dose • Review by an obstetrician should occur before exceeding a dose of 20 milliunits per minute

Side effects • Cardiovascular disturbances (e.g. bradycardia, tachycardia)68 • Headache (can be associated with fluid overload)68 • Gastrointestinal disorders (e.g. nausea, vomiting)68

Cease infusion if:

• Uterine activity becomes hypertonic68 • Resting uterine tone increases68 • Fetal compromise occurs (any concerning FHR abnormality)68 • Consult with an obstetrician before recommencing infusion

4.2.2 Oxytocin regimens The ideal dosing regime of Oxytocin is unknown.4 Suggested regimens are outlined in Table 20.

Table 20. Oxytocin regimen

Time after starting

(minutes)

Oxytocin dose (milliunits per

minute)

Volume infused (mL/hour) 10 IU in 500 mL

20 IU in 1000 mL

30 IU in 500 mL

0 1 3 3 1 30 2 6 6 2 60 4 12 12 4 90 8 24 24 8 120 12 36 36 12 150 16 48 48 16 180 20 60 60 20

Obstetrician review prior to exceeding 20 milliunits per minute 210 24 72 72 24 240 28 84 84 28 270 32 96 96 32



4.3 Artificial rupture of membranes

Table 21. Artificial rupture of membranes considerations

Artificial rupture of membranes (ARM)

Indications • Favourable cervix – Bishop score 7 or more74 • May be used alone especially in a multiparous woman (may initiate

contractions) or in combination with Oxytocin infusion74

Cautions • Caution should be exercised where the head is high due to the risk of cord prolapse1 [refer to Section 5]

Risk/Benefit

• Risk of pain, discomfort, bleeding74 • May shorten length of labour by speeding up contractions75 • Nulliparous women with ARM and immediate Oxytocin compared to

delayed Oxytocin (commenced 4 hours post ARM) showed76: o Increased rate of established labour 4 hours after ARM o Shorter ARM to birth interval o Increased rate of vaginal birth within 12 hours o Increased satisfaction with the induction process and the duration

of labour

Monitoring

• Before ARM: o Explain the procedure to the woman77 o Abdominal palpation to determine descent78 o Assess for possible cord presentation o Consult obstetrician if the head is not engaged78 or with possible

cord presentation • Immediately after ARM, examine to ensure there is no cord prolapse • Refer to Table 23 for risk factors associated with IOL including cord

prolapse • Monitor FHR immediately following procedure72 preferably by continuous

electronic monitoring. Confirm normal CTG before discontinuing • Document liquor colour and consistency • Encourage mobilisation to promote onset of uterine contractions • Following ARM, consider Oxytocin in:

o Multiparous women: if no contractions after 2 hours o Nulliparous women: immediately following ARM as few women will

commence contractions spontaneously unless the cervical score is 7 or more70



4.4 Transcervical catheters Transcervical catheters (e.g. Foley, Atad) are used to ripen the cervix through:

• Direct dilatation of the canal or • Indirectly by increasing prostaglandin and/or oxytocin secretion79

Table 22. Transcervical catheter considerations

Consideration Comment

Indications • May be particularly useful where the cervix is unfavourable • May be used where Dinoprostone has had no effect on cervical ripening • May be considered in women with previous CS

Cautions

• Contraindication: o Low lying placenta79

• Cautions: o Antepartum bleeding4 o Rupture of membranes4 o Cervicitis4

Risk/Benefit

• Low cost and no specific storage or temperature requirements79 • No evidence of an increased risk of chorioamnionitis or endometritis

although data is limited79 • May be associated with slight vaginal bleeding • In women with a very unfavourable cervix, use seems to reduce failed

IOL when compared to IOL with Oxytocin alone79

Monitoring • Monitor FHR as appropriate to individual clinical circumstances • If after 12 hours, the catheter has not spontaneously fallen out, obstetric

review is indicated



5 Risks associated with induction of labour IOL may increase the risk of the following conditions outlined in Table 23.

Table 23. Risk factors associated with IOL

Risk Good Practice Point

Failed IOL

• The criteria for failed IOL are not generally agreed1 • Recommended care options include1:

o Review the individual clinical circumstances o Assess fetal wellbeing using CTG o Discuss options for care with the woman o If appropriate consider discharging home for 24 hours followed by

second attempt at IOL o Caesarean section

Uterine hypercontractility

• Attempt removal of any remaining Dinoprostone gel80 • Remove Dinoprostone pessary if still in situ80 • Stop Oxytocin infusion1 while reassessing labour and fetal state • Position woman left lateral • Assess BP and FHR • Commence intravenous hydration if not contraindicated by maternal

condition • Pelvic exam to assess cervical dilation • If persists use tocolytics1:

o Terbutaline – 250 micrograms subcutaneously70 o Salbutamol – 100 micrograms by slow intravenous (IV) injection72 o *Sublingual Glyceryl Trinitrate (GTN) spray 400 micrograms72

• If clinically indicated perform emergency CS1

Cord prolapse

• Is a potential risk at the time of membrane rupture especially with ARM1 • Is an obstetric emergency1 • Precautions should include1:

o Assessment of engagement of the presenting part o Caution during ARM if the baby’s head is high

Uterine rupture

• Uterine rupture is an uncommon event with IOL1 • Uterine rupture is a life-threatening event for mother and baby • If suspected, prepare for an emergency CS,1 uterine repair or

hysterectomy *Not currently listed on the Queensland Health List of Approved Medications (LAM) Not TGA approved for this purpose



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http://www.ranzcog.edu.au/college-statements-guidelines.html



Acknowledgements Queensland Clinical Guidelines gratefully acknowledge the contribution of Queensland clinicians and other stakeholders who participated throughout the guideline development process particularly:

Working Party Clinical Lead

Associate Professor Kassam Mahomed, Senior Staff Specialist, Obstetrics and Gynaecology, Ipswich Hospital and University of Queensland

Working Party Members

Dr Michael Beckman, Director Obstetrics and Gynaecology, Mater Health Services, Brisbane Dr Lindsay Cochrane, Staff Specialist, Caboolture Hospital Ms Jennifer Fry, A/Midwife Educator, Women’s Health, Darling Downs West Moreton District Health Service Professor Michael Humphrey, Clinical Adviser, Office of Rural and Remote Health Associate Professor Rebecca Kimble, Clinical Director, Obstetric Services, Royal Brisbane and Women’s Hospital Ms Sarah Kirby, Midwifery Unit Manager, Royal Brisbane and Women’s Hospital Associate Professor Alka Kothari, Obstetrician, Redcliffe Hospital Dr David Moore, Obstetric Registrar, Ipswich Hospital Ms Gloria O’Connor, Clinical Midwife, Redcliffe Hospital Ms Jessie Offer, Consumer, Home Midwifery Association Ms Pamela Sepulveda, Clinical Midwifery Consultant, Logan Hospital Ms Rachel Thompson, Health Psychology Academic, Queensland Centre for Mothers and Babies Ms Mary Tredinnick, Pharmacist, Royal Brisbane and Women’s Hospital Ms Robin Turnbull, Network Coordinator, South Queensland and Maternity and Neonatal Clinical Network

Queensland Clinical Guidelines Team

Associate Professor Rebecca Kimble, Program Director Ms Jacinta Lee, Manager Ms Jackie Doolan, Clinical Midwifery Consultant Ms Lyndel Gray, Clinical Nurse Consultant Mr Keppel Schafer, Program Officer Steering Committee

Funding

This clinical guideline was supported by funding from Centre of Healthcare Improvement, Queensland Health

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