Induction of labour Maternity and Neonatal Clinical Guideline - Department of Health
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Department of Health
Maternity and Neonatal Clinical Guideline
Induction of labourQueensland Clinical Guideline: Induction of labour
Document title: Induction of labour
Publication date: September 2011
Document number: MN11.22-V4-R16
Document The document supplement is integral to and should be read in conjunction
supplement: 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
Email: Guidelines@health.qld.gov.au
Contact:
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
Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability
(including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred
for any reason associated with the use of this guideline, including the materials within or referred to
throughout this document being in any way inaccurate, out of context, incomplete or unavailable.
© State of Queensland (Queensland Health) 2015
This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to
copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines,
Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit
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(07) 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48,
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Refer to online version, destroy printed copies after use Page 2 of 26Queensland Clinical Guideline: Induction of labour
Flowchart: Induction of labour: summary of recommendations
Indications
• Maternal and fetal benefit
• Consider individual Indications
circumstances • Offer at 39 - 40 weeks • Monitor FHR appropriate to
clinical circumstances
Membrane
Potential circumstance Contraindications • Advise may cause
Sweep • Low lying placenta
• Prolonged pregnancy discomfort, bleeding and
• PPROM / PROM • Elective caesarean section irregular contractions
• Previous caesarean section is planned
• Obstetric cholestasis
• Diabetes
• Hypertensive disorder
• Twin pregnancy
• Suspected fetal macrosomia
Indications • Monitor FHR immediately
• Fetal growth restriction
• Favourable cervix post procedure
• IUFD
ARM • Document liquor colour/
• Maternal request
Cautions consistency
• Other maternal conditions
• Avoid with high head • Mobilise
Contraindications
• As for vaginal birth
Communication & information for
women Indications
• Maternal and fetal benefit & risk • Unfavourable cervix
• Indications • Monitor FHR appropriate to
Contraindication
• Methods of IOL Trans- clinical circumstances
• Low lying placenta • If not spontaneously expelled
• Pain relief cervical
• Possibility of failure Catheter Cautions
within 12 hours then obstetric
• Time for decision-making • Antepartum bleeding
review
• Document above • Rupture of membranes
• Cervicitis
Pre-induction assessment
• Review history
• Confirm gestation
• Baseline observations
(temperature, pulse, BP) Indications • Continuous CTG – minimum
• Abdominal palpation • Unfavourable cervix 30 minutes
(presentation, engagement) • Recumbent left lateral for 30
Contraindications minutes post insertion
• CTG
• Hypersensitivity to • Temperature, BP, pulse,
• Assess membrane status (intact Prosta-
glandin Prostaglandin monitor uterine activity and
or ruptured)
• Grandmultiparity – gel PV loss – hourly for 4 hours
• Vaginal examination
• High parity (>3) – pessary • VE reassess:
Cervix • Previous uterine surgery o Gel – after 6 hours
• Favourable: • High presenting part o Controlled release – after
o Bishop score > 6 • Malpresentation 12 hours
• Unfavourable:
o Bishop score ≤ 6
Declined induction Indications
• Offer increased antenatal • Favourable cervix • One-to-one midwifery care
monitoring x 2/week: o If cervix unfavourable • ARM prior to Oxytocin
o CTG consider Dinoprostone • Continuous CTG
o Ultrasound scan: (PGE2) • Assess uterine contractions
§ Amniotic fluid index for 10 minutes every 30
§ Umbilical arterial Doppler Oxytocin
Cautions minutes
• Not within 6 hours of • Observations as per QCG
Postponed induction Dinoprostone gel Normal birth guideline and
• Consider individual • Not within 30 minutes of prior to IV Oxytocin rate
circumstances removal of Dinoprostone increase
• Perform maternal and fetal pessary (Cervidil) • Maintain fluid balance
assessment • Previous uterine surgery • Assess progress of labour
• Document assessment and plan • High parity (>4)
of care in the health record
• Advise the woman to return if
concerned
Queensland Clinical Guideline (QCG): Induction of labour. Guideline No. MN11.22-V4-R16
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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
1
Amniotomy Artificial rupture of membranes to initiate or speed up labour.
A prelude to the onset of labour whereby the cervix becomes soft and
compliant. This allows its shape to change from being long and
Cervical ripening closed, to being thinned out (effaced) and starting to open (dilate). It
either occurs naturally or as a result of physical or pharmacological
1
interventions.
Dinoprostone Prostaglandin gel or pessary.
Induction of labour (IOL) commencing between 2 and 12 hours after
Expedited IOL – PROM 1
prelabour rupture of membranes (PROM).
Non-intervention at any particular point in the pregnancy, allowing
Expectant Management progress to a future gestational age. Intervention occurs only when
2
clinically indicated.
The cervix is said to be favourable when its characteristics suggest
Favourable cervix there is a high chance of spontaneous onset of labour, or of
1
responding to interventions made to induce labour.
Also known as intrauterine growth restriction (IUGR). Fetal growth
Fetal growth restriction
restriction (FGR) indicates the presence of a pathophysiological
(FGR) 3
process occurring in utero that inhibits fetal growth.
The process of artificial initiation of labour before its spontaneous
Induction of labour 4
onset.
1
Mechanical method Non-pharmacological method of inducing labour.
More than 5 contractions in 10 minutes for two consecutive 10 minute
Uterine hypercontractility 1
intervals or a contraction lasting more than 2 minutes.
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
Obstetrician
Practitioner Obstetricians, Specialist Obstetricians, Consultants,
Senior Registrars, Obstetric Fellows or other members of the team as
required.
+0 1
Prolonged pregnancy A pregnancy past 42 weeks gestation.
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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
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1 Introduction
Induction of labour (IOL) is a relatively common procedure. In 2009 the IOL rate in Queensland was
5
22.4%. 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.
6
In Queensland, only 27.1% of women who had an IOL reported having made an informed decision :
• Provide women with information on the :
1,4
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 choices
7
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.
8
At 41 weeks or later gestation, it has been shown for those women who :
• 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
9
monitoring consisting of twice weekly:
• Cardiotocography (CTG)
10
• Ultrasound assessment of amniotic fluid volume using:
10,11
o Estimation of maximum amniotic pool depth , or
12,13
o Amniotic fluid index
• Umbilical arterial Doppler ultrasound
12
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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
1
available
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
• Is not a method of IOL
Indication • Is used to reduce the need for formal IOL by encouraging spontaneous
labour
• From 38-40 weeks onwards, significantly reduced pregnancies beyond 41
14
weeks
• Repeated membrane sweeping has been found to decrease the proportion
15
of postterm pregnancies
•
16 15
Reduced need for formal IOL , particularly in multiparous women
•
17
Limited data on risk in Group B streptococcus (GBS) carriers
Risk/Benefit
•
14
No evidence of increased risk of maternal or neonatal infection
•
14,15
Associated with discomfort , vaginal bleeding and irregular
14
contractions
•
15
Most women would choose membrane sweeping again
• Optimal frequency unknown. Practice varies from weekly to several times a
1,14
week
• Consider offering membrane sweep at 39-40 weeks, especially to low risk
18
multiparous women
Recommendations • Advise of the benefits of repeated membrane sweeping
• If the cervix is closed and membrane sweeping is not possible, cervical
1
massage in vaginal fornices may achieve similar effect
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2 Specific circumstances
Considerations for specific IOL indications are outlined in the following sections.
2.1 Prolonged Pregnancy
Table 2. Prolonged pregnancy
Prolonged pregnancy
•
19
The risk of fetal death increases significantly with gestational age :
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
13
for at least one week is associated with :
Risk/Benefit 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%)
•
19
Most women prefer IOL at 41 weeks over serial antenatal monitoring
• For women with uncomplicated pregnancies, recommend IOL between 41
1,20
and 42 weeks
•
1,20,21
Recommendations Waiting after 42 weeks is not recommended
• 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
+0 +6
Gestation between 34 –36
• IOL versus expectant management:
22,23
o Reduces chorioamnionitis
22
o Reduces maternal length of stay
o Insufficiently sized studies to determine difference in:
22,23
§ Neonatal sepsis
23
§ Respiratory distress
23
§ Newborn intensive care resource use
Risk/Benefit • Decreased neonatal intensive care unit (NICU) length of stay and
hyperbilirubinaemia is demonstrated if delivery occurs after, rather than
24
before, 34 weeks
Gestation less than 34 weeks
• Birth before 34 weeks is associated with increased neonatal mortality ,
25
25 24
adverse neonatal outcomes including respiratory distress syndrome ,
24 24
intraventricular haemorrhage , necrotising enterocolitis and other long
25
term complications
• Mortality and morbidity increase with decreasing gestational age
25
+0 +6
Gestation between 34 –36
• Decision should be based on discussion with the woman and her partner
and on the local availability of Special Care Nursery/ NICU facilities
Recommendations
Gestation less than 34 weeks
• IOL is not recommended unless there are additional obstetric or fetal
1
indications
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2.3 Term prelabour rupture of membranes
Table 4. Term prelabour rupture of membranes
Term prelabour rupture of membranes (PROM)
•
26
Spontaneous labour commences
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
27
need for epidural analgesia
• A policy of expedited IOL compared to expectant management
28
decreases :
o Admissions to the NICU from 17% to 12.6%
Risk/Benefit 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
29
sepsis
• Women with planned management are more likely to view their care more
29
positively than expectantly managed women
• When associated with GBS:
o Compared to expectant management and IOL with Dinoprostone,
IOL with Oxytocin is associated with lower rate of neonatal infection
30
– 2.5% versus greater than 8%
•
31
Refer to Guideline: Early onset Group B streptococcal disease
• 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:
Recommendations 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
30
Oxytocin
2.4 Previous caesarean section
Table 5. Previous caesarean section
Previous caesarean section
•
32
Risk/Benefit Refer to guideline: Vaginal birth after caesarean section (VBAC)
• Taking into account individual circumstances, discuss IOL, CS and
1
expectant management
•
1,33
Recommendations Inform women of the increased risk of CS and uterine rupture in IOL
•
34
Discuss decisions about care with the responsible obstetrician
•
32
Refer to guideline: Vaginal birth after caesarean section (VBAC)
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2.5 Obstetric cholestasis
Table 6. Obstetric cholestasis
Obstetric cholestasis
•
35
There is no quality evidence to recommend best management
•
36
Is associated with increased risk of :
o Intrauterine fetal death (IUFD) – 2%
o Preterm birth – 44%
o Meconium staining of liquor – 25-45%
•
36
90% of fetal deaths occur after 37 weeks
• A correlation has been shown between serum bile acid levels and fetal
36,37
complication rates :
o Bile acids of less than 40 micromol/L were associated with no
increase in fetal risk
Risk/Benefit o Ursodeoxycholic acid has been shown to reduce serum bile acid
38,39
levels. It is uncertain if this translates to reduced perinatal risk
40
o Poor fetal outcome is associated with :
§ Deteriorating biochemical tests
§ Unresponsiveness to Ursodeoxycholic acid
• CTG and Doppler surveillance have no role in the prediction of perinatal
37
risk
• 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
41
literature
• Decision to deliver should be made on an individual basis
• Based on weak evidence, IOL may be recommended at 37 weeks
•
Recommendations 36
Consider IOL at 35-37 weeks for severe cases with jaundice ,
36
progressive elevations in serum bile acids and liver enzymes, and
36
suspected fetal compromise
2.6 Diabetes
Table 7. Gestational diabetes/diabetes mellitus
Gestational diabetes (GDM)/diabetes mellitus
• 27% of non-malformed stillbirths in women with pre-existing diabetes
42
occur after 37 completed weeks
•
th
In women with GDM on insulin, comparing IOL in the 38 week with
, 43
expectant management showed :
Risk/Benefit 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
•
44
Diet controlled, mild GDM is associated with good pregnancy outcome
o No data on risk of perinatal mortality after 40 weeks
• Until quality evidence becomes available, offer delivery at 38 weeks to
43
women with diabetes requiring insulin
Recommendations • 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
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2.7 Hypertensive disorders of pregnancy
Table 8. Hypertensive disorders of pregnancy
Hypertensive disorders of pregnancy
•
1,14,45
The only cure for pre eclampsia is birth
• In non-severe hypertension, compared to IOL, expectant management
Risk/Benefit showed increased poor maternal outcome, using a composite measure:
o 44% compared to 31% in IOL group
o No differences in composite neonatal outcome
• Consider individual circumstances when determining timing of birth
• Consider delivery where hypertension initially diagnosed after 37 weeks
Recommendations • Consider vaginal birth unless a caesarean section is required for other
4,46
obstetric indications
•
47
Refer to Guideline: Hypertensive disorders of pregnancy
2.8 Twin pregnancy
Table 9. Twin pregnancy
Twin pregnancy
•
48
Optimal timing for uncomplicated twin pregnancy is uncertain
• Retrospective studies demonstrate:
49
o Perinatal mortality rate is lowest for birth at 37 weeks gestation
50
o An increase in stillbirth, particularly from 38 weeks
o An underpowered randomised controlled trial (RCT) comparing
expectant management with IOL at 37 weeks showed no statistical
Risk/Benefit 51
difference in CS, CS for fetal distress or perinatal death
• In uncomplicated twin pregnancy there is insufficient data to support the
48
practice of planned birth from 37 weeks
• The main determinant of risk in a multiple pregnancy is chorionicity and
this may influence decisions regarding the timing of delivery in individual
cases
•
+0
Taking into account individual circumstances, plan birth soon after 38
50
weeks
Recommendations
• 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
•
52
Accuracy of estimating fetal weight varies :
o From 15-79% using ultrasound
o From 40-52% using clinical judgement
• Comparing IOL and expectant management there are no significant
53
Risk/Benefit differences in :
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
• In the absence of other indications, IOL should not be recommended
1,21,53
Recommendations simply on suspicion that a baby is macrosomic
• However, it is important to discuss and consider maternal concerns
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2.10 Fetal growth restriction
Table 11. Fetal growth restriction
Fetal growth restriction
• There are no clear guidelines supported by strong evidence on timing of
54
delivery when fetal growth restriction (FGR) has been diagnosed
• Use of umbilical artery and ductus venosus Doppler has been shown to
54
assist in improving perinatal outcome
Preterm FGR
• The GRIT study comparing expectant versus immediate birth (IOL and
CS) between 24-36 weeks showed:
55
o Expectant group
§ Prolonged pregnancy by 4 days
§ Decreased CS rate (79% versus 91%)
Risk/Benefit § Increased stillbirth rate (3.1% versus 0.7%)
§ Decreased post birth death rate, prior to discharge (6.2%
versus 9.1%)
56
o At two years :
§ 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
57
versus immediate birth at term, showed no significant difference in :
o Obstetric interventions, for example CS
o Neonatal morbidity
• In term and preterm pregnancies with FGR there is little evidence to guide
1
timing of birth
• Timing of birth will depend on gestational age, severity of FGR and results
Recommendations
of tests of fetal well being
• Recommend expedited birth for a woman with FGR diagnosed at term
58
• Severity affects the decision of the most appropriate mode of birth
55
2.11 Intrauterine fetal death
Table 12. Intrauterine fetal death
Intrauterine fetal death
•
1
There is no evidence addressing immediate versus delayed IOL
Risk/Benefit • Many women go into spontaneous labour within 2-3 weeks of IUFD
•
59
Risk of coagulopathy is usually only of concern after 4 weeks
• Support the woman's preferences regarding timing of IOL:
o Delaying IOL for a few days should be supported, if desired,
Recommendations provided:
§ Membranes are intact
1
§ No evidence of infection
2.12 Maternal request
Table 13. Maternal request
Maternal request
•
1
There are no studies that address this group specifically
Risk/Benefit • In uncomplicated pregnancies consider the risk of neonatal respiratory
13
distress syndrome and related adverse effects
• Consider IOL based on exceptional circumstances of the woman and her
Recommendations
family
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2.13 Other maternal conditions
Table 14. Other maternal conditions
Anticoagulant therapy and maternal cardiac condition
• For a woman on anticoagulant therapy, IOL is timed around the
60
medication protocol
Risk/Benefit • For maternal cardiac conditions, the objective of care is to minimise the
additional load on the cardiovascular system, ideally through spontaneous
60
onset of labour
• A multidisciplinary team, consisting of an obstetrician, cardiologist or
physician as appropriate, anaesthetist, and midwife is essential
•
60
Involve an intensivist and neonatologist as required
• Develop a plan for peripartum management of anticoagulant therapy
61
(prophylactic or therapeutic)
• If receiving anticoagulant therapy, wean and cease prior to IOL
Recommendations • For a woman with a maternal cardiac condition, plan for an IOL when
60
required :
o Anticoagulant therapy protocol
o Availability of medical staff
o Deteriorating maternal cardiac function
• Refer to Guideline: Venous thromboembolism (VTE) prophylaxis in
61
pregnancy and the puerperium
Refer to online version, destroy printed copies after use Page 13 of 26Queensland Clinical Guideline: Induction of labour
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
12
period
• 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
1
monitoring
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
62
then the scores are summed. Table 15 provides an example of a modified Bishop score .
• The state of the cervix is one of the important predictors of successful IOL
4
• The cervix is unfavourable if the score is 6 or less
4
Table 15. Modified Bishop score
Score
Cervical feature
0 1 2 3
Dilation (cm) 4
Length of cervix (cm) >3 2 1Queensland Clinical Guideline: Induction of labour
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
•
63,64
Known hypersensitivity to Dinoprostone or other constituents
•
64,65
Ruptured membranes – pessary contraindicated
•
65
Multiple pregnancies
• High parity
63
Contraindications o Gel – parity greater than 4 and
64
o Pessary – parity greater than 3
•
63,64,65
Previous CS or any uterine surgery
•
63
Malpresentation / high presenting part
• Unexplained vaginal discharge and / or uterine bleeding during current
63,64,65
pregnancy
•
65
Use caution in women with asthma due to potential bronchoconstriction
•
65
Ruptured membranes – use gel with caution
•
63,64,65
Oxytocin administration
Cautions
•
65
Epilepsy
•
65
Cardiovascular disease
•
65
Raised intraocular pressure, glaucoma
•
65
Nausea, vomiting and diarrhoea may occur soon after insertion
• Increased risk of hyperstimulation with or without FHR abnormality in
66
approximately 4% of women
•
66
Incidence of CS is not increased
• The risk of hyperstimulation is higher with the pessary than with the gel
67
Risk/Benefit (4.5% versus 2.4%)
•
68
Risk of hyperstimulation is higher if Oxytocin is also used
• 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,
1
the gel may be more appropriate for a woman with a favourable cervix
• 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
Monitoring for 4 hours
• Advise the woman to inform staff as soon as contractions commence
• When contractions commence, confirm fetal wellbeing with continuous
1
CTG for 30 minutes:
o If applicable, remove pessary
o Intermittent FHR auscultation may be used as in normal
1
spontaneous labour unless concerns are identified
• If contractions do not commence, reassess the modified Bishop score:
Assessment of 65
progress o Dinoprostone gel – 6 hours after insertion
65
o Dinoprostone pessary – 12 hours after insertion
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4.1.1 Dinoprostone dose and administration
Table 17. Dinoprostone administration
Aspect Dinoprostone administration
Dinoprostone gel
• Initial dose:
69
o Nulliparous – 2 mg PV
o Multiparous – 1 mg PV
• Repeat dose, after 6 hours:
Dose
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
Dinoprostone gel
• Maximum – 3 mg over 6 hours
65
Maximum dose
Dinoprostone pessary
• 4 mg (12 hours after insertion)
64
Dinoprostone gel
• Use water soluble lubricants (not obstetric cream)
• Remove from refrigeration and stand at room temperature for at least 30
63
minutes prior to use
• Insert into the posterior fornix of the vagina
63
• Not for intracervical administration
63
• Advise recumbent and left lateral position for 30 minutes after insertion
63
to facilitate absorption
Dinoprostone pessary
• Remove from freezer or fridge immediately prior to use
64
Administration
• Can be stored in the fridge for up to one month after removal from the
64
freezer
• Warming is not required
64
• 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 vagina in transverse position
65 64
• Ensure sufficient tape outside vagina to allow removal
64
• Remain recumbent for 30 minutes
64
• Advise women to avoid inadvertent removal of pessary and to report if
pessary falls out
Side effects • Uterine hypercontractility [For management: refer Section 5]
64
Dinoprostone pessary
• Onset of regular uterine contractions
• Membranes rupture (spontaneous or ARM)
• Fetal distress
Indications for • Uterine hypercontractility
removal • 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
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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
• IOL using ARM and intravenous Oxytocin infusion is the preferred method
Indications 70
once the cervix is favourable
• 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
64
of its removal
Cautions
• If not already ruptured, perform ARM prior to initiation of Oxytocin infusion
• Oxytocin is contraindicated in women with previous uterine scar or high
68
parity (greater than 4). Discuss with an obstetrician prior to
commencement
• Compared to IOL with vaginal Prostaglandin:
o Is associated with more failures to achieve vaginal birth within 24
71
hours
71
o Shows no significant difference in caesarean birth rates
71
o Increased the need for epidural
Risk/Benefit 1
o Mobility is restricted
o Refer to Table 16 for Dinoprostone considerations
• Is associated with lower infection rates in both mother and baby when
71
membranes are ruptured at the time of IOL
• Oxytocin induced contractions may be perceived as more painful
•
4
Provide one-to-one midwifery care
• Use continuous electronic FHR monitoring once Oxytocin infusion
72,68
commenced
• Titrate dose to achieve 3-4 strong regular contractions in 10 minutes
• Maternal and fetal observations:
73
Monitoring o Refer to guideline: Normal birth
o Assess maternal observations and FHR prior to any increase in the
infusion rate
• Maintain fluid balance as water intoxication may result from prolonged
68
infusion (rare with the use of isotonic solutions)
• Assess pain relief requirements
• Commence the partogram or intrapartum record with the start of the
Assessment of infusion
progress • When labour established, consider the use of alert and action lines to
monitor progress
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4.2.1 Oxytocin administration
Table 19. Oxytocin administration
Consideration Oxytocin administration
•
4,68
Use a volumetric pump to ensure an accurate rate of infusion
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
4
Administration o Titration should occur at 30 minute or greater intervals
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
•
4
Use the minimum dose required to establish and maintain active labour
• Record the dose in milliunits per minute
• Mark changes to dose clearly and contemporaneously on the CTG and / or
intrapartum record
• Review by an obstetrician should occur before exceeding a dose of 20
Maximum dose
milliunits per minute
•
68
Cardiovascular disturbances (e.g. bradycardia, tachycardia)
•
68
Side effects Headache (can be associated with fluid overload)
•
68
Gastrointestinal disorders (e.g. nausea, vomiting)
•
68
Uterine activity becomes hypertonic
•
68
Resting uterine tone increases
Cease infusion if:
•
68
Fetal compromise occurs (any concerning FHR abnormality)
• Consult with an obstetrician before recommencing infusion
4.2.2 Oxytocin regimens
4
The ideal dosing regime of Oxytocin is unknown. Suggested regimens are outlined in Table 20.
Table 20. Oxytocin regimen
Time after Oxytocin dose Volume infused (mL/hour)
starting (milliunits per 10 IU in 20 IU in 30 IU in
(minutes) minute) 500 mL 1000 mL 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
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4.3 Artificial rupture of membranes
Table 21. Artificial rupture of membranes considerations
Artificial rupture of membranes (ARM)
•
74
Favourable cervix – Bishop score 7 or more
Indications • May be used alone especially in a multiparous woman (may initiate
74
contractions) or in combination with Oxytocin infusion
• Caution should be exercised where the head is high due to the risk of
Cautions 1
cord prolapse [refer to Section 5]
•
74
Risk of pain, discomfort, bleeding
•
75
May shorten length of labour by speeding up contractions
• Nulliparous women with ARM and immediate Oxytocin compared to
76
delayed Oxytocin (commenced 4 hours post ARM) showed :
Risk/Benefit 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
• Before ARM:
77
o Explain the procedure to the woman
78
o Abdominal palpation to determine descent
o Assess for possible cord presentation
78
o Consult obstetrician if the head is not engaged 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
Monitoring
•
72
Monitor FHR immediately following procedure 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
70
7 or more
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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 secretion
79
Table 22. Transcervical catheter considerations
Consideration Comment
• May be particularly useful where the cervix is unfavourable
Indications • May be used where Dinoprostone has had no effect on cervical ripening
• May be considered in women with previous CS
• Contraindication:
79
o Low lying placenta
Cautions • Cautions:
4
o Antepartum bleeding
4
o Rupture of membranes
4
o Cervicitis
•
79
Low cost and no specific storage or temperature requirements
• No evidence of an increased risk of chorioamnionitis or endometritis
79
although data is limited
Risk/Benefit
• May be associated with slight vaginal bleeding
• In women with a very unfavourable cervix, use seems to reduce failed
79
IOL when compared to IOL with Oxytocin alone
• Monitor FHR as appropriate to individual clinical circumstances
Monitoring • If after 12 hours, the catheter has not spontaneously fallen out, obstetric
review is indicated
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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
•
1
The criteria for failed IOL are not generally agreed
•
1
Recommended care options include :
o Review the individual clinical circumstances
Failed IOL 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
•
80
Attempt removal of any remaining Dinoprostone gel
•
80
Remove Dinoprostone pessary if still in situ
•
1
Stop Oxytocin infusion while reassessing labour and fetal state
• Position woman left lateral
• Assess BP and FHR
Uterine • Commence intravenous hydration if not contraindicated by maternal
hypercontractility condition
• Pelvic exam to assess cervical dilation
•
1
If persists use tocolytics :
70
o Terbutaline – 250 micrograms subcutaneously
72
o Salbutamol – 100 micrograms by slow intravenous (IV) injection
72
o *Sublingual Glyceryl Trinitrate (GTN) spray 400 micrograms
•
1
If clinically indicated perform emergency CS
•
1
Is a potential risk at the time of membrane rupture especially with ARM
•
1
Is an obstetric emergency
•
Cord prolapse 1
Precautions should include :
o Assessment of engagement of the presenting part
o Caution during ARM if the baby’s head is high
•
1
Uterine rupture is an uncommon event with IOL
• Uterine rupture is a life-threatening event for mother and baby
Uterine rupture
•
1
If suspected, prepare for an emergency CS, uterine repair or
hysterectomy
*Not currently listed on the Queensland Health List of Approved Medications (LAM)
Not TGA approved for this purpose
Refer to online version, destroy printed copies after use Page 21 of 26Queensland Clinical Guideline: Induction of labour References 1. National Collaborating Centre for Women's and Children's Health. Induction of labour. Clinical Guideline. July 2008 [cited 2011 February 4]. Available from: http://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdf. 2. Caughey A, Sundaram V, Kaimal A, Cheng Y, Gienger A, Little S, et al. Maternal and neonatal outcomes of elective induction of labor. Evidence report/technology assessment no. 176. AHRQ Publication No. 09-E005. Rockville, MD.: Agency for Healthcare Research and Quality. Mar 2009 [cited 2010 December 16]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK38683/. 3. Queensland Clinical Guidelines. Term small for gestational age baby. Guideline No: MN10.16-V2-R15. 2010. Available from: www.health.qld.gov.au/qcg. 4. Society of Obstetricians and Gynaecologists of Canada. SOGC clinical practice guideline. Induction of labour at term. No. 107. J Obstet Gynaecol Can. 2001; August:1-12. 5. Queensland Health, Health Statistics Centre. Perinatal Statistics Queensland 2009. 2010 [cited 2011 March 18]. Available from: http://www.health.qld.gov.au/hic/peri2009/6_Lab&del_2009.pdf. 6. Miller Y, Thompson R, Porter J, Prosser S. Findings from the having a baby in Queensland survey, 2010. Queensland Centre for Mothers and Babies, the University of Queensland. 2011. 7. University of Queensland, Queensland Centre for Mothers and Babies. The having a baby in Queensland book: your choices during pregnancy and birth. 2010 [cited 2011 March 16]. Available from: http://www.havingababy.org.au/media/pdf/habiqbook.pdf. 8. Heimstad R, Romundstad P, Hyett J, Mattsson L, Salvesen K. Women's experiences and attitudes towards expectant management and induction of labor for post-term pregnancy. Acta Obstetricia et Gynecologica Scandinavica. 2007; 86(8):950- 6. 9. Heimstad R, Skogvoll E, Mattson L, Johansen O, Eik-Nes S, Salvesen K. Induction of labour or serial antenatal fetal monitoring in postterm pregnancy: a randomized controlled trial. Obstetrics & Gynecology. 2007; 109(3):609-17. 10. National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the healthy pregnant woman. Clinical Guideline 62. March 2008 [cited 2011 February 4]. Available from: http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf. 11. Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single deepest vertical pocket: a meta-analysis of randomized controlled trials. International Journal of Gynaecology and Obstetrics. 2009; 104(3):184-8. 12. Mandruzzato G, Alfirevic Z, Chervenak F, Gruenebaum A, Heimstad R, Heinonen S, et al. Guidelines for the management of postterm pregnancy. Journal of Perinatal Medicine. 2010; 38(2):111-9. 13. Gülmezoglu A, Crowther C, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews. 2006; Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2. 14. Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews. 2005 Issue 1. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub2:[Edited 2010 (no change to conclusions), content assessed as up-to-date: 8 November 2004]. 15. de Miranda E, van der Bam J, Bonsel G, Bleker O, Rosendaal F. Membrane sweeping and prevention of post-term pregnancy in low risk pregnancies: a randomised controlled trial. British Journal of Obstetrics and Gynaecology: an International Journal of Obstetrics and Gynaecology. 2006; 113(4):402-408. 16. Boulvain M, Fraser W, Marcoux S, Fontaine J, Bazin S, Pinault J, et al. Does sweeping of the membranes reduce the need for formal induction of labour? A randomised control trial. British Journal of Obstetrics and Gynaecology. 1998; 105:34- 40. 17. Netta D, Visitainer P, Bayliss P. Does cervical membrane stripping increase maternal colonization of Group B streptococcus? American Journal of Obstetrics and Gynecology. 2002; 187(6):S221. 18. Yildirim G, Gungorduk K, Karadag OI, Aslan H, Turhan E, Ceylan Y. Membrane sweeping to induce labor in low-risk patients at term pregnancy: A randomised controlled trial. The Journal of Maternal-Fetal and Neonatal Medicine. 2010; 23(7):681-7. 19. Heimstad R, Romundstad P, Eik-Nes S, Salvesen K. Outcomes of pregnancy beyond 37 weeks of gestation. Obstetrics and Gynecology. 2006; 108(3 Pt1):500-8. 20. Hermus MA, Verhoeven CJ, Mol BW, de Wolf GS, Fiedeldeij CA. Comparison of induction of labour and expectant management in postterm pregnancy: a matched cohort study. J Midwifery Womens Health. 2009; 54(5):351-6. Refer to online version, destroy printed copies after use Page 22 of 26
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