P2010/0493-001 2.

19-08WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported:

Dinoprostone (Cervidil) Cervical Ripening

Protocol for the Use of Cervidil in the Induction of Labour Induction of labour using Prostaglandin E2 (Prostin) Midwifery and Medical Staff, Queen Victoria Maternity Unit Prostin P2010/0321-001 Induction of Labour for Post Maturity P2010/0486-001 Intrapartum Fetal Monitoring P2010/0528-001 Uterine Hyperstimulation

Purpose: Vaginal prostaglandin E2 has been shown to be efficacious in ripening the cervix prior to the induction of labour. Dinoprostone releases Prostaglandin E2 (PEG2) to the cervical tissue continuously at a rate which allows cervical ripening to progress until complete (mean dose approximately 4mg over 12 hours) with the facility to remove the PEG2 if required. A second dose of Dinoprostone is not recommended, as the effects of a second dose have not been studied. Indication for Prostaglandin Dinoprostone is used where induction of labour is indicated and the Bishops score is <6. It should not be used in the place of ARM and Syntocinon where the cervix is favourable. The Bishops score must be documented in the womens progress notes. Bishops Score SCORE Dilation Length of Cervix Station Consistency Position

0 0 3 -3 Firm Posterior

1 1-2 2 -2 Medium Mid

2 3-4 1 -1 Soft Anterior TOTAL

3 5+ 0 0

Contraindications Known hypersensitivity to Dinoprostone or the any other constituent of the pessary (urethane). Multiple pregnancy History of previous uterine surgery Known or suspected cephalopelvic disproportion Malpresentation
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Non reassuring fetal heart rate Grand multiparity Where vaginal birth is contraindicated placenta praevia, active genital herpes Unexplained vaginal bleeding in pregnancy Ruptured membranes Hyperactive or hypertonic uterine contractions Dinoprostone should be used in caution in women with compromised cardiovascular function, history of uterine hypertony, glaucoma, epilepsy or asthma.

Use with Caution Dinoprostone should be used in caution in women with suspected fetal compromise and continuous CTG monitoring should be considered. In this situation consideration should be given to the timing of administration to facilitate increased fetal surveillance. Administration Women for Dinoprostone cervical ripening should present to 4B between 1930 and 2000. Women with suspected fetal compromise should have Dinoprostone administered at 0800 to facilitate increased fetal surveillance. A CTG must be performed prior to the administration to establish fetal wellbeing. The Dinoprostone is to be administered by the obstetric registrar/consultant or senior midwife after cervical assessment for Bishop scoring. Dinoprostone should be inserted high into the posterior fornix of the vagina, using only a small amount of water soluble lubricant to aid insertion. The Dinoprostone should be placed transversely in the posterior fornix. After insertion the excess withdrawal tape may be cut with scissors ensuring there is sufficient tape outside the vagina to allow removal. A CTG must be performed for thirty minutes following the administration of Dinoprostone. Continuous CTG is recommended in women with suspected fetal compromise. The woman should remain recumbent for thirty minutes following administration of Dinoprostone. Dinoprostone can remain insitu for a maximum of 12 hours. The woman will then be reviewed with a view to ARM and oxytocin infusion. Oxytocin infusion must not be commenced until 30 minutes after the removal of Dinoprostone.

Clinical Observations
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Maternal observations should be recorded prior to the insertion of Dinoprostone, one hour after the insertion of Dinoprostone and thereafter, every four hours. Fetal heart rate should be auscultated every fours. A CTG should be performed once regular contractions begin or there is any clinical change in fetal or maternal condition eg SROM, APH, elevated BP, chest pain or shortness of breath. More frequent fetal surveillance (continuous CTG) is warranted if there is suspected fetal compromise. For women who are healthy and have had an otherwise uncomplicated pregnancy once normality is confirmed, intermittent monitoring can be used (RCOG 2001).

Indications for Removal of Prostin The presence of regular painful uterine contractions occurring every 3 minutes irrespective of any cervical change Spontaneous rupture of membranes or amniotomy Uterine hyperstimulation or hypertonic uterine contractions Evidence of fetal distress Maternal systemic adverse PEG2 effects such as nausea, vomiting, hypotension or tachycardia At least 30 minutes prior to starting an intravenous infusion of oxytocin If there has been insufficient cervical ripening in 12 hours. Further Use of Prostaglandins Further use of prostaglandins (PGE2 or repeat Dinoprostone) should not occur until 24 hours after the removal of the initial Dinoprostone.
Attachment 1

References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr F Clark Acting Co-Director (Medical) Womens & Childrens Services

Date: _________________________

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ATTACHMENT 1 REFERENCES CSL 2003 Cervidil Product Information online: http://www.csl.com.au/PharmaceuticalGynaecologyCervidil.asp King Edward Memorial Hospital 2005 Induction of Labour Clinical Guideline Online: http://www.kemh.health.wa.gov.au/development/manuals/sectionb/index.htm Royal Hobart 2006 Induction of Labour Clinical Guideline Online: http://intra.dhhs.tas.gov.au/dhhs-online/page.php?id=16562

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