Induction of labour

Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

Document title: Publication date: Document number: Document supplement: Replaces document: Author: Audience: Review date: Endorsed by:

Induction of labour September 2011 MN11.22-V2-R16 The document supplement is integral to and should be read in conjunction with this guideline MN11.22-V1-R16 Queensland Maternity and Neonatal Clinical Guidelines Program Health professionals in Queensland public and private maternity services September 2016 Queensland Maternity and Neonatal Clinical Guidelines Program Statewide Maternity and Neonatal Clinical Network Queensland Health Patient Safety and Quality Executive Committee Email: MN-Guidelines@health.qld.gov.au URL: http://www.health.qld.gov.au/qcg

Contact:

Disclaimer These guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Information in this guideline is current at time of publication. Queensland Health does not accept liability to any person for loss or damage incurred as a result of reliance upon the material contained in this guideline. Clinical material offered in this guideline does not replace or remove clinical judgement or the professional care and duty necessary for each specific patient case. Clinical care carried out in accordance with this guideline should be provided within the context of locally available resources and expertise. This Guideline does not address all elements of standard practice and assumes that individual clinicians are responsible to: Discuss care with consumers in an environment that is culturally appropriate and which enables respectful confidential discussion. This includes the use of interpreter services where necessary Advise consumers of their choice and ensure informed consent is obtained Provide care within scope of practice, meet all legislative requirements and maintain standards of professional conduct Apply standard precautions and additional precautions as necessary, when delivering care Document all care in accordance with mandatory and local requirements

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 2.5 Australia licence. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/2.5/au/ State of Queensland (Queensland Health) 2010 In essence you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the authors and abide by the licence terms. You may not alter or adapt the work in any way. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email ip_officer@health.qld.gov.au , phone (07) 3234 1479. For further information contact Queensland Maternity and Neonatal Clinical Guidelines Program, RBWH Post Office, Herston Qld 4029, email MN-Guidelines@health.qld.gov.au phone (07) 3131 6777.

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

Flowchart: Summary of recommendations for Induction of labour

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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

Definition of Terms Amniotomy Artificial rupture of membranes to initiate or speed up labour.1 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 Prostaglandin gel or pessary. Induction of labour (IOL) commencing between 2 and 12 hours after prelabour rupture of membranes (PROM).1 Non-intervention at any particular point in the pregnancy, allowing progress to a future gestational age. Intervention occurs only when clinically indicated.2 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 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 The process of artificial initiation of labour before its spontaneous onset.4 Non-pharmacological method of inducing labour.1 More than 5 contractions in 10 minutes for two consecutive 10 minute intervals or a contraction lasting more than 2 minutes.1 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. A pregnancy past 42+0 weeks gestation.1

Cervical ripening

Dinoprostone Expedited IOL PROM Expectant Management

Favourable cervix Fetal growth restriction (FGR) Induction of labour Mechanical method Uterine hypercontractility

Obstetrician

Prolonged pregnancy

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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 Clinical standards......................................................................................................................... 6 1.6 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 ....................................................................................................... 10 2.5 Obstetric cholestasis .................................................................................................................. 10 2.6 Diabetes ..................................................................................................................................... 11 2.7 Hypertensive disorders of pregnancy......................................................................................... 11 2.8 Twin pregnancy .......................................................................................................................... 11 2.9 Suspected fetal macrosomia (>4000grams) .............................................................................. 12 2.10 Fetal growth restriction ............................................................................................................... 12 2.11 Intrauterine fetal death ............................................................................................................... 13 2.12 Maternal request ........................................................................................................................ 13 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 References.................................................................................................................................................. 22

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...........................................................................................................10 Table 6. Obstetric cholestasis......................................................................................................................10 Table 7. Gestational diabetes/diabetes mellitus ..........................................................................................11 Table 8. Hypertensive disorders of pregnancy ............................................................................................11 Table 9. Twin pregnancy..............................................................................................................................11 Table 10. Suspected fetal macrosomia........................................................................................................12 Table 11. Fetal growth restriction.................................................................................................................12 Table 12. Intrauterine fetal death .................................................................................................................13 Table 13. Maternal request ..........................................................................................................................13 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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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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 womans 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

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

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

1.6

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

Risk/Benefit

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

2
2.1

Specific circumstances
Prolonged Pregnancy

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

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 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 womens preferences and local circumstances

Recommendations

2.2

Preterm prelabour rupture of membranes

Table 3. Preterm prelabour rupture of membranes

Preterm prelabour rupture of membranes Gestation between 34+036+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 Gestation between 34+036+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

Risk/Benefit

Recommendations

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

2.3

Term prelabour rupture of membranes

Table 4. Term prelabour rupture of membranes

Term prelabour rupture of membranes (PROM) 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 To confirm PROM, offer sterile speculum vaginal examination (VE) Discuss expectant management (provided a digital VE has not been performed) and expedited management Recommend expedited IOL 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 Refer to Guideline: Early onset Group B streptococcal disease31

Risk/Benefit

Recommendations

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

2.4

Previous caesarean section

Table 5. Previous caesarean section

Previous caesarean section Risk/Benefit Dinoprostone (Prostin, Prostaglandin E2) gel and pessary are widely used in the UK, with good effect1 Data on risk of uterine rupture are mainly based on retrospective studies32 The risk of uterine rupture with33: o Spontaneous labour is 4/1000 o Augmentation with Oxytocin is 9/1000 o Induction with Oxytocin is 11/1000 o Induction with Prostaglandin with/without Oxytocin is 14/1000 o Induction with mechanical methods with/without Oxytocin 9/1000 In a large study, neither induction nor augmentation of labour was associated with uterine rupture, compared to women who labour spontaneously. However risk of uterine rupture increased when both Oxytocin and Prostaglandin were used for labour induction34 Taking into account individual circumstances, discuss IOL, CS and expectant management1 Inform women of the increased risk of CS and uterine rupture in IOL1,35 Discuss decisions about care with the responsible obstetrician36 Refer to guideline: Vaginal birth after caesarean section (VBAC)37

Recommendations

2.5

Obstetric cholestasis

Table 6. Obstetric cholestasis

Obstetric cholestasis There is no quality evidence to recommend best management38 Is associated with increased risk of39: o Intrauterine fetal death (IUFD) 2% o Preterm birth 44% o Meconium staining of liquor 25-45% 90% of fetal deaths occur after 37 weeks39 A correlation has been shown between serum bile acid levels and fetal complication rates39,40: 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 risk41,42 o Poor fetal outcome is associated with43: Deteriorating biochemical tests Unresponsiveness to Ursodeoxycholic acid CTG and Doppler surveillance have no role in the prediction of perinatal risk40 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 literature44 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 jaundice39, progressive elevations in serum bile acids39 and liver enzymes, and suspected fetal compromise39

Risk/Benefit

Recommendations

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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 weeks45 In women with GDM on insulin, comparing IOL in the 38th week with expectant management,showed46: 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 outcome47 o No data on risk of perinatal mortality after 40 weeks Until quality evidence becomes available, offer delivery at 38 weeks to women with diabetes requiring insulin46 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

Recommendations

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 birth1,14,48 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 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 indications4,49 Refer to Guideline: Hypertensive disorders of pregnancy50

Recommendations

2.8

Twin pregnancy

Table 9. Twin pregnancy

Twin pregnancy Optimal timing for uncomplicated twin pregnancy is uncertain51 Retrospective studies demonstrate: o Perinatal mortality rate is lowest for birth at 37 weeks gestation52 o An increase in stillbirth, particularly from 38 weeks53 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 death54 In uncomplicated twin pregnancy there is insufficient data to support the practice of planned birth from 37 weeks51 The main determinant of risk in a multiple pregnancy is chorionicity and this may influence decisions regarding the timing of delivery in individual cases Taking into account individual circumstances, plan birth soon after 38+0 weeks53 Refer for specialist consultation when risk factors, such as twin-to-twin transfusion syndrome, indicate the need

Risk/Benefit

Recommendations

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

2.9

Suspected fetal macrosomia (>4000grams)

Table 10. Suspected fetal macrosomia

Suspected fetal macrosomia Risk/Benefit Accuracy of estimating fetal weight varies55: o From 15-79% using ultrasound o From 40-52% using clinical judgement Comparing IOL and expectant management there are no significant differences in56: 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 simply on suspicion that a baby is macrosomic1,21,56 However, it is important to discuss and consider maternal concerns

Recommendations

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 delivery when fetal growth restriction (FGR) has been diagnosed57 Use of umbilical artery and ductus venosus Doppler has been shown to assist in improving perinatal outcome57 Preterm FGR The GRIT study comparing expectant versus immediate birth (IOL and CS) between 24-36 weeks showed: o Expectant group58 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 years59: 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 in60: o Obstetric interventions, for example CS o Neonatal morbidity 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 term61 Severity affects the decision of the most appropriate mode of birth58

Risk/Benefit

Recommendations

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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 weeks62 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

Recommendations

2.12 Maternal request

Table 13. Maternal request

Maternal request Risk/Benefit Recommendations There are no studies that address this group specifically1 In uncomplicated pregnancies consider the risk of neonatal respiratory distress syndrome and related adverse effects13 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 protocol63 For maternal cardiac conditions, the objective of care is to minimise the additional load on the cardiovascular system, ideally through spontaneous onset of labour63 A multidisciplinary team, consisting of an obstetrician, cardiologist or physician as appropriate, anaesthetist, and midwife is essential Involve an intensivist and neonatologist as required63 Develop a plan for peripartum management of anticoagulant therapy (prophylactic or therapeutic)64 If receiving anticoagulant therapy, wean and cease prior to IOL For a woman with a maternal cardiac condition, plan for an IOL when required63: 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 puerperium64

Recommendations

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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 score65. 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 Dilation (cm) Length of cervix (cm) Station (relative to ischial spines) Consistency Position

Score 0 <1 >3 -3 Firm Posterior 1 1-2 2 -2 Medium Mid 2 3-4 1 -1 / 0 Soft Anterior 3 >4 <1 +1 / +2

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)

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Queensland Maternity and Neonatal 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 Indications

Dinoprostone Unfavourable cervix Known hypersensitivity to Dinoprostone or other constituents66,67 Ruptured membranes pessary contraindicated67,68 Multiple pregnancies68 High parity o Gel - parity greater than 466 and o Pessary - parity greater than 367 Previous CS or any uterine surgery66,67,68 Malpresentation / high presenting part66 Unexplained vaginal discharge and / or uterine bleeding during current pregnancy66,67,68 Use caution in women with asthma due to potential bronchoconstriction68 Ruptured membranes use gel with caution68 Oxytocin administration66,67,68 Epilepsy68 Cardiovascular disease68 Raised intraocular pressure, glaucoma68 Nausea, vomiting and diarrhoea may occur soon after insertion68 Increased risk of hyperstimulation with or without FHR abnormality in approximately 4% of women69 Incidence of CS is not increased69 The risk of hyperstimulation is higher with the pessary than with the gel (4.5% versus 2.4%)70 Risk of hyperstimulation is higher if Oxytocin is also used71 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 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 If contractions do not commence, reassess the modified Bishop score: o Dinoprostone gel 6 hours after insertion68 o Dinoprostone pessary 12 hours after insertion68

Contraindications

Cautions

Risk/Benefit

Monitoring

Assessment of progress

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

4.1.1

Dinoprostone dose and administration

Table 17. Dinoprostone administration

Aspect

Dose

Dinoprostone administration Dinoprostone gel Initial dose: o Nulliparous 2 mg PV72 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)69 Dinoprostone gel Maximum 3 mg over 6 hours68 Dinoprostone pessary 4 mg (12 hours after insertion)67 There is no information on the use of Dinoprostone if no cervical change after pessary insertion67 To avoid hyperstimulation, the gel should not be inserted within 6 hours of pessary removal Dinoprostone gel Use water soluble lubricants (not obstetric cream) Remove from refrigeration and stand at room temperature for at least 30 minutes prior to use66 Insert into the posterior fornix of the vagina66 Not for intracervical administration66 Advise recumbent and left lateral position for 30 minutes after insertion66 to facilitate absorption Dinoprostone pessary Remove from freezer or fridge immediately prior to use67 Can be stored in the fridge for up to one month after removal from the freezer67 Warming is not required67 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 vagina68 in transverse position67 Ensure sufficient tape outside vagina to allow removal67 Remain recumbent for 30 minutes67 Advise women to avoid inadvertent removal of pessary and to report if pessary falls out Uterine hypercontractility [For management: refer Section 5] Dinoprostone pessary67 Onset of regular uterine contractions Membranes rupture (spontaneous or ARM) Fetal distress Uterine hypercontractility Insufficient cervical ripening after 12 hours

Maximum dose

Administration

Side effects

Indications for Removal

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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 Indications

Clinical practice point IOL using ARM and intravenous Oxytocin infusion is the preferred method once the cervix is favourable73 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 removal67 If not already ruptured, perform ARM prior to initiation of Oxytocin infusion Oxytocin should be used with caution in women with previous uterine scar or high parity (greater than 4).71 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 hours74 o Shows no significant difference in caesarean birth rates74 o Increased the need for epidural74 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 IOL74 Oxytocin induced contractions may be perceived as more painful Provide one-to-one midwifery care4 Use continuous electronic FHR monitoring once Oxytocin infusion commenced75,71 Titrate dose to achieve 3-4 strong regular contractions in 10 minutes Assess maternal observations and FHR prior to any increase in the infusion rate Maternal observations (more frequently if clinically indicated) o Temperature 2 hourly o BP hourly o Pulse hourly o Vaginal loss hourly Maintain fluid balance as water intoxication may result from prolonged infusion71 (rare with the use of isotonic solutions) Assess pain relief requirements 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

Cautions

Risk/Benefit Monitoring

Assessment of progress

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

4.2.1

Oxytocin administration

Table 19. Oxytocin administration

Consideration

Oxytocin administration Use a volumetric pump to ensure an accurate rate of infusion4,71 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 Review by an obstetrician should occur before exceeding a dose of 20 milliunits per minute Cardiovascular disturbances (e.g. bradycardia, tachycardia)71 Headache71 Gastrointestinal disorders (e.g. nausea, vomiting)71 Uterine activity becomes hypertonic71 Resting uterine tone increases71 Fetal compromise occurs (any concerning FHR abnormality) 71 Consult with an obstetrician before recommencing infusion

Administration Maximum dose Side effects

Cease infusion if:

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) 0 30 60 90 120 150 180 210 240 270

Oxytocin dose Volume infused (mL/hour) (milliunits per 30 IU in 10 IU in 20 IU in minute) 500 mL 1000 mL 500 mL 1 3 3 1 2 6 6 2 4 12 12 4 8 24 24 8 12 36 36 12 16 48 48 16 20 60 60 20 Obstetrician review prior to exceeding 20 milliunits per minute 24 72 72 24 28 84 84 28 32 96 96 32

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

4.3

Artificial rupture of membranes

Table 21. Artificial rupture of membranes considerations

Artificial rupture of membranes (ARM) Indications Cautions Risk/Benefit Favourable cervix Bishop score 7 or more76 May be used alone especially in a multiparous woman (may initiate contractions) or in combination with Oxytocin infusion76 Caution should be exercised where the head is high due to the risk of cord prolapse1 [refer to Section 5] Risk of pain, discomfort, bleeding76 May shorten length of labour by speeding up contractions77 Nulliparous women with ARM and immediate Oxytocin compared to delayed Oxytocin (commenced 4 hours post ARM) showed78: 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 Prior to ARM, assess for 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 procedure75 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 more73

Monitoring

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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 Indications

Comment 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 Contraindication: o Low lying placenta79 Cautions: o Antepartum bleeding4 o Rupture of membranes4 o Cervicitis4 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 Monitor FHR as appropriate to individual clinical circumstances If after 12 hours, the catheter has not spontaneously fallen out, obstetric review is indicated

Cautions

Risk/Benefit

Monitoring

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

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 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 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 subcutaneously73 o Salbutamol 100 micrograms by slow intravenous (IV) injection75 If clinically indicated perform emergency CS1 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 babys head is high 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

Failed IOL

Uterine hypercontractility

Cord prolapse

Uterine rupture

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Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

References
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Acknowledgements
The Queensland Maternity and Neonatal Clinical Guidelines Program 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, Womens 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 Womens Hospital Ms Sarah Kirby, Midwifery Unit Manager, Royal Brisbane and Womens Hospital Associate Professor Alka Kothari, Obstetrician, Redcliffe Hospital Dr David Moore, Obstetric Registrar, Ipswich Hospital Ms Gloria OConnor, 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 Womens Hospital Ms Robin Turnbull, Network Coordinator, South Queensland and Maternity and Neonatal Clinical Network Program Team Associate Professor Rebecca Kimble, Program Director, Queensland Maternity and Neonatal Clinical Guidelines Program Ms Jacinta Lee, A/Manager, Queensland Maternity and Neonatal Clinical Guidelines Program Ms Jackie Doolan, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program Ms Lyndel Gray, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program Mr Keppel Schafer, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program Steering Committee, Queensland Maternity and Neonatal Clinical Guidelines Program

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

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