WAHT-OBS-010

It is the responsibility of every individual to ensure this is the latest version of the document

Induction of Labour (IOL)

This guidance does not override the individual responsibility of health professionals to make appropriate
decision according to the circumstances of the individual patient in consultation with the patient and/or
carer. Health care professionals must be prepared to justify any deviation from this guidance.

INTRODUCTION
Women with uncomplicated pregnancies may be offered membrane sweep after 40 weeks and then
induction of labour by 40+12.
The process for induction of labour should only be considered when vaginal delivery is felt to be the most
appropriate route of delivery. The decision on timing and method of IOL should be made at consultant
level. This guideline refers to all women who require induction of labour with specific guidance for the
following:
 Prolonged pregnancy,
 Diabetes in pregnancy,
 Suspected fetal Macrosomia without maternal diabetes.
 Multiple pregnancy
 Pelvic Girdle Dysfunction /Symphysis Pubis Dysfunction,
 Trial of induction of labour (TOL) after a caesarean section

For Sweeping of membranes refer to WAHT-OBS-064.

This guideline discusses different methods of IOL:

 Use Of Propess®
 Amniotomy (ARM)
 Oxytocin
PROPESS® is a vaginal pessary containing 10mgs of Dinoprostone (Prostaglandin E2) presenting as a
thin flat rectangular polymeric pessary contained in a knitted polyester retrieval system.
The release rate is approximately 0.3mg per hour over 24 hours in women with intact membranes, release
being higher with prelabour SROM.
OXYTOCIN: See below for dosage / regimen
One of the common reasons in unsuccessful IOL is irregularities in incrementing oxytocin dose. Once
oxytocin is commenced the protocol (see below) should be strictly followed as undue delay in
incrementing the oxytocin dose renders it less effective and results in unsuccessful induction. Oxytocin
should only be discontinued for definite indications e.g. abnormal/ pathological CTG or hypertonic uterine
contractions.
This guideline should be used in conjunction with WAHT-OBS-016, WAHT-OBS-038, WAHT-OBS-046,
WAHT-OBS-064, WAHT-OBS-083, and WAHT-OBS-058

THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS :

All obstetricians and midwives in the Trust

Lead Clinician(s)
Miss R Imtiaz Consultant Obstetrician
Miss R Duckett Consultant Obstetrician

Judi Barratt Clinical Midwife Specialist

th
Approved by Obstetric Clinical Governance Committee 19 April 2013
nd
Extension approved by Trust Management Committee on: 22 July 2015
st
This guideline should not be used after end of: 1 August 2016

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Key amendments to this guideline

Date Amendment By:
27.08.2009 Minor amendments by Clinical Leads Judi Barratt
15.02.2010 Minor amendments by Clinical Leads Judi Barratt
15.03.2010 Guidance for booking arrangements and managing capacity Judi Barratt
for Induction of Labour
24.03.11 After 24 hrs: If unsuitable for ARM, refer for senior medical Judi Barratt
vaginal examination and management plan by Consultant-on Rachel Rees
call. A full assessment of the pregnancy in general, the
woman’s condition and fetal wellbeing using electronic fetal
monitoring (EFM) should be made, as well as a repeat
vaginal examination by a senior doctor to confirm cervical
findings.
21.10.11 IOL for maternal request should be ONLY be considered Rabia Imtiaz
when there are compelling psychological or social reasons. Rachel Rees
Woman requesting IOL should be seen / discussed by the
consultant, preferably consultant in-charge of her care. Such
women may have to be called back to the clinic to be seen by
the consultant if the consultant is not present in the clinic
otherwise discuss it with the on-call consultant.
Clarification of guidance on monitoring of maternal and fetal
wellbeing.
Revised version agreed Obstetric Clinical Governance-Risk
Management Group.
19.10.12 Propess® to be moved immediately if there is evidence of
definite local hypersensitivity reaction. Option for further
cycle of Propess® if induction of labour has been
unsuccessful after 24 hours is now:
1. Delivery by caesarean section
If there is a delay between the decision to perform LSCS
and its execution, the woman should be re-examined
vaginally in case there have been significant cervical
changes in the interim.
2. Review by the on-call Consultant regarding the possibility
of a further cycle of Propess® after a break of >24 hours.
23.10.12 Clarified when to stop oxytocin. R Imtiaz
Addition of extra audit criteria. R Duckett
18.01.13 Clarification that maternal observations that should be carried K Kokoska
out during induction prior to established labour include BP,
temperature and maternal pulse. These observations should
be checked at least once.
19.4.13 Insertion on advice regarding IOL for women age 40 and
above.
29.04.15 Document extended for 3months L Thirumalaikumar

13.08.15 Document extended for 12 months as per TMC paper TMC

approved on 22nd July 2015

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INDUCTION OF LABOUR (IOL)

PATIENTS COVERED
All women where induction of labour is indicated.
Induction of labour is indicated when it is agreed that the fetus or mother will benefit from a higher
probability of a healthy outcome than if birth is delayed.
While booking IOL cervical status – Bishop Score and logistics of delivery suite should be
considered.
At the time of booking IOL women should be informed that there may be a delay in commencing
IOL depending on the activity in the delivery suite and to avoid prolonged delays they may be
offered transfer between Alexandra Hospital/WRH sites.

PLACE OF INDUCTION
Membrane sweeping – Sweeping of the membranes may be carried out in the women’s home or
at a clinic.
Low risk induction – For low risk women IOL using Propess® can be carried out on the
antenatal ward.
High Risk women – For women with the recognised risk factors the IOL should be carried out in
Delivery suite.
Decision on timing and method of IOL should be made at consultant level.
See Managing IOL and Delays in IOL, pages 9-10.

INDICATIONS FOR INDUCTION OF LABOUR

1. Prolonged pregnancy
Current evidence suggests that women should be delivered by 40+14. Such a policy is associated
with reduced perinatal morbidity and mortality although the absolute risk is small.
There is no increase in instrumental delivery rate, caesarean section, use of epidural analgesia or
fetal heart rate abnormalities during labour with routine policy of IOL for post-dates.
In WAHT women with uncomplicated pregnancies may be offered membrane sweep after 40
weeks and then IOL by 40+12.

Women who decline IOL for prolonged pregnancy

Epidemiological studies suggest increased risk of prenatal death beyond 42 (40+14) completed
weeks.
Women who decline IOL for post-dates should be offered increased antenatal monitoring from 42
weeks in the form of alternate day CTG and a single USS estimation of amniotic fluid volume.
However, data supporting this monitoring as a method of preventing sudden stillbirth are limited
and this should be discussed with the women. These women should be discussed with their
consultant.

2. Diabetes in pregnancy
The perinatal mortality rate is increased 4-5 times in pregnancies complicated with diabetes. In
women with IDDM/Type II Diabetes/Gestational diabetes requiring insulin, IOL is recommended
at 38-39 weeks. Earlier IOL depending on fetal growth, diabetic control and other complications
may be indicated in individual cases and this should be a consultant decision.
See guidelines on diabetes in pregnancy (WAHT-OBS-038).

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3. Maternal medical / fetal indications

For different maternal medical/fetal conditions (e.g. PET/Alloimmunisation/ IUGR) IOL may be
booked at different gestations by the consultant in charge of woman’s care. See the guidelines for
PET WAHT-OBS-028 and IUGR WAHT-OBS-089.

4. Trial of vaginal birth after caesarean section (VBAC) and IOL

See WAHT-OBS-046
There is limited evidence available for the safety and efficacy of induction of labour in this group.
However it would appear that rates of successful VBAC similar to those for spontaneous labour
may be achieved. The risk of uterine scar rupture is however greater Women who have never
delivered vaginally are at the highest risk from uterine rupture following IOL.
 Timing and method of induction of labour should be decided at consultant level and
documented carefully in the notes.
 IOL should occur in delivery suite
 Propess should be used with caution and only after discussing with the consultant.
 If cervix is favourable for amniotomy (ARM) it should be performed and if no progress or lack
of uterine contractions after two hours oxytocin should be commenced.

5. Suspected fetal Macrosomia without maternal diabetes.

In the light of currently available evidence IOL for suspected fetal macrosomia in non-diabetic
women has not been shown to alter the risk of maternal or neonatal morbidity. In WAHT IOL for
suspected fetal macrosomia without maternal diabetes is not recommended.

6. Multiple pregnancy
Current evidence suggests that perinatal mortality increases at 40 weeks in twin pregnancy
compared to singletons.

In WAHT in uncomplicated diamniotic twin pregnancies vaginal delivery may be considered if the
presenting twin is cephalic presentation

See the guideline for multiple pregnancies. WAHT-OBS-016.

7. Pre-labour rupture of membranes at term

Use Propess® with caution after discussing with the consultant on-call.

At Term - See rupture of membranes at term guidelines (WAHT-OBS-005).

Women with PROM at term should be offered a choice of immediate IOL (18-24 hours) or
expectant management.

Expectant management should not exceed 96 hours following PROM. Follow guidance in
WAHT-OBS-005 SROM guideline

GBS positive women –. See guidelines on GBS (WAHT-OBS-002)

Preterm-prelabour rupture of membranes (PPROM) - see PPROM guidelines WAHT-OBS-009

Use Propess® with caution only after discussing with the consultant on-call.

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8. Maternal Request for IOL

Staff are reminded that the Directorate does not support IOL on maternal request only. IOL for
maternal request should be ONLY be considered when there are compelling psychological or
social reasons. Woman requesting IOL should be seen / discussed by the consultant, preferably
consultant in-charge of her care. Such women may have to be called back to the clinic to be seen
by the consultant if the consultant is not present in the clinic otherwise discuss it with the on-call
consultant.

9. Pelvic Girdle Dysfunction (PGD)/Symphysis Pubis Dysfunction (SPD) WAHT-OBS-083

SPD/PGD is not an indication for induction. The risks of IOL often outweigh the benefits in cases
of SPD. However IOL may occasionally be offered to women in extreme pain who are severely
limited in their mobility and daily activity provided the women has favourable cervix and she is
fully aware of the potential risks involved.

10. Medical Termination of Pregnancy for Fetal Abnormality or Intrauterine Death

See guideline “Management of Medical Termination of Pregnancy using Mifepristone/Misoprostal
for Fetal Abnormality or Intrauterine Death from 20 Weeks” WAHT-OBS-075
11. Induction of labour for women age 40 and above

The risk of unexplained stillbirth is doubled in women aged ≥ 40 as compared to women aged
below 35 at >40 weeks. It is advised that women aged ≥ 40 with no additional risk factors should
be offered induction of labour to aim for delivery by 41 weeks gestation.

In women aged >40 who also have concurrent co-morbidities, who are nulliparous or of Afro
Carribbean ethnicity have higher stillbirth risk and these women should be offered induction of
labour to aim for delivery by 40 weeks.

Evidence suggest that such a policy would not increase the number of operative vaginal
deliveries or emergency caesarean sections. All women for induction of labour should be offered
membrane sweep prior to IOL.

Women who decline induction of labour

Women who decline induction of labour should be reviewed by an experienced obstetrician
explaining the need for induction of labour and risks involved in prolonging the pregnancy. An
individualised plan for maternal and fetal monitoring should be clearly documented in the notes if
the patient still wishes to continue with the pregnancy.

CONTRAINDICATION FOR IOL:

 Previous uterine rupture
 Vertical uterine incision
 >1 Previous LSCS
 Any other contraindication to vaginal delivery

Contraindications for use of Propess®.

 All of the above
 When labour has started
 When oxytocic drugs are being given
 A history of hypersensitivity to dinoprostone or the excipients
 When there is current pelvic inflammatory disease, unless adequate prior treatment has
been instituted.

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Propess® should be used with CAUTION in:

- Previous 1 caesarean section
- SROM
- Gestation 34 - 38 weeks
- Grand Multiparity >3
- Multiple pregnancy
- In patients with history of uterine atony, glaucoma or asthma
All non steroidal anti inflammatory drugs and Aspirin should be stopped before administration of
Propess®.
No clinical trials have yet been conducted to confirm the safety / efficacy of Propess® in the
above mentioned conditions, therefore Propess® should be used at consultant discretion, after
careful counselling of the woman.
Note: Propess® has the advantage of constant, low dose release per hour over 24 hour period,
ability to retrieve when required and has a short half life,

METHODS OF IOL
At the time of booking IOL women should be counselled that there may be a delay in
commencing IOL depending on the activity in the delivery suite and to avoid prolong delays they
may be offered transfer between Alex/WRH sites.
Book IOL with delivery suite and ask the woman to ring delivery suite prior to admission/IOL time
to confirm availability.
The methods of induction of labour include:
 Membrane sweep
 Propess
 Amniotomy/ARM
 Oxytocin

PRIOR TO IOL
Prior to commencement of the IOL process, a baseline of maternal observations should be
recorded including blood pressure, maternal pulse, temperature, urinalysis and abdominal
palpation. To ensure fetal wellbeing perform a CTG.

Amniotomy/ARM
Aim to perform ARM as soon as Bishop score is favourable. (This may be prior to the use of
Propess).

USE OF PROPESS
Prescribe Propess® pessary 10mg.
Propess® is to be used for the initiation of cervical ripening (See contraindications and use with
caution above)

INSERTION OF PROPESS®
- Perform abdominal palpation to assess fetal lie, presentation and size.
- Perform vaginal examination and determine Bishop Score.
- Document findings of palpation and VE in notes and sign prescription chart.
- Perform CTG. If CTG is reassuring and cervix unfavourable for ARM insert Propess as
per instructions below.
- If cervix is favourable transfer to delivery suite for ARM.

The recommended Propess® administration technique is described below.

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1. Insertion 2. Positioning 3. After positioning 4. Removal

Holding the Propess® insert
between the index and middle
fingers of the examining hand,
insert it high into the vagina
towards the posterior vaginal
fornix using only small
amounts of water soluble
lubricants.
The index and middle fingers
should now be twisted a
quarter turn clockwise, pushing
the Propess insert higher up,
behind the posterior fornix and
turning it through 90º so that it
lies transversely in the
posterior fornix.
Carefully withdraw the fingers To stop prostaglandin E2
leaving the Propess® insert in release, gently pull the retrieval
the position shown in this tape and remove the Propess
diagram where it should remain insert.
in situ. After insertion ensure
that the patient remains
recumbent for 20-30 minutes to
allow time for the Propess®
insert to swell. Again, this will
help it to remain in place for the
duration of the treatment. Allow
sufficient tape to remain outside
the vagina to permit easy
retrieval.

- If the Propess® insert falls out and has remained clean, i.e. dropped onto clean bed sheets
and not dropped on to the floor or into the toilet it may be reinserted and used to the 24
hour limit.
- If it is not possible to re-insert the Propess® due to contamination, a new one may be
inserted and used up to 24 hours after the insertion of the first Propess®.
- The excess tape outside the vagina may be cut and removed to prevent accidental removal
of the Propess® insert when the patient removes underwear to go to the toilet for example.
However, sufficient tape should be left to allow for easy removal when required. The
woman should be advised to take extra care not to pull the insert out accidentally when
going to the toilet or bathing.
- Experience from clinical trials suggest that dinoprostone release from the Propess® insert
is unaffected by bathing or showering. The manufacturer advises against excessive use of
soap and care should be taken not to pull the retrieval tape.

Post Propess® insertion – monitoring of maternal & fetal well-being

PRIOR TO ESTABLISHED LABOUR

Maternity observations
Maternal observations that should be carried out during induction prior to established labour
include BP, temperature and maternal pulse. These observations should be checked at least
once. The frequency of observations will depend upon clinical condition of the woman.
Fetal observations
There is limited evidence as to the most appropriate protocol for fetal monitoring following vaginal
prostaglandin administration in low risk pregnancies. However, NICE recommends that fetal
wellbeing should be assessed with continuous electronic fetal monitoring when contractions
begin after administration of vaginal prostaglandin. Once the CTG is confirmed as normal
intermittent auscultation should be used unless there are clear indications for continuous
electronic fetal monitoring.

For high risk women, fetal heart should be monitored as per individualised plan.

High risk women: Most women undergoing IOL with any obstetric or medical risk factor should be
managed in the antenatal ward. Only women with need for intensive fetal / maternal monitoring
need to be admitted to delivery suite for induction of labour.

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Women with parity>1 and the ones included in “use with caution category” above should also be
managed as inpatient.

The woman should be instructed to inform the midwife/ delivery suite if:
- Contractions become regular (every 5 minutes or more frequent)
- She becomes uncomfortable with contractions
- She has bleeding
- Membranes rupture
- Propess falls out or drops lower in the vagina

The occasional undesirable effects seen have been those normally associated with intravaginal
dinoprostone administration. Gastrointestinal effects such as nausea, vomiting and diarrhoea
have been reported.

A CTG is to be performed if the woman complains of any painful uterine activity or excessive
uterine activity at any time. This can be discontinued after 30 minutes if CTG is reassuring.
When to remove Propess®
Propess® is designed to remain in the vagina for up to 24 hours; however, it should be removed
immediately in the following instances:
- When labour is established
- PV bleeding (not just show)
- Uterine hyperstimulation or hypertonic uterine contractions with CTG abnormalities.
- Evidence of fetal compromise
- At least 30 minutes prior to starting an intravenous infusion of oxytocin
- Following 24 hours, even if labour is not established
- Evidence of maternal systemic adverse dinoprostone effects such as vomiting,
hypotension or tachycardia, provided there is no other obvious cause of these signs or
symptoms which can be corrected e.g. tachycardia due to dehydration and vomiting
following injection of opiates and/or local hypersensitivity reaction.

To remove Propess®, apply gentle traction on the retrieval tape (the insert will have swollen to 2-3
times its original size and be pliable). Document time of removal in the patient notes.
NB: Please make every effort to refrain from removing the pessary unnecessarily.
After 24 hours:
- Remove the Propess® insert
- Perform a CTG for at least 30 minutes
- Perform a VE to assess suitability for ARM
- If suitable for ARM, transfer to Delivery Suite for ARM and/or oxytocin
- Oxytocin can be commenced 30 minutes after removal of Propess®
- If unsuitable for ARM, refer for senior medical vaginal examination and management
plan by Consultant on-call.

Document within the intra partum records the date and time of insertion and removal of
the Propess®.

Management of Hyperstimulation / Hypertonicity

Tachysystole =  5 contractions in 10 minutes with normal CTG
Hypertonus = painful contraction lasting  90 seconds with normal CTG
Hyperstimulation = Tachysystole or hypertonus with abnormal CTG

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- If any hyperstimulation is suspected CTG monitoring should be commenced

immediately.
- The shift coordinator/ obstetric registrar must be informed.
- If the woman is NOT in established labour and the fetal heart is normal DO
NOT remove pessary, CTG should be continued as long as there is evidence
of uterine hyperstimulation.
- If CTG is pathological the Propess® should be removed and the registrar informed
immediately. Terbutaline 250 micrograms s/c should be considered, however due to
the short half-life of dinoprostone and the low dose released per hour, the
hyperstimulation should resolve spontaneously in 15 – 20 minutes.
- If the CTG improves following removal of Propess®/ tocolysis perform vaginal
examination and attempt to perform ARM and consider augmentation with oxytocin.
A further Propess® should not be inserted in such a case.

Spontaneous rupture of membranes with Propess® in situ

- Commence CTG and assess contractions.
- If there is regular uterine activity, perform a VE to assess if labour is established. If
the woman is in established labour remove Propess®.
- If there is no regular uterine activity or labour is not established, do NOT remove
pessary, observe uterine activity and fetal heart, until either labour does establish or
24 hours has elapsed since insertion
- Maternal observations should be recorded 4 hourly.
Recommendations on unsuccessful induction of labour after 24 hours
The decisions regarding further management must be made by the on-call consultant in
accordance with the women’s wishes and with regard to the clinical circumstances. A full
assessment of the pregnancy in general, the woman’s condition and fetal wellbeing using
electronic fetal monitoring (EFM) should be made, as well as a repeat vaginal examination by a
senior doctor to confirm cervical findings.
Options for subsequent management are:
1. Delivery by caesarean section
If there is a delay between the decision to perform LSCS and its execution, the woman should be
re-examined vaginally in case there have been significant cervical changes in the interim.
2. Review by the on-call Consultant regarding the possibility of a further cycle of Propess®
after a break of >24 hours.
NB: Currently Propess® is not licensed to be repeated as a second dose. There is a consensus
that in carefully selected woman, the dose may be repeated only after review of the case by the
consultant, this should only be done after an informed verbal consent.

OXYTOCIN FOR INDUCTION OR AUGMENTATION OF LABOUR :

 It is recommended that maternal assessment including vaginal examinations is carried out
prior to commencement of Oxytocin and fetal monitoring should be by EFM during the use
of oxytocin. Maternal assessment should include BP, pulse, temperature and abdominal
palpation.

 The individual management plan about the decision to commence Oxytocin should be
documented in the yellow labour notes when Oxytocin commences.

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 For dose schedules including frequency of increment see below. One of the common
reasons in unsuccessful IOL is irregularities in incrementing oxytocin dose. Once oxytocin
is commenced the protocol (see below) should be strictly followed as undue delay in
incrementing the oxytocin dose renders it less effective and results in unsuccessful
induction. Oxytocin should only be discontinued for definite indications e.g. abnormal/
pathological CTG or hypertonic uterine contractions.
 For fetal monitoring in labour refer to the guideline WAHT-OBS-001

 Maternal monitoring: The frequency of observations will depend upon clinical condition of
the woman. As a minimum requirement maternal pulse should be checked every hour and
BP, temperature every 4 hours.

When should oxytocin be stopped?

 If the CTG is suspicious, the clinical situation, including maternal and fetal observations,
should be reviewed to assist in decision making with regards to oxytocin
augmentation/incrementation.
 If CTG is pathological, in most cases it will be necessary to stop the oxytocin. The clinical
situation, including maternal and fetal observations, should be reviewed to assist in
decision making with regards to whether it is appropriate to recommence oxytocin.
 Management of hyperstimulation/hypertonicity
Tachysystole =  5 contractions in 10 minutes with normal CTG
Hypertonus = painful contraction lasting  90 seconds with normal CTG
Hyperstimulation = Tachysystole or hypertonus with abnormal CTG
 If CTG is pathological, stop oxytocin and inform the registrar/coordinator
immediately.
 Terbutaline 250 micrograms s/c should be considered, however due to the short
half-life of dinoprostone and the low dose released per hour, the hyperstimulation
should resolve spontaneously in 15 – 20 minutes.
 If the CTG improves following tocolysis/stopping oxytocin the clinical situation, including
maternal and fetal observations, should be reviewed to assist in decision making with
regards to whether it is appropriate to recommence oxytocin.

Guidance for booking arrangements and managing capacity for Induction of Labour

 No more than 3 inductions to be booked in a 24 hour period at the Alexandra Hospital.

 No more than 5 inductions to be booked in a 24 hour period at Worcestershire Royal

Hospital.

 Inductions booked by Community Midwives are to be phoned directly to the Delivery

Suite Co-ordinator, entered into the induction diary and signed by the Delivery Suite
Co-ordinator. Under no circumstances should Community Midwives enter them into the
book directly.

 When the induction is booked women must be asked to phone the antenatal ward or
delivery suite at 9am to determine if there is a bed available and at what time they
should attend the ward.

 After the 9:00am ward round the on-call Consultant Obstetrician and the Band 7
Labour Ward Coordinator must review all inductions for the day. They must discuss

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these with the antenatal ward to establish capacity to enable the inductions to be
performed. If capacity is reduced please refer to attached flow chart.

 Inductions of labour from the previous day must also be reviewed to establish that
these were performed not delayed and to ascertain the outcome. This process is to
ensure that no inductions are overlooked or delayed unnecessarily.

 If after discussion with the on-call Consultant there are serious concerns regarding the
number of inductions pending and the Units capacity please escalate this to the
Maternity Matron or Senior Manager. Options for utilising sister sites for induction of
labour should be considered.

 Delivery Suites are encouraged to create their own way of marking in the book the
outcome of each induction from the previous few days.

 Inductions of labour for non-obstetric reasons (only required in exceptional circumstances)

should only be a consultant decision. In such cases name of the consultant sanctioning
the IOL and indication should be clearly documented in the health records. If there is no
consultant present in the clinic, it should be discussed with the on-call consultant.

 Offering membrane sweep and performing Bishop Score prior to booking IOL are part of
the IOL procedure.

 Elective IOL should be offered a membrane sweep and Bishop Score prior to coming for
IOL. If a woman is less than 40 weeks this may have to be done in antenatal clinic or day
assessment unit. If the woman is preterm the obstetrician may have to do the sweep
themselves. If you book IOL antenatally in advance then make sure that appropriate
follow up is in place for sweep in addition to the date of IOL.

 Commencing IOL on unfavourable cervix prolongs the process or makes it more likely to
be unsuccessful

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Induction of labour

Delayed due to capacity or activity concerns

No Yes

Inform woman offer

Continue with Inform Band 7 apologies and
planned Induction Labour Ward explanation
of labour Coordinator Document in woman’s
records

Band 7 Labour Ward Coordinator

discuss with on-call Consultant

Consider Is it possible for

transferring to induction to be
WRH/Alex if they performed later
have capacity that day?

No Yes
Perform a CTG & review
clinical situation

Delay induction Continue induction later

Decision to be made by on-call Consultant. in the day. Ensure
Document plan in medical records. Consultant aware
If sent home ensure she has a time to return.

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MONITORING TOOL
STANDARDS:
Item % Clinical exceptions
Individual indications as mentioned in guideline 100%
Documentation of management plan prior to commencement of 100%
Oxytocin /IOL
Fetal/maternal assessment performed prior to commencement 100%
of oxytocin/IOL
Oxytocin stopped as per guideline 100%
The main outcomes considered to be important in relation to 100%
induction of labour with Propess include:
- Outcome based on parity, gestation and number of fetuses
- Outcome in trial of VBAC
- Time to vaginal delivery or vaginal delivery rates within a
specified time
- Hours of hospital stay during IOL before delivery
- Operative delivery rates (caesarean section and
instrumental vaginal delivery)
- Length of labour/incidence of prolonged labour
- Measures of effectiveness (oxytocin augmentation rates,
epidural usage, cervix Unfavourable/unchanged at 12–24
hours)
- Other adverse outcomes (e.g. uterine hypercontractility,
postpartum haemorrhage, maternal adverse effects)
- Measures of maternal satisfaction.
How will monitoring be carried out? Audit and case review meetings
Who will monitor compliance with the guideline? Obstetric Governance Committee
REFERENCES
NICE Induction of Labour evidence based guideline CG70 July 2008
Kelly AJ, Kavanagh J, Thomas J. Vaginal prostaglandin (PGE2 and PGF2a) for induction of
labour at term. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.:
CD003101. DOI: 10.1002/14651858.CD003101
Lyrenas Sven et al., In vivo controlled release of PGE2 from a vaginal insert (0.8mm, 10mg)
during induction of labour, BJOG, February 2001,Vol. 108, pp169-178.
El-Shawarby SA and Connell RJ. Induction of labour at term with vaginal prostaglandins
preparations: a randomised controlled trial of Prostin vs Propess. Journal of Obstetrics and
Gynaecology 2006; 26:(7)627–30.
Induction of Labour. National Institute for Clinical Excellence Inherited Clinical Guideline D, June
2001
Induction of labour for suspected fetal macrosomia – Cochrane database of systematic reviews
2007 issue1.
Induction of labour for improving birth outcomes for women at or beyond term - Cochrane
database of systematic reviews 2006 issue4.
Symphysis pubis dysfunction: a practical approach to management. S Jain at al. The Obstetrician
& Gynaecologist 2006;8:153-158

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OXYTOCIN REGIMEN

Induction with oxytocin Oxytocin (in the presence of ruptured membranes)

Time after Dose delivery  Most women should have adequate
 Treatment regimes: Starting (milliunits/ contractions at 12 milliunits per
milliunits per minute
(minutes) minute)
not milliltres per minute minute
0 1
 1 millilitres/hr = 1 milliunits/min 30 2
 Trials have used doses up to 32
60 4 milliunits per minute
 Deliver via either syringe driver or 90 8
infusion pump with non-return 120 12  Maximum licensed dose is 20
valve 150 16 milliunits per minute
180 20
 Oxytocin performance optimised  If regular contractions not
210 24 established after TOTAL of 5 units (5
with ruptured membranes 240 28
hours on suggested regimen) then
270 32
induction should be stopped

Alexandra Hospital Worcestershire Royal Hospital

Dosage: 5units in 500mls normal saline Dosage: 6units in 50 mls normal saline
Time Dose Time Pump Dose
after mls/hr (mU after Setting (mU
starting (milliunits) starting (mls/hr) (milliunits)
(Mins) (Mins)
0 6 ml/hr 1 mU/min 0 0.5 1 mU/min
30 12 ml/hr 2 mU/min 30 1.0 2 mU/min
60 24 ml/hr 4 mU/min 60 2.0 4 mU/min
90 48 ml/hr 8 mU/min 90 4.0 8 mU/min
120 72 ml/hr 12 mU/min < Recommended Maximum for multips > 120 6.0 12 mU/min
150 96 ml/hr 16 mU/min 150 8.0 16 mU/min
180 120 ml/hr 20 mU/min 180 10.0 20 mU/min
NB: Using normal saline infusion.

NB: For patients with severe PET / Cardiac patients – refer to WRH regime

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CONTRIBUTION LIST

Key individuals involved in developing the document

Name Designation
Miss R Imtiaz Consultant Obstetrician
Miss R Duckett Consultant Obstetrician
Rachel Rees Audit-Training Midwife
Mariam Lokman O and G registrar
Circulated to the following individuals for comments
Name Designation
Mr S Agwu Consultant Obstetrician/Gynaecologist
Mrs P Arya Consultant Obstetrician/Gynaecologist
Mrs A Blackwell Consultant Obstetrician/Gynaecologist
Miss R Duckett Consultant Obstetrician/Gynaecologist
Mrs S Ghosh Consultant Obstetrician/Gynaecologist
Mr J Hughes Consultant Obstetrician/Gynaecology
Miss M Pathak Consultant Obstetrician/Gynaecologist
Mrs J Shahid Consultant Obstetrician/Gynaecologist
Miss D Sinha Consultant Obstetrician/Gynaecologist
Miss L Thirumalaikumar Consultant Obstetrician/Gynaecologist
Mr A Thomson Clinical Director - Consultant Obstetrician/Gynaecologist
Mr J Uhiara Consultant Obstetrician/Gynaecologist
Mr J F Watts Consultant Obstetrician-Gynaecologist
Dr K Karri SpR Obstetrics & Gynaecology
R Fletcher Clinical Pharmacist
P Paine Head of Midwifery
K Kokoska Maternity Services Risk Manager
R Carter Matron IP WRH
M Stewart Matron OP-Community
A Talbot Matron IP Alexandra Hospital
A Bennett/F Pagan Delivery Suite Managers, Alexandra Hospital
P Jones Delivery Suite Manager, WRH
User representatives LW Forum
Midwife members of MGDG (For consultation with their peers)
J A Barratt Clinical Midwife Specialist
T Cooper Consultant Midwife/Supervisor of Midwives
M Byrne Midwife, Alexandra Hospital
H Doherty/J McGivney Community Midwife, Bromsgrove-Redditch Team
J S Farmer Midwife, Antenatal Clinic, WRH
C Parry Community Midwife, Evesham Team
J Martin Midwife, Alexandra Hospital
T Meredy Midwife, Antenatal Clinic, Alexandra Hospital
R Rees Audit & Training Midwife/WRH representative
G Robinson Community Midwife, Worcester Team
H Walker Community Midwife, Kidderminster
V Tristram Midwife, Kidderminster Hospital/Supervisor of Midwives
J Voyce Community Midwife, Malvern Team
B Wilkes Midwife, Alexandra Hospital
R Williams Midwife, WRH

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Supporting Document 1 – Checklist for review and approval of key documents

This checklist is designed to be completed whilst a key document is being developed / reviewed.

A completed checklist will need to be returned with the document before it can be published on
the intranet.

For documents that are being reviewed and reissued without change, this checklist will still need
to be completed, to ensure that the document is in the correct format, has any new
documentation included.

1 Type of document Guideline

2 Title of document Induction of labour
3 Is this a new document? Yes No
If no, what is the reference number
WAHT-OBS-010
4 For existing documents, have you Yes No
included and completed the key
amendments box?
5 Owning department Obstetrics
6 Clinical lead/s Miss Rachel Duckett
7 Pharmacist name (required if Rosie Fletcher
medication is involved)
8 Has all mandatory content been Yes No
included (see relevant document
template)
9 If this is a new document have Yes No
properly completed Equality
Impact and Financial Assessments N/A
been included?
10 Please describe the consultation Circulated to members of the Obstetric Governance
that has been carried out for this Committees
document
11 Please state how you want the title Induction of labour (IOL)
of this document to appear on the
intranet, for search purposes and
which specialty this document
relates to.
Once the document has been developed and is ready for approval, send to the Clinical
Governance Department, along with this partially completed checklist, for them to check format,
mandatory content etc. Once checked, the document and checklist will be submitted to relevant
committee for approval.

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Implementation
Briefly describe the steps that will be taken to ensure that this key document is implemented

Action Person responsible Timescale

Information included in Effective Handover Miss Rachel Duckett January 2013

Plan for dissemination

Disseminated to Date
Medical and midwifery staff via Effective Handover January 2013

Step 1 To be completed by
Clinical Governance
1 Department
Is the document in the correct Yes No
format?

Has all mandatory content been Yes No

included?

Date form returned

23/04/2013
2 Name of the approving body Obstetric Governance Committee
(person or committee/s)
Step 2 To be completed by Committee Chair/ Accountable Director
3 Approved by (Name of Chair/ Miss Rabia Imtiaz
Accountable Director):
4 Approval date 19th April 2013

Please return an electronic version of the approved document and completed checklist to the
Clinical Governance Department, and ensure that a copy of the committee minutes is also provided
(or approval email from accountable director in the case of minor amendments).

Office use only Reference Number Date form received Date document Version No.
published
WAHT-OBS-010 23/04/2013 24/04/2013 5.5

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