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induction of labour

Induction of Labour CPG

To guide the induction of labour (IOL) process when it is agreed that the mother and fetus will benefit from a higher probability of a healthy outcome and vaginal birth than if birth is delayed

1

.

This includes the phase of cervical ripening.




Definition of terms


Induction of labour (IOL): is an intervention (ARM or intravenous oxytocin administration) designed to artificially initiate uterine contractions resulting in progressive effacement and dilatation of the cervix and birth of the baby1.

Cervical ripening: process of IOL employed when the cervix is unfavourable, in order to facilitate dilation as labour is established1.

Augmentation: an intervention that increases the rate of the progress of spontaneous labour 1.

Prolonged pregnancy: is a pregnancy with gestation of more than 41 completed weeks1 (i.e. 41+0, 41+1, 41+2, 41+3, 41+4, 41+5, 41+6). Gestation should be based on the agreed EDD. The EDD is based on the LNMP and modified by the dating scan, if outside the margin of error of the scan (refer to agreed error margin for ultrasound scan for each gestation).
Note: It is recommended that all women have a dating scan < 14 weeks gestation.

Uterine hypercontractility:
  • uterine hypercontractility without fetal heart rate (FHR) changes = uterine tachysystole (more than 5 contractions per 10 minutes for at least 20 minutes) 1
  • uterine hypersystole / hypertonus = a contraction lasting at least 2 minutes1
  • uterine hyperstimulation with FHR changes = uterine tachysystole / hypersystole + FHR changes e.g. persistent decelerations / tachycardia / decreased short term variability1.

Bishop score: A measure of cervical suitability for IOL. A favourable cervix has a Bishop score >7.

Bishop score
0
1
2
3
Dilation (cm)
0
1-2
3-4
5+
Length of Cx (cm)
3
2
1
0
Station
-3
-2
-1, 0
+1,+2
Consistency
firm
med
soft
Position
post
med
ant


Consider IOL for the following indications:


  • gestation of at least 41 completed weeks
  • evidence of fetal compromise (fetal growth restriction and/or non-reassuring fetal surveillance)1,2
  • maternal medical conditions (diabetes, renal disease, significant pulmonary disease, hypertension-gestational or chronic, antiphospholipid syndrome)2
  • pre-labour rupture of membranes1
  • suspected or confirmed chorioamnionitits2
  • gestational diabetes with complication1
  • multiple pregnancy1
  • abruption2
  • macrosomia1
  • fetal death in utero2
  • history of precipitate labour1
  • maternal obesity
  • previous poor obstetric history
  • isoimmunisation
  • fetal abnormality.

Risks of IOL


IOL may increase the risk of:
  • cord prolapse
  • uterine rupture
  • post partum haemorrhage
  • requiring an epidural
  • requiring an operative vaginal birth
  • requiring a caesarean section.


Responsibility


Medical staff complete the:
  • antenatal preparation for IOL (refer below)
  • formal informed consent (i.e. written / signed MR/43027 Consent to Operative Treatment & Administration of Anaesthetic Form)
  • order for 'prostaglandin E2 dose according to procedure using Bishop Score findings"'on medication chart MR 90124
  • document orders for intravenous oxytocin administration.

The midwifery / medical team manage the procedures on the day(s) of IOL, including:
  • cervical ripening - prostaglandin E2
  • artificial rupture of membranes
  • intravenous oxytocin administration
  • cervical ripening using Cervical Ripening Balloon Catheter.

Equipment and medications


Refer to the Women's procedures:

Process


Antenatal preparation for induction


Assess suitability for IOL


Prior to booking the IOL, the medical officer will:
  • document the indication for IOL
  • establish whether there are any contraindications to IOL
  • confirm gestational age / expected date of delivery
  • assess fetal wellbeing (refer below)
  • obtain informed consent (refer below).

Assess fetal wellbeing / surveillance


There is limited evidence regarding the optimal method of assessment of fetal wellbeing in a prolonged pregnancy. The following is based on the Royal College of Obstetricians and Gynaecologists (RCOG) recommendations1, specifically relating to IOL for prolonged pregnancy.

Gestation 40+5 - 41+2 (i.e. 40+5, 40+6, 41+0, 41+1, 41+2)
Review by obstetrician and offer CTG and AFI assessment:
  • if AFI < 5 refer to the Unit Registrar for IOL asap (i.e. within 24 hours)
  • if AFI > 5 book IOL to occur sometime between 41+0 and 41+6.

Gestation > 42 weeks
  • offer IOL
  • if woman declines IOL, offer second-daily CTG and
  • AFI assessment, and
  • perform IOL if AFI <5 or CTG abnormal.

Obtain informed consent


IOL should only follow formal informed consent by the woman (i.e. written / signed), including the:
  • reason of IOL
  • choice of IOL method(s) to be used
  • potential risks of IOL (as listed earlier)
  • consequences for accepting or refusing an offer of IOL1.

Give the woman the Royal Women's Hospital information leaflet on IOL.

The medical officer and woman must complete a Women's consent form.

Book IOL


The medical officer will book the IOL according to availability:
  • electronically via specific computer program in the Outpatient Department and the Pregnancy Day Care Centre (PDCC)
  • follow the prompts
  • provide the woman with the time and date of the IOL
  • document order for 'prostaglandin E2 dose according to Procedure using Bishop Score findings' on medication chart MR /90124.

Day of IOL


06.45 hours - Present for admission


Women present to Royal Women's Hospital Admissions department at 06.45, and triaged as follows:
  • prostaglandin E2 administration will be undertaken Monday - Friday in the PDCC or Antenatal ward / Birth Centre if already admitted
  • In exceptional circumstances prostaglandin E2 can be administered on Saturday - Sunday in the Birth Centre.
  • ARM, intravenous oxytocin administration and cervical ripening balloon catheter insertion will be undertaken in the Birth Centre only.

Assess / confirm suitability for IOL


Prior to commencing the IOL, the PDCC midwife / medical officer will document the following:
  • informed consent has been obtained prior to admission
  • indication for IOL
  • any contraindications to IOL
  • confirm gestational age / expected date of delivery
  • discuss with the woman the indication for IOL and risks associated with IOL
  • assessment of fetal lie / presentation / position
  • membrane status (intact / ruptured)
  • assessment of fetal wellbeing
  • Bishop score assessment.

IOL methods


The Women's procedures (Intranet only)

References


Evidence table


(pdf 21kb)


Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.

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