Induction and Augmentation of Labour Guideline Women’s and Children’s Page 1 of 27 Document Control Title Induction and Augmentation of Labour Guideline Author Author’s job title Consultant Obstetrician, Labour Ward Lead Consultant Obstetrician& Gynaecologist Directorate Womens and Childrens Department Maternity Version Date Issued Status Comment / Changes / Approval 0.1 May 2017 Draft Initial version for consultation; this new guideline replaces the previous ‘Induction of Labour’ guideline and the ‘Use of Oxytocin’ guideline 1.0 July 2017 Final Approved by Maternity Guidelines group 1.1 Jul 2018 Revision 2.0 Oct 2018 Final Approved by Maternity Governance Forum meeting Main Contact Mrs Eleni Lekoudis Ladywell Unit North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Tel: Direct Dial – 01271 322577 Tel: Internal – 4036 Email: [email protected]Lead Director Medical Director Superseded Documents ‘Induction of Labour’ guideline and the ‘Use of Oxytocin’ guideline Issue Date October 2018 Review Date October 2021 Review Cycle Three years Consulted with the following stakeholders: (list all) Senior Obstetricians Senior Midwives Drug & Therapeutic Committee Approval and Review Process Maternity Governance Forum Local Archive Reference G:\OBSGYNAE\Risk\Archives\Maternity Services Local Path Guidelines folder Filename Induction and Augmentation of Labour Guideline Policy categories for Trust’s internal website (Bob) Maternity Tags for Trust’s internal website (Bob) Induction & Augmentation
Transcript
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 1 of 27
Document Control
Title
Induction and Augmentation of Labour Guideline
Author
Author’s job title Consultant Obstetrician, Labour Ward Lead Consultant Obstetrician& Gynaecologist
Directorate Womens and Childrens
Department Maternity
Version Date
Issued Status Comment / Changes / Approval
0.1 May 2017
Draft Initial version for consultation; this new guideline replaces the previous ‘Induction of Labour’ guideline and the ‘Use of Oxytocin’ guideline
1.0 July 2017
Final Approved by Maternity Guidelines group
1.1 Jul 2018
Revision
2.0 Oct 2018
Final Approved by Maternity Governance Forum meeting
Main Contact Mrs Eleni Lekoudis Ladywell Unit North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB
Superseded Documents ‘Induction of Labour’ guideline and the ‘Use of Oxytocin’ guideline
Issue Date October 2018
Review Date October 2021
Review Cycle Three years
Consulted with the following stakeholders: (list all)
Senior Obstetricians
Senior Midwives
Drug & Therapeutic Committee
Approval and Review Process
Maternity Governance Forum
Local Archive Reference G:\OBSGYNAE\Risk\Archives\Maternity Services Local Path Guidelines folder Filename Induction and Augmentation of Labour Guideline
Policy categories for Trust’s internal website (Bob) Maternity
Tags for Trust’s internal website (Bob) Induction & Augmentation
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 2 of 27
CONTENTS
Document Control ............................................................................................................... 1
9. Appendix A ................................................................................................................. 20
10. Appendix B ............................................................................................................... 240
11. Appendix C…………………………………………………………………………………….21
12. Appendix D…………………………………………………………………………………….23
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 3 of 27
1. Purpose 1.1. The purpose of this document is to detail the process for induction of labour at
NDDH. Induction of labour is a relatively common procedure. Every year in the UK approximately 20-25% of labours are induced. It has an impact on birth experience and the health of women and their babies. It may be less efficient, increase risk and can be more painful than spontaneous labour. Therefore it needs to be clinically justified. The decision should be made when the interests of the mother or baby, or both, are better served by inducing labour than by continuing the pregnancy (NICE, 2008).
1.2. The policy applies to midwives and obstetricians with appropriate training only. Those who have not been trained to use the induction or augmentation methods should seek the skills to do so and in the meantime ask an appropriately trained colleague to undertake the intervention.
1.3. Implementation of this policy will ensure that augmentation or induction of labour at NDDH
follows an evidence based sequence of methods; based on national guidance, manufacturer recommendations or local needs (e.g. outpatient induction is not available due to geographical distance)
is recommended based on consistent clearly documented clinical rationale and undertaken by appropriately trained clinicians
is timebound with a clearly documented timeframe for each method and a ‘latest expected delivery date’.
2. Definitions 2.1. Induction of labour is the use of artificial means to initiate labour to avoid
increased risk to maternal or fetal morbidity or mortality. This may be due to risks associated with prolonged pregnancy, prolonged rupture of membranes, pregnancy associated complications or risks associated with long term conditions such as maternal diabetes.
2.2. Induction of labour is a risk factor and therefore should be under Obstetric led care and all assessments of maternal and fetal wellbeing are required during the process.
2.3. Augmentation of labour is the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the confirmed delay of established labour in the first or second stages. Confirmation is achieved via cervical assessment and assessment of contractions (frequency and duration) (WHO, 2014).
If delay in the established first stage is suspected, assess all aspects of progress in labour when diagnosing delay, including:
Cervical dilatation of less than 2 cm in 4 hours for first labours
Cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours (NICE, 2017).
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 4 of 27
NDDH – North Devon District Hospital
IOL – Induction of labour
ARM – Artifical Rupture of Membranes
USS – Ultrasound scan
Uterine tachysystole - contractions >5:10 with normal fetal heart
assessment.
Uterine hyperstimulation - contractions >5:10 with an abnormal fetal
heart assessment.
3. Responsibilities 3.1. Role of the Midwife
The midwife is responsible for:
Ensuring that all women with low risk pregnancies are offered a membrane sweep (see Chapter 4) to avoid prolonged pregnancy.
Ensuring that all women with low risk pregnancies are offered a date for induction of labour to avoid prolonged pregnancies.
Ensuring that all women with high risk pregnancies have an appointment with an obstetrician to make a decision about induction of labour
Ensuring that appropriate referrals are made for women who choose not to have the clinically recommended induction of labour as planned.
3.2. Role of the Obstetrician
The obstetrician is responsible for:
Ensuring that women have appropriate information with which to make an informed choice about induction or augmentation of labour.
Ensuring that a full discussion is undertaken and clearly documented including;
The reason for induction or augmentation, The risks and benefits of the process, The proposed methods to be used, The plan when IOL fails
N.B. Using Induction of Labour Decision Sticker in Appendix C
Ensuring that all women with high risk pregnancies are offered a date for induction of labour in keeping with guidance for their specific risk factors.
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 5 of 27
4. Induction of labour 4.1. PROPESS®IOL ALGORITHM
Prior to IOL
Check gestation Check IOL indication on the form / notes Maternal observations (P, BP, Temp) History of contractions / membrane rupture Abdominal Examination Presentation (USS if required) CTG 20-30 minutes Investigations relevant to the diagnosis.
Prescription Chart: Confirm Allergy status and sign Propess® 10mg PV as once only Terbutaline 250mcg SC as once only Paracetamol 1g PO/IV QDS as required Codeine Phosphate 30mg PO QDS as required IV Antibiotics if Group B Streptococcus
If no evidence regular painful contractions, perform Vaginal Examination with verbal consent
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 6 of 27
Membranes Intact Confirmed ruptured membranes
4.2. INDICATIONS FOR INDUCTION OF LABOUR
4.2.1. Induction of labour (IOL) at NDDH will be undertaken for two reasons:
Low risk pregnancies postdate pregnancy and pre-labour rupture of membranes at term (PROM).
High risk pregnancies where the benefits of induction outweigh those of continuing pregnancy to mother or fetus or both. This will include high risk pregnancies complicated by pregnancy associated conditions or risks associated with long term conditions.
Cervix uneffaced+
<3cm dilated
Cervix fully effaced +>3cm
dilated
24 hours post insertion
of Propess®
CTG every 6 hours OR when painful uterine activity commences
6 hrly maternal observations on MEOWS
Propess® into posterior fornix
CTG for 60mins
Transfer to Labour Ward VE +/- amniotomy +/- oxytocin
Bishops Score ≥6
OR regular painful
contractions
Bishops Score
<6
Propess® into posterior fornix
CTG for 60mins
Fetal heart auscultation every 6 hours OR when painful uterine activity commences
6 hrly maternal observations on MEOWS
24 hours post insertion of Propess®
If not ARM-able, Prostin gel.
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 7 of 27
Maternal Conditions
Indication Gestation that IOL may be offered
Evidence
Prolonged pregnancy 41+0 to 42+0, normally 41+5
NICE Clinical Guideline 70: Inducing Labour
Ruptured Membranes Term (PROM)=/>37/40 AND not contracting No GBS/meconium Group B Streptococcus Meconium (thick) Meconium (thin) Suspected chorioamnionitis Pre-term (PPROM) <37 / 40
Increased risk of hyperstimulation with Propess®/Prostin if SROM: Offer IOL 24 hours after SROM Offer IOL as soon as SROM confirmed, commence IV Antibiotics Offer IOL as soon as SROM confirmed, commence oxytocin Offer IOL as soon as SROM confirmed Offer IOL as soon as SROM confirmed, commence IV Antibiotics Not before 34 weeks
Local RD&E &NDDH consensus: Pre labour rupture of membranes (PROM) at term guideline RCOG Green-Top Guideline 36: Group B Streptococcal Disease. Local RD&E and NDDH consensus : Preterm prelabour rupture of membranes (PPROM) guideline
Unstable lie May offer stabilising induction from 38 weeks.
Local RD&E and NDDH consensus
Ante-Partum Haemorrhage at Term or recurrent (unexplained)
If severe/uncontrolled BP, may induce earlier Not before 37 Not before 37 Preferably not before 34 Stabilise and deliver
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 9 of 27
IVF pregnancy 39- 40
Local RD+E and NDDH consensus
Maternal age =/>40 39-40
RCOG Scientific Impact Paper 34: Induction of Labour at Term in Older Mothers
Maternal Request eg partner posted abroad
40 if favourable
NICE Clinical Guideline 70: Inducing Labour
Pelvic Girdle Pain / Symphysis pubis dysfunction
From 39 if favourable
Local RD&E and NDDH consensus
Precipitate Labour Should not be offered IOL
NICE Clinical Guideline 70: Inducing Labour
Previous Caesarean Section
Not an indication for IOL. Cervical ripening balloon catheter preferred as increased of risk uterine scar rupture with Prostaglandins. Neither are licensed although in common use in UK. Offer Caesarean Section as an alternative. Consultant discussion and decision advised.
RCOG Green-Top Guideline 45: Birth After Previous Caesarean Birth Local RD&E and NDDH consensus: Vaginal birth after caesarean section (VBAC) guideline
Previous Stillbirth Individualised care
Local RD&E and NDDH consensus
Red Cell Antibodies 37-38 (if stable). May be earlier if unstable or rising titres
RCOG Green-Top Guideline 65: Red Cell Antibodies During Pregnancy
Sickle Cell Disease 38
RCOG Green-Top Guideline 61: Sickle Cell Disease in Pregnancy
Venous Thromboembolism on treatment dose heparin.
Not an indication for IOL. Consider timing of IOL to minimise omitted heparin doses
RCOG Green-Top Guideline 37A: Thrombosis and Embolism During Pregnancy
Parity >4 Not an indication for IOL. Cervical ripening balloon catheter preferred as increased
NICE Clinical Guideline 129: Multiple Pregnancy Local RD&E and NDDH consensus: Multiple pregnancy guideline
Polyhydramnios 39
Local RD&E and NDDH consensus:
Reduced fetal movements with normal scan findings
Plan to be discussed with on call Consultant
When a woman recurrently perceives RFM, her case should be reviewed to exclude predisposing causes. Caregivers should be aware of the increased risk of poor perinatal outcome in women presenting with recurrent RFM.
Stillbirth/Intra-uterine fetal demise
Offer mifepristone at time of IUD diagnosis with misoprostol 36-48 hours later. Propess® / oxytocin not routinely used.
Local RD&E and NDDH consensus:
4.3. IOL BOOKING PROCESS – Postdates Low risk inductions
4.2.1. Dates should be confirmed by the booking ultrasound scan.
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 12 of 27
4.2.2. In cases of uncomplicated post-dates pregnancies or PROM at term, the decision to induce labour should not be made without discussion with a senior Obstetrician. 4.2.3. The woman should be offered a membrane sweep at 40 weeks gestation if she is a primip (41 weeks for multips). Membrane sweep can be repeated again after 48 hours to a maximum of three membrane sweeps in total from 40 weeks gestation to 41+3 weeks gestation. Membrane sweeps are associated with
Reduced time between treatment and spontaneous labour
Reduced incidence of prolonged pregnancy
Reduced need for formal methods of IOL
Increased maternal discomfort and bleeding Membrane sweeps are not associated with maternal or neonatal infection. 4.2.5. A decision to induce is a decision to deliver. Women should not be sent home once an IOL has begun. 4.2.6. Each IOL should be booked in the IOL diary. Low risk IOL for postdates will be booked by CMW via telephone to the ANC. Recommended information required: patient name, hospital number, parity, gestation, indication for IOL and any other important risk factors (eg high BMI). 4.2.7. The indications and arrangements for IOL should be discussed with the woman and ideally her partner in the ANC or by the CMW at home if it is a routine postdates induction. The method of induction, any specific management and the plan if IOL fails must be documented in the notes by the authorising clinician. 4.2.8. A patient information leaflet including details of admission should be given to the patient when an IOL is booked. 4.2.9. All women for low risk IOL will be undertaken in the DAU/AN/PN ward. For high risk patients, the location will be assessed by the LW co-ordinator and Consultant on call based on maternal/fetal risk factors and clinical activity of the day. 4.2.10. For high risk patients, there must be a comprehensive Obstetric assessment documented on admission as the woman’s history and relevant risk factors may have altered since the original consultation for Induction of Labour.
4.4. LOWER RISK IOL: PROLONGED PREGNANCY AND PRE-LABOUR
RUPTURE OF MEMBRANES (PROM) AT TERM.
4.3.1. For women declining IOL at term +14, an appointment to see their Consultant should be made at term +14. She should be offered twice weekly outpatient CTG and USS assessment to include measurement of liquor volume and uterine Dopplers. A full discussion should be undertaken and clearly documented in the maternity records with a clear management plan. 4.3.2. Women with PROM at term should be induced as soon as possible following 24 hours unless they request the ‘wait and see approach’. 4.3.3. Women with PROM and known risk factor for Group B Streptococcus should be commenced on IV antibiotics and IOL commenced immediately. Propess® may be used if the cervix is unfavourable. 4.3.4. Women with PROM and thick meconium should be transferred to Labour Ward and IOL commenced immediately with oxytocin. If meconium is
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 13 of 27
thin, IOL should still be commenced but Propess® may be used if the cervix is unfavourable. 4.3.5. If a patient is seen with spontaneous rupture of membranes and contractions and has a vaginal examination but is not in established labour, it is important that their IOL should commence by 24 hours, if IOL declined or delayed please liaise with the Consultant on call. 4.3.6. Propess® is the only prostaglandin licensed for the use in PROM but should be used with caution due to the increased risk of hyperstimulation. To reduce this risk, women should only be given Propess® if there is no evidence of regular painful contractions and the Bishops score is <6. In the event of painful contractions or Bishops score ≥6 women should be transferred to Labour Ward for assessment and IOL with oxytocin.
4.5. IOL WITH PROPESS®
4.4.2. If the Propess falls out prior to 24 hours, the same pessary can be re-inserted as long as it was contained within a clean environment (e.g the woman’s sanitary towel or underwear). If not, a new pessary can be inserted (once prescribed) however the original timeline remains i.e. the original Propess removal date and time is still the time that the Propess should be removed.
4.4.3. MANAGEMENT OF HYPERSTIMULATION
Uterine hyperstimulation can appear as tachysystole or hypertonus, which may lead to FHR changes.
The incidence of uterine hyperstimulation with or without FHR change ranged from 1% to 5%.
Contraction frequency being more than five in 10 minutes (for at least 20 minutes) or contractions exceeding 2 minutes in duration.
Hyperstimulation is more likely with Propess® in the presence of PROM.
Terbutaline is a B2 agonist which relaxes the uterus.
Prolonged Bradycardia: Remove Propess® and give 250 mcg terbutaline S/C and transfer to Labour Ward for senior obstetrician review.
Pathological CTG: Remove Propess® and give 250 mcg terbutaline S/C if needed and transfer to Labour Ward for senior obstetrician review.
Suspicious CTG: Transfer to Labour Ward, continue CTG and get senior obstetrician review. If in labour – remove Propess®.If not in labour, leave Propess® in situ. The review may take place prior to transfer. Subsequent management will depend on senior obstetrician assessment.
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 14 of 27
Normal CTG: Diagnosis of hyperstimulation not confirmed – leave Propess® in and continue CTG. Women may remain on Bassett ward provided adequate midwives to monitor CTG. Discuss with the Labour Ward Coordinator or SAS doctor if concerned.
4.6. IOL WITH CERVICAL RIPENING BALLOON CATHETER
4.5.1. A cervical ripening balloon catheter is used as an alternative to Propess® to facilitate amniotomy without risk of hyperstimulation associated with Propess®. A cervical ripening balloon catheter should not be used in the presence of ruptured membranes. 4.5.2. Indications for a cervical ripening balloon catheter are
For women who are for IOL and have had one previous C/S
For other high risk groups of women for whom Propess® is not preferable eg. grand multiparity (Para >4)
Patient choice
For women for whom Propess® has failed to ripen the cervix for amniotomy
4.5.3. INDUCTION OF LABOUR ALGORITHM FOR CERVICAL RIPENING BALLOON CATHETER
Prior to commencing IOL with a Cervical Ripening Balloon Catheter
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 15 of 27
Check gestation Check IOL indication on the form / notes Maternal observations (P, BP, Temp) History of contractions / membrane rupture Abdominal Examination Presentation (USS if required) CTG 20-30 minutes Investigations relevant to the diagnosis
Prescription Chart: Confirm Allergy status and sign Paracetamol 1g PO/IV QDS as required Codeine Phosphate 30mg PO QDS as required IV Antibiotics if Group B Streptococcus
If no evidence regular painful contractions, perform Vaginal Examination with verbal consent
4.7. SUBSEQUENT MANAGEMENT INCLUDING LW CARE
4.6.1. Women who have started in labour with Propess®: If a women labours with Propess® alone then provided that the CTG remains normal for a 30 minutes post removal of Propess®, the woman is not started on oxytocin and there are no fetal or maternal reasons requiring continuous electronic fetal monitoring, then subsequent monitoring can be by intermittent auscultation as per unit guideline. 4.6.2. Women who have not laboured in the 24 hour period post Propess® insertion: Any patient who has not laboured over the 24 hours following Propess® insertion needs to be assessed on Bassett ward and either insert a Prostin or transfer to Labour Ward and a CTG commenced. A cannula and bloods (FBC / G&S) are NOT required prior to amniotomy for every patient.
Membranes intact
Cervix uneffaced and <2cm dilated
Cervix fully effaced and >2cm dilated
Cervical ripening balloon catheter
CTG for 60 minutes
CTG every 6 hours OR if painful uterine activity commences. Maternal observations 6hrly
12-24 hours post insertion of balloon Transfer to Labour Ward
VE + amniotomy +/- oxytocin
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 16 of 27
4.6.3. If cervix is dilated enough to allow access to the fetal membranes an amniotomy will be performed and oxytocin commenced. Please ensure there is a 30 minutes period between removal of Propess® and amniotomy 4.6.4. If cervix is not dilated enough for ARM, Prostin should be inserted. 4.6.4. If SROM occurs but labour is not established DO NOT remove pessary, observe uterine activity and fetal heart at that time, followed by 6 hourly CTGs until either labour does establish or 24 hours has elapsed since insertion. 4.6.5. Women who have had a cervical ripening balloon catheter that has spontaneously fallen out should have an amniotomy performed on Labour Ward. No delay is necessary from amniotomy to starting oxytocin. 4.6.6. Women who have had a cervical ripening balloon catheter that has remained in situ should have the 30mL balloon deflated, the balloon removed and an amniotomy performed on Labour Ward. No delay is necessary from removal of balloon and amniotomy to starting oxytocin. 4.6.7. The oxytocin intravenous infusion should be prescribed on a fluid chart as 500mL 0.9% Normal Saline with 30 IU Syntocinon®. (APPENDIX ) 4.6.8. Continuous CTG. Follow Intrapartum and Fetal Monitoring guidelines and use NDDH Fresh Eyes Intrapartum CTG assessment sticker. 4.6.9. If amniotomy not possible after balloon deflation or 6 hrs post-prostin , : Decision about further management should be in accordance with the woman’s wishes and should take account of the clinical circumstances. Full discussion should occur between the Consultant and patient. Caesarean Section is advisable. In exceptional cases, further induction may be considered depending on the individualised circumstances. 4.8. DECISION TO DELAY IOL DUE TO EXCESSIVE WORKLOAD
4.7.1. The elective workload should be reviewed at the Labour Ward handover by the Labour Ward Consultant and the Labour Ward Coordinator. Any decision to postpone IOL or delay transfer to Labour Ward MUST be made by the Labour Ward Consultant and the Labour Ward Coordinator and should be based on clinical need and / or priority. The decision to delay IOL must be recorded in the woman’s IOL paperwork with a clear plan. There should be a documented discussion with the woman and her partner, ideally by a Senior Midwife/ Labour Ward Coordinator. 4.7.2. The women will then be assessed with CTG, basic observations, take a history of fetal movements and review of maternal wellbeing where appropriate before revised IOL date.
5. Augmentation of labour
5.1. First stage of labour augmentation. 5.1.1. In the first stage of labour augmentation may be undertaken using two
methods; ARM and Oxytocin infusion.
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 17 of 27
5.1.2. Cervical assessment will diagnose delay of established labour and ARM should be undertaken with consent as a first line response. The woman will be re-assessed after two hours for assessment for further intervention with an oxytocin infusion.
5.1.3. If the membranes are already ruptured on diagnosis of delay in established labour an oxytocin infusion should be commenced. (APPENDIX )for specific guidance on this method.
5.1.4. The condition of the mother and fetus must be carefully assessed, including a clearly documented cervical assessment before commencing oxytocin. Oxytocin must not be commenced without a fully documented Obstetric (Staff Grade or Consultant) assessment and plan, with the appropriate prescription.
5.1.5. Continuous electronic fetal monitoring is necessary once the oxytocin infusion has commenced. If the fetal monitoring trace becomes abnormal, STOP the oxytocin infusion.
5.1.6. Aim for regular contractions 4-5:10 minutes, NO MORE THAN 5:10. Do not rely solely on the external transducer to monitor contractions – you MUST also manually palpate the frequency, strength of and rest time between contractions.
5.1.7. Once the oxytocin infusion is commenced, a vaginal examination will take place maximum four hours after the onset of regular contractions 4-5:10 OR six hours after commencing oxytocin, whichever time is reached first. This timeframe will need to be individualised to the cervical assessment at commencement of the oxytocin infusion as well as maternal/fetal risk factors.
5.2. Second stage of labour augmentation. 5.2.1. In the second stage of labour augmentation may be undertaken using
two methods; ARM and Oxytocin infusion. 5.2.2. The condition of the mother and fetus must be carefully assessed,
including a clearly documented vaginal examination before commencing oxytocin. Oxytocin must not be commenced without a fully documented Obstetric (Staff Grade or Consultant) assessment with the appropriate prescription. Further action plan must also be written by an obstetrician who reviewed the woman including expected time of review.
5.2.3. If tachysystole is suspected, REDUCE the infusion rate. Tachysystole is the presence of contractions >5:10 with a normal fetal heart trace. If hyperstimulation is suspected – STOP the infusion.
Hyperstimulation is presence of contractions >5:10 with an abnormal fetal heart trace.
Immediate Obstetric assessment is required and consider subcuticular Terbutaline 0.25mg.
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 18 of 27
Oxytocin infusion Dose schedules and frequency of increment
This table applies to the first and second stage of labour. Under no circumstances should
contractions exceed 5:10 minutes (VBAC 3-4:10).
Syntocinon 30 international units added to 500ml of Normal Saline, contents thoroughly mixed.
Time after starting (mins) Syntocinon dose (milliunits per min) Volume infused (mls per hr)
0 1 1
30 2 2
60 4 4
90 8 8
120 12 12
150 16 16
180 20 20
210 24 24
240 28 28
270 32 32
Maximum licensed dose is 20 milliunits per minute.
Contact the obstetrician if contractions < 4-5:10 at 20 milliunits per minute.
Doses above 20 milliunits should be prescribed upon the infusion medication chart.
Dose of Syntocinon should not exceed 32 milliunits per minute.
If the Oxytocin infusion is commenced in second stage it MUST commence at 1ml per hour. In
exceptional circumstances in can be increased every 15 mins ONLY AT THE STANDARD
INCREMENT i.e. 1/2/4/8.
6. Monitoring Compliance with and the Effectiveness of the
Guideline Standards/ Key Performance Indicators
6.1. Key performance indicators comprise: Documentation; the reason for induction or augmentation, the
risks and benefits of the process, the proposed methods to be used and a time bound plan.
Outcome Length of time from commencement to delivery Maternal and Fetal observations Feedback from the women
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 19 of 27
7. Process for Implementation and Monitoring Compliance and Effectiveness
7.1. The cervical ripening balloon implementation process will commence with training, a six month trial of the new process and ratification of the guidance following review of the trial audit results.
7.2. The Induction and Augmentation of Labour Guideline implementation process will commence following ratification at the Maternity Guidelines meeting. New aspects of the guideline will be disseminated in practice and staff training.
7.3. The monitoring process: An annual audit of at least 100 sets of maternity records will be undertaken monitoring the following elements:
7.3.1.1. Indication for IOL 7.3.1.2. Outcome 7.3.1.3. Length of time from commencement to delivery 7.3.1.4. Maternal and Fetal observations 7.3.1.5. Feedback from the women
7.4. A report will be produced yearly, presented at Maternity governance meeting & circulated to all medical staff. It will also be submitted alongside an Audit Outcome Form to the Health group Quality Facilitator.
7.5. Any identified deficiencies will be discussed at The maternity governance meeting and a timeframe for actions agreed. Completion of these actions will be identified through the Maternal Governance meeting.
7.6. Required changes to practice will be identified and actioned within the time frame identified through Labour Ward Forum. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders.
8. References Specific guidelines linked to IOL indications or timings are available
in the table in Section 4.0
National Institute for Clinical Excellence (2015) Insertion of double
balloon catheter for induction of labour in pregnant women without
CERVICAL RIPENING BALLOON FOR INDUCTION OF LABOUR AUDIT FORM
AGE
PARITY GESTATION
BMI INDICATION FOR IOL ‘DECISION FOR IOL’ STICKER USED
BISHOPS SCORE PRIOR
TO INSERTION
DATE/TIME INSERTED DATE/TIME REMOVED
FELL OUT
BISHOPS SCORE AFTER
REMOVAL
ESTABLISHED LABOUR
ACHIEVED DURING IOL
WITH CRB ONLY
ARM ACHIEVED POST
REMOVAL OF CRB
OXYTOCIN INFUSION
COMMENCED FOLLOWING
CRB IOL
DELIVERY DATE & TIME MODE OF DELIVERY
MATERNAL COMPLICATIONS
NEONATAL COMPLICATIONS
Y/N
Circle which
Y/N
Circle which
Y/N
Circle which
Y/N
Circle which
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 23 of 27
INDUCTION OF LABOUR AUDIT FORM
AGE PARITY GESTATION
BMI INDICATION FOR IOL ‘DECISION FOR IOL’ STICKER USED
COMPLETE ONE ROW FOR EACH IOL METHOD USED
DATE/TIME COMMENCED
DATE/TIME COMPLETED
BISHOPS SCORE
PRIOR TO
………………………… (State method)
BISHOPS SCORE
AFTER
……………………………. (State method)
DATE/TIME COMMENCED
DATE/TIME COMPLETED
BISHOPS SCORE
PRIOR TO
………………………… (State method)
BISHOPS SCORE
AFTER
……………………………. (State method)
DATE/TIME COMMENCED
DATE/TIME COMPLETED
BISHOPS SCORE
PRIOR TO
………………………… (State method)
BISHOPS SCORE
AFTER
……………………………. (State method)
DATE/TIME COMMENCED
DATE/TIME COMPLETED
BISHOPS SCORE
PRIOR TO
………………………… (State method)
BISHOPS SCORE
AFTER
……………………………. (State method)
ESTABLISHED LABOUR ACHIEVED DURING IOL WITH (State method)
DELIVERY DATE & TIME MODE OF DELIVERY
MATERNAL COMPLICATIONS
NEONATAL COMPLICATIONS
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 24 of 27
12. Appendix D
Cook Medical Cervical ripening balloon catheter (CRB) is a silicone double balloon
catheter. The maximum balloon inflation is: 80ml/balloon. (Fig.A)It is engineered to
naturally and gradually dilate the cervix and facilitate labour induction. Ripening and dilation is accomplished by the balloons’ gentle and constant pressure at the level of
the cervix from both the internal and external os.
Fig.A
Advantages
It safely ripens and dilates the cervix without pharmaceuticals
It eliminates the potential side effects of repeat medications
The silicone balloons adapt to the contour of the cervical canal
It is easily placed and quickly removed Prior to insertion
Confirm gestational age, singleton pregnancy, vertex presentation, intact membranes, exclude placenta praevia and any contraindications to vaginal birth
A CTG must be performed for 30 minutes before CRB insertion.
Ensure the woman has emptied her bladder.
Confirm maternal pulse, blood pressure, respiration rate and uterine activity meet accepted criteria for induction.
Perform an abdominal palpation to confirm presentation and vaginal examination to obtain a Bishop’s score (unfavourable cervix and ARM not feasible)
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 25 of 27
Fig B :
Perform a VE and record the Bishop’s score. Insert 2 fingers into the vagina,
then using the other hand to guide, gently advance the CRB through the
cervix until both balloons have entered the cervical canal. (Fig.B)
Fig C:
Inflate the uterine balloon with 20-40ml of saline through the catheter valve U.
Once the uterine balloon is inflated, pull the device back until the balloon
abuts the internal cervical os. (Fig. C)
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 26 of 27
Fig D
Once it is confirmed that the lower vaginal balloon is now outside the external
os, inflate the vaginal balloon catheter valve V with 20ml saline. (Fig D).
Fig E.
Once the Balloons are situated on either side of the cervix, add saline (slowly
in 20ml increments) - a maximum of 80mL per balloon (Fig.E)
You may allow the catheter to hang down loosely or tape it to the side of the thigh if deemed
more comfortable.
Alternatively
The procedure can also be conducted using the speculum method.
Place the women in a lithotomy position
Insert speculum and visualize the cervix. Clean the cervical os with sterile
water
Pass the cervical ripening balloon catheter through the cervix (using sponge
forceps) until both balloons have entered the cervical canal
Then follow the steps as above.
Observations during admission following Insertion of cervical balloon;
Induction and Augmentation of Labour Guideline
Women’s and Children’s Page 27 of 27
6 hourly fetal heart rate and movements- commence a CTG if any fetal heart rate abnormalities are detected.
Further vaginal examinations are unnecessary unless regular contractions are established or SROM occurs. N.B. perform CTG at this time.
Indications for catheter removal include:
Ruptured membranes
Uterine hyperstimulation or uterine tachystole
Abnormal CTG requiring urgent delivery
Urinary retention - remove some or all fluid from the balloon(s)
Maximum recommended time reached
To remove the cervical balloon;
Remove the CRB after 12 hours and perform a VE to assess suitability for ARM.
Deflate both balloons through the corresponding valve marked U and V and remove itvaginally .The balloon may fall out as the cervix dilates prior to 12 hours’ time limit.
ARM should be performed in labour ward and the management of labour should be conducted as per Care in Labour guideline.
Propess Pessary insertion diagram Secure the pessary between the fore and middle fingers. With consent, using the
same technique as a vaginal examination pass the pessary into the posterior fornix. Rotate it gently so that it lies transverse in the posterior fornix ‘wrapped’ behind the cervix.
Ensure there is sufficient tape at the introitus to remove the pessary if necessary.
