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Induction of labour
Document title:
Induction of labour
Publication date:
September 2011
Document number:
MN11.22-V4-R16
Document
supplement:
Amendments
Amendment date
April 2015
Replaces document:
MN11.22-V3-R16
Author:
Audience:
Review date:
September 2016
Endorsed by:
Contact:
Email: Guidelines@health.qld.gov.au
URL: www.health.qld.gov.au/qcg
Disclaimer
This guideline is intended as a guide and provided for information purposes only. The information has
been prepared using a multidisciplinary approach with reference to the best information and evidence
available at the time of preparation. No assurance is given that the information is entirely complete,
current, or accurate in every respect.
The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice.
Variation from the guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are
responsible for:
Providing care within the context of locally available resources, expertise, and scope of practice
Supporting consumer rights and informed decision making in partnership with healthcare practitioners
including the right to decline intervention or ongoing management
Advising consumers of their choices in an environment that is culturally appropriate and which
enables comfortable and confidential discussion. This includes the use of interpreter services where
necessary
Ensuring informed consent is obtained prior to delivering care
Meeting all legislative requirements and professional standards
Applying standard precautions, and additional precautions as necessary, when delivering care
Documenting all care in accordance with mandatory and local requirements
Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability
(including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred
for any reason associated with the use of this guideline, including the materials within or referred to
throughout this document being in any way inaccurate, out of context, incomplete or unavailable.
State of Queensland (Queensland Health) 2015
This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to
copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines,
Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit
http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en
For further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email Guidelines@health.qld.gov.au, phone
(07) 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48,
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Page 2 of 26
Indications
Maternal and fetal benefit
Consider individual
circumstances
Potential circumstance
Prolonged pregnancy
PPROM / PROM
Previous caesarean section
Obstetric cholestasis
Diabetes
Hypertensive disorder
Twin pregnancy
Suspected fetal macrosomia
Fetal growth restriction
IUFD
Maternal request
Other maternal conditions
Indications
Offer at 39 - 40 weeks
Membrane
Sweep
Contraindications
Low lying placenta
Elective caesarean section
is planned
Indications
Favourable cervix
ARM
Cautions
Avoid with high head
Contraindications
As for vaginal birth
Communication & information for
women
Maternal and fetal benefit & risk
Indications
Methods of IOL
Pain relief
Possibility of failure
Time for decision-making
Document above
Pre-induction assessment
Review history
Confirm gestation
Baseline observations
(temperature, pulse, BP)
Abdominal palpation
(presentation, engagement)
CTG
Assess membrane status (intact
or ruptured)
Vaginal examination
Indications
Unfavourable cervix
Transcervical
Catheter
Postponed induction
Consider individual
circumstances
Perform maternal and fetal
assessment
Document assessment and plan
of care in the health record
Advise the woman to return if
concerned
Cautions
Antepartum bleeding
Rupture of membranes
Cervicitis
Prostaglandin
Oxytocin
Contraindications
Hypersensitivity to
Prostaglandin
Grandmultiparity gel
High parity (>3) pessary
Previous uterine surgery
High presenting part
Malpresentation
Indications
Favourable cervix
o If cervix unfavourable
consider Dinoprostone
(PGE2)
Indications
Unfavourable cervix
Cervix
Favourable:
o Bishop score > 6
Unfavourable:
o Bishop score 6
Declined induction
Offer increased antenatal
monitoring x 2/week:
o CTG
o Ultrasound scan:
Amniotic fluid index
Umbilical arterial Doppler
Contraindication
Low lying placenta
Cautions
Not within 6 hours of
Dinoprostone gel
Not within 30 minutes of
removal of Dinoprostone
pessary (Cervidil)
Previous uterine surgery
High parity (>4)
Page 3 of 26
Abbreviations
ARM
CS
CTG
FGR
FHR
GBS
GDM
IOL
IUFD
NICU
PGE2
PPROM
PROM
PV
RCT
TGA
VBAC
VE
Definition of Terms
1
Amniotomy
Cervical ripening
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
1
interventions.
Dinoprostone
Favourable cervix
Fetal growth restriction
(FGR)
Induction of labour
Mechanical method
Uterine hypercontractility
Obstetrician
Prolonged pregnancy
Page 4 of 26
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
Care if induction of labour postponed .................................................................................... 7
1.6
Clinical standards .................................................................................................................. 7
1.7
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................................................................................................... 9
2.5
Obstetric cholestasis ............................................................................................................ 10
2.6
Diabetes ............................................................................................................................... 10
2.7
Hypertensive disorders of pregnancy .................................................................................. 11
2.8
Twin pregnancy ................................................................................................................... 11
2.9
Suspected fetal macrosomia (> 4000 grams) ...................................................................... 11
2.10 Fetal growth restriction ........................................................................................................ 12
2.11 Intrauterine fetal death ......................................................................................................... 12
2.12 Maternal request .................................................................................................................. 12
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
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 .................................................................................................... 9
Table 6. Obstetric cholestasis ............................................................................................................. 10
Table 7. Gestational diabetes/diabetes mellitus .................................................................................. 10
Table 8. Hypertensive disorders of pregnancy .................................................................................... 11
Table 9. Twin pregnancy ..................................................................................................................... 11
Table 10. Suspected fetal macrosomia ............................................................................................... 11
Table 11. Fetal growth restriction ........................................................................................................ 12
Table 12. Intrauterine fetal death ......................................................................................................... 12
Table 13. Maternal request .................................................................................................................. 12
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
Refer to online version, destroy printed copies after use
Page 5 of 26
Introduction
Induction of labour (IOL) is a relatively common procedure. In 2009 the IOL rate in Queensland was
5
22.4%. 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
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.
6
In Queensland, only 27.1% of women who had an IOL reported having made an informed decision :
1,4
Provide women with information on the :
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
7
Consider the use of decision aids to assist the woman make informed choices
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
Women who decline IOL should have their decision respected. Usually, these are women who have
been offered IOL for prolonged pregnancy.
8
At 41 weeks or later gestation, it has been shown for those women who :
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
9
monitoring consisting of twice weekly:
10
Cardiotocography (CTG)
Ultrasound assessment of amniotic fluid volume using:
10,11
o Estimation of maximum amniotic pool depth
, or
12,13
o Amniotic fluid index
12
Umbilical arterial Doppler ultrasound
Page 6 of 26
1.5
Take into account the womans individual clinical circumstances and preferences, the indication for
IOL and the local service capabilities and priorities when determining if a booked IOL can be
postponed (e.g. due to resourcing issues or as a result of maternal request). When a booked
induction of labour is postponed:
Perform an assessment of maternal and fetal wellbeing
Involving the woman, develop a plan for continued care including, arrangements for
ongoing monitoring (if required) and return for IOL
Document the assessment and plan in the health record
Advise the woman to contact the facility if she has concerns about her wellbeing or that of
her baby
1.6
Clinical standards
1.7
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
Risk/Benefit
Recommendations
Page 7 of 26
Specific circumstances
Considerations for specific IOL indications are outlined in the following sections.
2.1
Prolonged Pregnancy
Prolonged pregnancy
Risk/Benefit
Recommendations
2.2
19
Risk/Benefit
Recommendations
+6
Gestation between 34 36
IOL versus expectant management:
22,23
o Reduces chorioamnionitis
22
o Reduces maternal length of stay
o Insufficiently sized studies to determine difference in:
22,23
Neonatal sepsis
23
Respiratory distress
23
Newborn intensive care resource use
Decreased neonatal intensive care unit (NICU) length of stay and
hyperbilirubinaemia is demonstrated if delivery occurs after, rather than
24
before, 34 weeks
Gestation less than 34 weeks
25
Birth before 34 weeks is associated with increased neonatal mortality ,
25
24
adverse neonatal outcomes including respiratory distress syndrome ,
24
24
intraventricular haemorrhage , necrotising enterocolitis and other long
25
term complications
25
Mortality and morbidity increase with decreasing gestational age
+0
+6
Gestation between 34 36
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
1
indications
Page 8 of 26
2.3
Risk/Benefit
Recommendations
2.4
26
Recommendations
32
Page 9 of 26
2.5
Obstetric cholestasis
Obstetric cholestasis
Risk/Benefit
Recommendations
2.6
35
Diabetes
Risk/Benefit
Recommendations
Page 10 of 26
2.7
Risk/Benefit
Recommendations
2.8
1,14,45
Twin pregnancy
Twin pregnancy
Risk/Benefit
Recommendations
2.9
48
Risk/Benefit
Recommendations
52
Page 11 of 26
Risk/Benefit
Recommendations
Recommendations
Maternal request
Risk/Benefit
Recommendations
Page 12 of 26
Risk/Benefit
Recommendations
Page 13 of 26
3.1
Cervical assessment
The Bishop score is commonly used to assess the cervix. Each feature of the cervix is scored and
62
then the scores are summed. Table 15 provides an example of a modified Bishop score .
4
The state of the cervix is one of the important predictors of successful IOL
4
The cervix is unfavourable if the score is 6 or less
Table 15. Modified Bishop score
Cervical feature
Score
0
Dilation (cm)
<1
1-2
3-4
>4
>3
<1
-3
-2
-1 / 0
+1 / +2
Firm
Medium
Soft
Posterior
Mid
Anterior
Consistency
Position
Page 14 of 26
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
Dinoprostone
Indications
Contraindications
Cautions
Risk/Benefit
Monitoring
Assessment of
progress
Unfavourable cervix
63,64
Known hypersensitivity to Dinoprostone or other constituents
64,65
Ruptured membranes pessary contraindicated
65
Multiple pregnancies
High parity
63
o Gel parity greater than 4 and
64
o Pessary parity greater than 3
63,64,65
Previous CS or any uterine surgery
63
Malpresentation / high presenting part
Unexplained vaginal discharge and / or uterine bleeding during current
63,64,65
pregnancy
65
Use caution in women with asthma due to potential bronchoconstriction
65
Ruptured membranes use gel with caution
63,64,65
Oxytocin administration
65
Epilepsy
65
Cardiovascular disease
65
Raised intraocular pressure, glaucoma
65
Page 15 of 26
4.1.1
Aspect
Dose
Dinoprostone administration
Dinoprostone gel
Initial dose:
69
o Nulliparous 2 mg PV
o Multiparous 1 mg PV
Repeat dose, after 6 hours:
o Nulliparous 2 mg
o Multiparous 1-2 mg
Dinoprostone pessary
66
10 mg PV (released at a rate of approximately 4 mg in 12 hours)
Dinoprostone gel
65
Maximum 3 mg over 6 hours
Maximum dose
Dinoprostone pessary
64
4 mg (12 hours after insertion)
Dinoprostone gel
Use water soluble lubricants (not obstetric cream)
Remove from refrigeration and stand at room temperature for at least 30
63
minutes prior to use
63
Insert into the posterior fornix of the vagina
63
Not for intracervical administration
63
Advise recumbent and left lateral position for 30 minutes after insertion
to facilitate absorption
Administration
Side effects
Indications for
removal
Dinoprostone pessary
64
Remove from freezer or fridge immediately prior to use
Can be stored in the fridge for up to one month after removal from the
64
freezer
64
Warming is not required
Open the foil only after decision has been made to use it
Use water soluble lubricants (not obstetric cream)
65
64
Insert into the posterior fornix of the vagina in transverse position
64
Ensure sufficient tape outside vagina to allow removal
64
Remain recumbent for 30 minutes
Advise women to avoid inadvertent removal of pessary and to report if
pessary falls out
Uterine hypercontractility [For management: refer Section 5]
64
Dinoprostone pessary
Onset of regular uterine contractions
Membranes rupture (spontaneous or ARM)
Fetal distress
Uterine hypercontractility
Insufficient cervical ripening after 12 hours
o There is minimal evidence on the administration of Dinoprostone
gel if there is no cervical change 12 hours after pessary insertion.
Base decision on the womans individual circumstances. Timing of
gel administration at the obstetricians discretion
Page 16 of 26
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
Cautions
Risk/Benefit
Monitoring
Assessment of
progress
IOL using ARM and intravenous Oxytocin infusion is the preferred method
70
once the cervix is favourable
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
64
of its removal
If not already ruptured, perform ARM prior to initiation of Oxytocin infusion
Oxytocin is contraindicated in women with previous uterine scar or high
68
parity (greater than 4). 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
71
hours
71
o Shows no significant difference in caesarean birth rates
71
o Increased the need for epidural
1
o Mobility is restricted
o Refer to Table 16 for Dinoprostone considerations
Is associated with lower infection rates in both mother and baby when
71
membranes are ruptured at the time of IOL
Oxytocin induced contractions may be perceived as more painful
4
Provide one-to-one midwifery care
Use continuous electronic FHR monitoring once Oxytocin infusion
72,68
commenced
Titrate dose to achieve 3-4 strong regular contractions in 10 minutes
Maternal and fetal observations:
73
o Refer to guideline: Normal birth
o Assess maternal observations and FHR prior to any increase in the
infusion rate
Maintain fluid balance as water intoxication may result from prolonged
68
infusion (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
Page 17 of 26
4.2.1
Oxytocin administration
Consideration
Oxytocin administration
Administration
Maximum dose
Side effects
4,68
Time after
starting
(minutes)
0
30
60
90
120
150
180
210
240
270
Oxytocin dose
Volume infused (mL/hour)
(milliunits per
10 IU in
20 IU in
30 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
Page 18 of 26
4.3
Risk/Benefit
Monitoring
74
Page 19 of 26
4.4
Transcervical catheters
Transcervical catheters (e.g. Foley, Atad) are used to ripen the cervix through:
Direct dilatation of the canal or
79
Indirectly by increasing prostaglandin and/or oxytocin secretion
Table 22. Transcervical catheter considerations
Consideration
Indications
Cautions
Comment
Risk/Benefit
Monitoring
Page 20 of 26
IOL may increase the risk of the following conditions outlined in Table 23.
Table 23. Risk factors associated with IOL
Risk
Failed IOL
Uterine
hypercontractility
Cord prolapse
Uterine rupture
*Not currently listed on the Queensland Health List of Approved Medications (LAM)
Not TGA approved for this purpose
Page 21 of 26
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Acknowledgements
Queensland Clinical Guidelines gratefully acknowledge the contribution of Queensland clinicians and
other stakeholders who participated throughout the guideline development process particularly:
Funding
This clinical guideline was supported by funding from Centre of Healthcare Improvement,
Queensland Health
Page 26 of 26