Maternity & Newborn Clinical Network Induction of Labour – Victorian standard Victorian Standard for Induction of Labour Acknowledgement We gratefully acknowledge the clinical expertise of the Maternity and Newborn Clinical Network Induction of Labour Expert Clinical Advisory Group. We also thank the National Institute of Clinical Excellence (NICE) for their permission to use their IOL Guideline1, which forms the basis of this document and the Mercy Hospital for Women, Southern Health and the Royal Women’s Hospital for sharing components of their Induction of Labour (IOL) Guidelines. Rationale for the standard This Victorian Standard for IOL has been prepared by the Maternity Newborn Clinical Network (MNCN) with the objective of providing Maternity Service providers in Victoria with an agreed Standard of Care based on the best currently available evidence. Individual Maternity Services are encouraged to use the Standard as the basis for reviewing, or developing their own Clinical Practice Guideline (CPG) that take into account the specific conditions (eg access to and staffing of operating theatres), applying to their own service. Example CPG’s are included. Because of the movement of maternity service staff between health services, it is strongly recommended that where at all possible, variation between practices, especially for drug regimens, should be avoided. Introduction Induced labour has an impact on the birth experience of women. It may be less efficient and may be more painful than spontaneous labour. Epidural analgesia and assisted birth are more likely to be required than for spontaneous labour. www.health.vic.gov.au/clinicalnetworks page 1 of 16 Department of Health February 2010 IOL is a relatively common procedure. In 2005 and 2006, 17,000 or 25% of labours in Victoria were induced. This includes induction for all medical reasons. When labour was induced 60% of women gave birth without further intervention, with 18% having instrumental births and 20% having emergency caesarean section2. Although some of these interventions may be related to the indication for induction, it is likely that there is a contribution from IOL itself. IOL, as with all clinical interventions, should be clinically justified, weighing the risks of the induction against those of continuing the pregnancy. IOL is usually more consuming of healthcare resources than spontaneous labour. Obligatory intrapartum fetal surveillance, managing oxytocin infusions, longer periods of ‘observed’ labour and increased need for operative birth all add to the workload. When planning inductions of labour, hospitals should take into account the requirement for additional resources and plan staffing accordingly. These standards offer best practice advice on the care of women who are undergoing or being recommended an IOL. 1. Informed Consent Treatment and care should take into account women’s individual needs and preferences. Women who are having or being offered IOL should have the opportunity to make informed decisions about their care and treatment in partnership with their clinicians. Good communication between clinicians and women is essential. It should be supported by evidence-based written information tailored to the needs of the individual woman. Treatment and care, and the information women are given, should be culturally appropriate. It should also be accessible to women, their partners and families, taking into account any additional needs such as physical or cognitive disabilities, and limitations regarding their ability to understand written or spoken English. www.health.vic.gov.au/clinicalnetworks page 2 of 16 Department of Health February 2010 At full term, around the 38-40 week antenatal visit, all women should be offered information about the risks associated with pregnancies that last longer than 41 weeks, and their options. The information should cover: • membrane sweeping: − what membrane sweeping is − that, on average, membrane sweeping makes the onset of spontaneous labour sooner more likely, which may reduce the need for formal IOL to prevent prolonged pregnancy in some women − that discomfort and vaginal bleeding are possible from the procedure • IOL is recommended between 41+3 and 42+0 weeks • recommendations for fetal surveillance prior to IOL or the onset of spontaneous labour Clinicians should explain the following points to women in whom IOL is recommended: • the reasons for induction being recommended • when, where and how induction could be carried out • the arrangements for support and pain relief • the alternative options if the woman chooses not to have IOL at this time • the risks and benefits of IOL in specific circumstances and the proposed induction methods • the possibility that the IOL may be unsuccessful and what options are available (see section 7.2) • this information should be made available where possible in the woman’s own language www.health.vic.gov.au/clinicalnetworks page 3 of 16 Department of Health February 2010 Clinicians recommending IOL should: • allow the woman time to discuss the information with her partner before coming to a decision • encourage the woman to look at a variety of sources of information • invite the woman to ask questions, and encourage her to think about her options • support the woman in whatever decision she makes 2. Establishing the Estimated Due Date (EDD) Pregnancy cannot be said to be prolonged without accurate dating of the pregnancy. • if early ultrasound (<14 weeks) is available the estimated due date (EDD) should be calculated from the ultrasound, overriding calculation of the EDD using the last known menstrual period (LNMP) • if ultrasound performed >14 weeks, the EDD should be calculated from the LNMP unless the ultrasound differs by more than one week • for women with oligomenorrhoea, lactational amenorrhoea or oral contraceptive withdrawal bleeding where a calculation cannot be based on the LNMP, then the first ultrasound should be used to determine the EDD www.health.vic.gov.au/clinicalnetworks page 4 of 16 Department of Health February 2010 3. Contraindications to Induction of Labour • malpresentation: transverse or oblique lie, footling breech, brow • previous classical uterine incision or previous caesarean section of unknown type • cord presentation • abnormal fetal surveillance (eg CTG) requiring immediate delivery • placenta praevia or vasa praevia • active genital herpes • cervical carcinoma • or any other contraindication to labour or vaginal birth 3.1 Require lead obstetrician discussion • frank breech • previous caesarean section • severe intrauterine growth restriction • cardiotocographic non-reassuring fetal status www.health.vic.gov.au/clinicalnetworks page 5 of 16 Department of Health February 2010 4. Methods of induction 4.1 Membrane sweeping Membrane sweeping involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua. If the cervix will not admit a finger, massaging around the cervix in the vaginal fornices may achieve a similar effect. For the purpose of this standard, membrane sweeping is regarded as an adjunct to IOL rather than an actual method of induction. Clinicians should always check that there is no evidence of a low-lying placental site before membrane sweeping: • prior to formal IOL, women may be offered a vaginal examination for membrane sweeping • at the 40 and 41 week antenatal visits, nulliparous women may be offered a vaginal examination for membrane sweeping • at the 41 week antenatal visit, multiparous women may be offered a vaginal examination for membrane sweeping • when a vaginal examination is carried out to assess the cervix, the opportunity may be taken to offer the woman a membrane sweep • additional membrane sweeping may be offered if labour does not start spontaneously • in some circumstances, (eg Group B Strep (GBS) carriage), the clinician may choose not to recommend membrane sweeping prior to IOL. There is insufficient evidence to define infection rates in women who are GBS positive, with and without membrane sweeping but the number of cases of consequent chorioamnionitis is likely to be small www.health.vic.gov.au/clinicalnetworks page 6 of 16 Department of Health February 2010 4.2 Artificial rupture of membranes (ARM, amniotomy) Artificial rupture of membranes may be used alone or in combination with oxytocin therapy. Oxytocin therapy should not be commenced within 6 hours of insertion of prostaglandin gel. The decision to perform ARM and await onset of contractions may be considered when there is a past history of rapid labour, grand multiparity, previous lower segment caesarean section or when the mother has expressed strong preference for giving some time to await spontaneous labour after ARM. The preferred instrument is an amniotomy hook. Alligator or other toothed forceps should not be used unless the ARM is technically difficult. The practice of obtaining fetal hair to confirm membrane rupture is usually not necessary. 4.3 Oxytocin A standardised regimen is recommended and attached (see Oxytocin (Syntocinon®) Induction and Augmentation of Labour CPG). Prior to commencement of oxytocin: • forewater rupture confirmed, in some circumstances it is reasonable to commence oxytocin first and then perform the ARM • > 6 hours should have elapsed since Dinoprostone PGE2 vaginal gel administration • > 30 minutes should have elapsed after removal of Dinoprostone ® PGE2 continuous release pessary (Cervidil ) www.health.vic.gov.au/clinicalnetworks