Induction of Labour Audit

Muhammad Uthman KhanFY2 in Obstetrics

Airedale General HospitalApril-August 2011

Aim

• To look at the indications, process and outcome of induction of labour at Airedale

• To determine whether this meets the CNST Maternity Standards 2011 and NICE Guidance (clinical guideline 70 – Induction of labour, July 2008)

Aim

• To gain an appreciation of the efficacy of single-dose Propess® (vaginal PGE2 controlled-release pessary), the most commonly used agent at Airedale, in inducing labour

• To determine the caesarean section and assisted delivery rates of inductions and review the indications both for inducing and mode of delivery in these instances

PurposeAudit will aim to benefit patients and the Trust by:• Ensuring induction is carried out only when

indicated to encourage normality in the labouring process

• Ensuring where induction is indicated, that the process meets specified standards, and where this falls short, changes made in the induction process that result in improved patient care, better outcomes and maternal satisfaction

Background

• Definition An intervention to of IOL:stimulate uterine contractions in

pregnancy prior to labour beginning spontaneously

• Reason: Deemed that early delivery is safer for the mother and/or foetus than allowing the pregnancy to continue its natural course

Background

• Around 1/5 deliveries in the UK induced1

• Induced labour may be less efficient and more painful than spontaneous labour2

• Associated with higher rates of assisted delivery (17-19%) compared to 12% with spontaneous labour1

1. Hospital Episode Statistics, Maternity data 2009-102. NICE clinical guideline 70, Induction of labour, July 2008

Methodology• Sample of 60 patients from those induced at

Airedale Hospital between January-March 2011• Used both hand-held + hospital maternity records

to gather data• Defined as those administered vaginal

prostaglandin (in either pessary, gel or tablet form) and/or those in whom amniotomy was performed when the woman was not in labour

Results

Maternal demographics

Age

Ethnicity

Parity

Parity

24

19

7 6

20 0

2

0

5

10

15

20

25

30

0 1 2 3 4 5 6 7

Previous C-Section

Induction information

Gestation at Induction (weeks)

Reason for Inducing

‘Other’ reasons

• Foetal tachycardia, reduced movements

• Hughes syndrome (antiphospholipid syndrome)

• Severe symphysis pubis dysfunction

• Suspicious CTG after presenting in query labour

Induction in specific circumstances

PROMLabour ward busy

Woman returning >24 hours later

Post-dates

Information provision and time of induction

Treatment and care to be offeredNo documentation

Time of induction

PROM

Admitted from clinic

Labour ward busy

Maternofoetal assessment & monitoring prior to and during

induction, before the establishment of labour

Prior to induction

• EFM to assess foetal wellbeing, performed in all (100%) cases

Modified Bishop Score

Information in notes but not formally calculated

Vaginal PGE2 used

Repeat CTG performed in all (100%) women who developed

contractions

Intermittent auscultation following normal CTG?

Laboured prior or CTG not normal

EFM

Maternal observations

Laboured prior

6-hourly

Propess®: duration in-situ

Time to labour:

Modified Bishop score reassessed in all (100%) women

who did not labour 24hrs following Propess® insertion

Prostin™

Outcome of Induction

Instrumental deliveries – reasons for induction

Indication for instrumental delivery

Caesarean sections – reasons for induction

Indication for caesarean section

Maternal complications

• A total of 3 women (6% of those receiving Propess®) suffered from uterine hyperstimulation

• 2/3 given Terbutaline

Failed Inductions

• Both induced for post-dates• Both had 24 hours of Propess®• One was a previous C-section therefore no

Prostin™ → C-section• The other woman had 2x Prostin™ 6 hours

apart, amniotomy performed after but did not labour → C-section

• Both had EFM following failed induction

Previous C-section managementReason for induction

All women had Propess®

None had Prostin™

Previous C-section managementOutcome of induction

Findings

• Single-dose Propess® (controlled-release vaginal prostaglandin E2 pessary) is effective as an induction agent in the majority of women (88%)

• Lower instrumental delivery (12%) and C-section rates (16%) in this audit compared to national average (England: 16-19% and 21-23% respectively)1

1. Hospital Episode Statistics, Maternity data 2009-10

Main Recommendations

• Scope for reducing intensity of foetal monitoring in low-risk women prior to establishment of labour to promote normality

• To review local guidelines on frequency of maternal observations during induction, prior to establishment of labour

• To re-audit in the near future after implementation of the new Induction of Labour proforma to determine effects

Areas for development

• To record timing of P/PROM from induction to delivery

• To identify whether epidural analgesia was administered

• Recording of actual bishop scores to allow analysis of correlation amongst successful and failed inductions

Thank you for listening

Any Questions?