Post-dates induction of labour

Michelle Wise MD MSc FRCSC FRANZCOG

Senior Lecturer, Department of O&G, FMHS

Obstetrician & Gynaecologist, National Women’s

13 June 2017

Objectives

• Present the evidence for reducing post-term pregnancy

• Propose a way forward

LEVELS OF EVIDENCE

Diabetes

Fetal growth restriction

Preeclampsia

Oligohydramnios

Decreased FM

Macrosomia

Age > 35 ↑ risk

of CS

Twins

Post-term

Indications for IOL

THE EVIDENCE FOR ↓ POST-TERM

Post-term

• ≥ 42 weeks

• Associated with oligohydramnios, meconium, “fetal distress”

• Post-maturity syndrome

PinsDaddy

Reduce post-term pregnancy

1. Accurate dating of pregnancy

< 14 weeks scan +/- 5 days

2. Membrane sweeping at term

3. Policy of labour induction at 41 wks

Reduce post-term pregnancy

1. Accurate dating of pregnancy

< 14 weeks scan +/- 5 days

2. Membrane sweeping at term

3. Policy of labour induction at 41 wks

Reduce post-term pregnancy

1. Accurate dating of pregnancy

< 14 weeks scan +/- 5 days

2. Membrane sweeping at term

3. Policy of labour induction at 41 wks

Pregnant women at 41+0

Policy of expectant management

Policy of labour induction

10 outcome: perinatal death

20 outcomes: CS, MAS, admit NICU

Results

• 22 RCTs of 9,383 women

• Policy of labour induction at 41+0 vs. policy of expectant management

• Fewer perinatal deaths (RR 0.31)

• Fewer caesareans (RR 0.82)

• Fewer babies developed meconium aspiration syndrome (RR 0.50)

Cochrane review 2012

PMMRC 2015

• Perinatal related mortality risk from 41+0 weeks = 3.2 per 1000 ongoing pregnancies

• Policy of IOL at 41+0 (RR 0.31) could ↓ risk to

1.0 per 1000

CURRENT PRACTICE

Evidence-based practice

• Offer IOL when appropriate, and avoid IOL when not appropriate (NICE guideline)

Risk to mum

and/or babe

Benefit to mum

and/or babe

Strong IOL governance

• Multidisciplinary, engage all stakeholders

Strong IOL governance

• Clinical prioritisation of IOLs

Indications for IOL at NWH 2015

IOLs at term

diabetes

PROM

post-dates

sga

HTN

latent phase

fetal

Other

Strong IOL governance

• Reduce variation in practice

– by individuals

– by DHB

National Maternity Indicators 2015

Auckland consensus guidelines 2014

• To guide clinicians to offer IOL when appropriate (i.e. where evidence shows that benefit to mother and/or baby outweighs the risk) and to avoid IOL when not appropriate

• http://nationalwomenshealth.adhb.govt.nz/ health-professionals/induction-of-labour

Risk to mum

and/or babe

Benefit to mum and/or babe

Auckland consensus guidelines 2014

• IOL should be arranged around 41+5, but this can be individualised where resources allow

• Could offer fetal assessment at 41+0 (e.g. ultrasound scan, CTG) and if there are any concerns about fetal well-being, then IOL should be offered.

ELECTIVE Induction of Labour (IOL) Booking Request Form

For all urgent/acute IOL required within 24-48 hours, please call the L&BS SMO on call

Referring Doctor to complete and fax to DAU: int. 25905 and ext. 09-307-8904

Requested date for IOL ....../………/……

Requested time for IOL ☐ 07:30 ☐ 09:30 ☐ 10:30 ☐ 12:00 ☐ 16:30 ☐ other: ______

☐ anytime

Today’s date ....../………/……

EDD ……/………/……

Gestational age on requested date ……………weeks ………….days

Parity …………….

LMC Name: ☐ Self Employed Midwife

☐ Hospital Midwife

☐ Private obstetrician Mobile:

Specialist responsible for IOL decision:

Guideline based indication for IOL Other factors (tick all that apply)

☐ Rupture of membranes, pre-labour ☐ Maternal age 35 -39 years

☐ Multiple pregnancy ☐ Obesity: Booking BMI ______

☐ Pre-eclampsia ☐ IVF pregnancy

☐ Diabetes

Detail: __________________________

☐ Slowing of growth

☐ Antepartum haemorrhage (APH)

☐ Small for gestational age (SGA)

Detail: __________________________

☐ Maternal request

☐ Maternal medical condition

☐ Maternal age ≥ 40 years ☐ Fetal condition ___________________

☐ Post-dates

☐ Hypertension, no preeclampsia ☒ Other __________________________

_________________________________

Location

☐ WAU ☐ L&BS ☐ HDU

Method

☐ PGs ☐ Balloon ☐ ARM ☐ Synto ☐ Team to decide

☐ ADHB IOL pamphlet provided ☐ Stretch and sweep offered to woman

To start IOL: ☐ LMC ☐ Hospital MW Care in labour: ☐ LMC ☐ Hospital MW

Interpreter needed? ☐Y ☐ N Language:

Staff Use only:

Confirmed IOL Date: ....../………/……

Confirmed IOL Time: ……:……

MUST ATTACH PATIENT LABEL HERE SURNAME: ___________________________ NHI: ______________ FIRST NAMES: ________________________ DOB: _____________

Please ensure you attach the correct visit patient label

Strong IOL governance – next steps

• IOLs requested outside of consensus guidelines → peer review

• Audit

– % IOLs as per IOL guidelines

– Unintended consequences

PROPOSE WAY FORWARD

National 2018Auckland consensus guidelines 2014

YES

• Arrange IOL

• No scan, no CTG, no extra visit

NO

• Fetal surveillance

• Risk assessment

Offer IOL at 41+0

National 2018Auckland consensus guidelines 2014

For women who decline IOL at 41+0

• Fetal surveillance

– counsel re limitations of research

– daily FMs (prompt assessment if ↓)

– CTG

– deepest fluid pocket

• Risk assessment

– exclude fetal growth restriction and hypertension

National 2018

Auckland consensus guidelines 2014

• Email me if you want to participate

m.wise@auckland.ac.nz

Outpatient foley balloon vs.

Inpatient PG gel RCT for low-risk women having IOL

CENTRE