Induction of Labour Propess, Cervical Ripening Balloon, … · 2019-10-11 · Presentation other than cephalic Macrosomia and previous precipitate labour (Induction has not been shown

Version: 5 Title: Induction Of Labour –Propess, Cervical Ripening Balloon, Prostaglandin Gel

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Date: 12/04/2018 Next Review Date: January 2021

Induction of Labour –Propess, Cervical Ripening Balloon, Prostaglandin Gel

Document type: Clinical Guideline

Version: 5

Author (name and designation): J Tomlinson, Consultant Obstetrician & Gynaecologist

K Christie, Midwife and Ward Manager M2

Juthica Bardapure, Junior doctor

Validated by Women’s Quality Forum

Date validated 10th April 2018

Ratified by: Procedural Document Oversight Committee

Date ratified: 13th February 2018

Name of responsible committee/individual: Women’s Quality Forum

Name of Executive Lead (for policies only)

Master Document Controller: Dawn Thorpe, WQF Secretary

Date uploaded to intranet: 12th April 2018

Key words Induction, Labour, Propess, Cervical Ripening Balloon, Prostaglandin

Review date: January 2021

Version control

Version Type of Change Date Revisions from previous issues

4 Full review

5 Full review Jan 2018 Clarification on timing of fetal monitoring after commencement of induction. Includes out-patient induction

Equality Impact

Bolton NHS Foundation Trust strives to ensure equality of opportunity for all service users, local people and the workforce. As an

employer and a provider of healthcare Bolton NHS FT aims to ensure that none are placed at a disadvantage as a result of its policies


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and procedures. This document has therefore been equality impact assessed to ensure fairness and consistency for all those covered by

it regardless of their individuality. The results are shown in the Equality Impact Assessment (EIA).

Contents

1. Purpose 3

2. Terminology and Definitions 3

3. Content

- Timing

- Membrane Sweeping

- Process for dealing with maternal requests

- Organisation

- Low Risk Women (Induction on Antenatal Ward)

- Low Risk Women (Out-Patient Induction)

- Induction of Labour with Propess®

- Induction of Labour with Cervical Ripening Balloon (Cook Medical)

- Induction of Labour with Prostaglandin Gel

- Amniotomy

- Method Of Induction In High Risk Women Include

- Individual Management Plan When Induction Of Labour Fails

- Individual Management Plan For Women Who Decline IOL

- Linked guidelines

3

3

4

4

5

5

6

12

16

17

18

19

19

19

4. Duties and Responsibilities 19

5. Monitoring 20

6. References 20

7. Appendices

- Appendix 1: Modified Bishop’s score

- Appendix 2: Red Amber Green Risk Assessment

- Appendix 3: Patient information about out-patient induction of labour

- Equality Impact Assessment Tool

- Document Development Checklist

21

22

23

26

27


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1. Purpose

1.1. Induction of labour is the process by which labour is initiated in women in whom

delivery is required before the onset of labour where there will be benefit to the

mother, baby or both parties as a result of this intervention.

1.2. This guideline is intended to assist Midwives & Obstetricians in determining when,

where & how to induce labour in pregnant women.

2. Terminology and Definitions

2.1. Induction of labour (IOL) is an intervention designed to artificially initiate uterine

contractions leading to progressive dilatation and effacement of the cervix and the

delivery of the baby. IOL is undertaken for a variety of clinical indications but should

only be considered when a vaginal delivery is felt to be the appropriate method of

delivery.

3. Content

Timing

3.1 Induction of labour should be offered to women with uncomplicated pregnancies from

T+11 to T+14. Women should be informed that most women will go into labour

spontaneously by 42 weeks. They should be offered information about risks

associated with pregnancies longer than 42 weeks, and their options

Membrane Sweeping

3.2 Recommendations for membrane sweeping

Women should be offered a vaginal examination for membrane sweeping prior to the

induction of labour. They should also be told that the procedure is safe but some

discomfort & bleeding are possible after it.

For nulliparous woman - At the 40 and 41 week antenatal visits

For parous women - At the 41 week antenatal visit


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3.3 Contraindications for membrane sweep

Low lying placenta

Undiagnosed vaginal bleeding in pregnancy

High/unengaged head

Presentation other than cephalic

Macrosomia and previous precipitate labour (Induction has not been shown to

improve outcome)

Process for dealing with maternal requests

3.4 Induction of labour on maternal request or non-medical grounds is not advised. Any

requests will need to be referred to the consultant.

Organisation

3.5 The woman should receive a patient information leaflet when the induction of labour

is booked. An Individual Management Plan for Induction of Labour should be

documented in the Antenatal Handheld Notes

3.6 Women should be informed and involved in the decision for induction of

labour

3.7 The information given to women will include:

Indication for IOL

Where, when & how it will be carried out

Advice regarding support & pain relief including that IOL likely to be more painful

than spontaneous labour.

Risks & benefits of IOL and the proposed induction method

That induction may not be successful and what the woman’s options would be.


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Alternative arrangements if IOL declined. Refer to consultant midwife to support

the woman with her decision making and help formulate joint plan of care.

Allow time to discuss with partner, ask questions, and support her decision

3.8 Vaginal assessment can be performed in either the community or hospital antenatal

clinic. A Modified Bishop’s score should be documented – see Appendix - and

arrangements made with M2 for admission on a suitable day. This should be coupled

with stretch and sweep. (See 3.1 above)

3.9 The date of induction should be placed in the Induction Diary. The woman will be

contacted by telephone on the day and told what time to attend M2.

3.10 The M2 Ward Clerk on a daily basis will amend the induction diary, to ensure that

only undelivered women remain in the Induction Diary.

3.11 If overbooking is required the Ward Manager / Shift Leader of M2 should be informed

to review appropriate timing of the request. If there is significant issues with numbers

of inductions the Ward Manager / Shift Leader will escalate to CDS Coordinator and

Consultant on call.

3.12 When booking IOL from the Antenatal Clinic, method of induction i.e. Propess,

Prostaglandin (Prostin) Gel or cervical ripening balloon (CRB) should be documented

in the notes and Propess/Prostin should be prescribed along with appropriate

analgesia, to avoid delays when the woman attends for admission.

Low Risk Women (Induction on Antenatal Ward)

3.13 A CTG is performed for at least 20 minutes prior administration of the propess,

prostaglandin gel or cervical ripening balloon.

3.14 Women with an unfavourable cervix should be given Prostaglandin Gel/Propess in

preference to amniotomy unless there are specific contraindications.

3.15 In the presence of strong uterine activity and an unfavourable cervix, prostaglandin

gel/Propess/Cervical Ripening Balloon should not be used.

Low Risk Women (Out Patient Induction)

3.16 All low risk women after term (see green RAG rating appendix 2) may be offered

outpatient IOL


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3.17 A full antenatal check will be performed on admission to the ward including a 20 minute CTG and IOL labour process commenced using Propess. As long as the women is not contracting the CTG does not need to be continued following Propess administration.

3.18 Each woman will be advised following insertion of Propess they have to remain on the ward for 30 minutes then if there are no concerns they will be discharged home.

3.19 They will be given a patient information leaflet (See appendix 3) and they will have open access to triage and must telephone triage any concerns, there will be a low threshold for any women calling triage.

3.20 If the woman returns to the ward/triage and in established labour and no additional risk factors have developed then they can then labour on Birth Suite providing they maintain on the low risk pathway.

3.21 The woman will be given prior to discharge a time to return to the ward if labour does not progress in which they will recommence the IOL

Induction of Labour with Propess®

3.22 Pre-requisites/Indications for use of Propess®

Cephalic presentation

Singleton pregnancy

Bishops Score < 6

3.23 Contra-indications

Fetal Pregnancy Maternal

Severe FGR Placenta praevia Grand multi para >5

Absent or Reversed

End Diastolic Flow

On Doppler

Vasa praevia Previous hysterotomy, classical

caesarean section,

Abnormal CTG

Undiagnosed

vaginal bleeding in

pregnancy

History of myomectomy or other

full thickness uterine incision

Presenting part above

pelvic inlet Pelvic structural abnormality

Cephalo-pelvic Prior use of CRB or Active cardiac, pulmonary, renal


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disproportion prostaglandin Gel or hepatic disease

Transverse lie Any contraindication

to labour induction Active genital herpes

Oblique lie Invasive cervical cancer

Untreated Severe maternal

hypertension

Hypersensitivity to

prostaglandins

Relative Contraindications

Increased Pulsatility

Index on Doppler Multiple pregnancy Previous Caesarean section

Asthma and glaucoma

3.24 Discuss with the Consultant or Middle Grade Doctor in case of doubt

3.25 Insertion of Propess®

Maternal observations to be performed before insertion to include Early

Warning Score (MOEWS)

Perform abdominal palpation to assess fetal lie, presentation and 5ths palpable

in the abdomen.

CTG for 20-30 minutes prior to insertion.

Perform vaginal examination and determine Bishop Score.

If CTG is reassuring and Bishop Score is 6 or less, insert Propess as per

instructions. The CTG does not need to be continued following Propess

administration unless she is contracting (see below).

If Bishop Score is 7 or greater, arrange for transfer to CDS for ARM when safe to

do so.

Use Modified Bishops score sticker and document in the notes.

If the Propess insert falls out and has remained clean, i.e. dropped onto clean

bed sheets and not dropped on to the floor or into the toilet it may be reinserted

and used to the 24-hour limit.

If the Propess is contaminated, a new one may be inserted and used up to 24

hours after the insertion of the first Propess®.


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Sufficient tape should be left to allow for easy removal when required.

The woman should be advised to take extra care not to pull the insert out

accidentally when going to the toilet or bathing.

The woman should be instructed to inform the midwife in case of:

o Regular and painful contractions (every 5 minutes or more frequent)

o Vaginal bleeding

o Rupture of membranes – if this occurs presentation should be checked and

the fetal heart auscultated.

o Propess falls out

3.26 Post Propess® Monitoring - Maternal

Maternal observations should include as a minimum a MOEWS every 12 hours,

unless differs from individual management plan (PROM, Diabetes etc – see

appropriate guideline)

Frequency of contractions

Colour of liquor

3.27 Post Propess® Monitoring - Fetal

Fetal monitoring with a CTG should be performed twice daily (approximately 12

hours apart, however if woman is asleep this can be deferred until she wakes)

for all women being induced.

Monitoring may be requested more frequently depending on the risk status

4 hourly auscultation of fetal heart during the day. This can be 6 hourly at night if

the woman is sleeping, to allow the her to have sufficient rest

CTG should be recommenced if the woman complains of any regular painful

uterine activity (contractions every 3 minutes for at least 30 minutes irrespective

of cervical changes- Ferring Summary of Product Characterisitics) at any time or

if clinically indicated (SROM, APH, escalating need for analgesia etc)

3.28 When to transfer to Delivery Suite

When labour is established (Contractions are regular, painful, up to 4

contractions in 10 minutes, cervix is effaced, os is dilated > 3 cm).


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Do not remove Propess whilst waiting for transfer to Delivery Suite

3.29 When to remove Propess®

Propess is designed to remain in the vagina for up to 24 hours; however, it

should be removed immediately in the following instances:

o Vaginal bleeding.

o Uterine hyperstimulation or hypertonic uterine contractions.

o Evidence of fetal compromise.

o Evidence of maternal adverse prostaglandin effects.

o Following 24 hours, even if labour is not established.

o 30 minutes prior to starting an intravenous infusion of oxytocin.

3.30 If in labour

3.31 To remove Propess®, apply gentle traction on the retrieval tape (the insert will have

swollen to 2-3 times its original size and be pliable).

3.32 Document time of removal in the patient notes.

3.33 24 hours following 1st Propess

Perform a CTG for at least 30 minutes

Remove the Propess® insert

Perform a VE to assess suitability for ARM

If suitable, transfer to Central Delivery Suite for ARM and oxytocin

Normal Progress of Labour

Yes No

Leave Propess

In-situ

Remove Propess

Perform ARM and commence syntocinon

after 30 minutes


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Oxytocin can be commenced 30 minutes after removal of Propess

Oxytocin should be commenced with 30 minutes of normal CTG

3.34 If unsuitable for ARM

Commence a further cycle of Propess®

3.35 24 hours following 2nd Propess

Woman can have light breakfast on the day of 24 hours post 2nd Propess review.

If the woman is due for review before midday, the assessment should be done

by the team at morning ward round to assess suitability for ARM

If the woman is due for review after midday, the assessment should be done by

the Gynaecology Middle Grade to assess suitability for ARM

See instructions above regarding procedures to be followed as is same following

2nd propess as with 1st.

If unsuitable for ARM, further management should be discussed with woman’s

Consultant or Consultant of the week.

Consultant should review the woman for confirming the diagnosis of ‘failed

induction’ and decision for subsequent management

3.36 Subsequent management includes:

Caesarean section

Or any other option decided by the woman’s Consultant or Consultant of the

week

3.37 Maximum Propess that can be used is 2 (Maximum Propess that can be

used with SROM is 1)

3.38 If there is a delay between the decision to perform LSCS and its

execution, the woman should be re-examined vaginally in case there have

been significant cervical changes in the interim.


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3.39 Spontaneous rupture of membranes with Propess® in situ

Commence CTG and assess contractions.

Perform vaginal examination

Propess can be left in situ if regular uterine activity is not established or os is not

dilated

Alternatively, the Propess can be removed and an oxytocin infusion is

commenced 30 minutes later.

Remove Propess® if hyperstimulated

3.40 Propess® for Spontaneous rupture of membranes


If CTG is reassuring and Bishop Score is 6 or less, insert Propess as per

instructions and review for augmentation with an oxytocin infusion after 24 hours.

If Bishop Score is 7 or greater, arrange for transfer to CDS for an oxytocin

infusion.

Document findings in the notes.

Use Modified Bishops score sticker to document the score

If the Propess insert falls out due to flow of liquor, do not reinsert Propess,

continue augmentation of labour with Prostaglandin gel, which should be inserted

30 minutes after removal of Propess

3.41 Management of Hyperstimulation - Uterine hyperstimulation can be

Uterine Tachysystole is 5 contractions/10 min for at least 20 minutes

Uterine hypersystole/hypertonicity: Single contraction lasting for > 2 min

If tachysystole or hypertonus is suspected, CTG monitoring should be

commenced immediately.


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If the CTG is normal, CTG should be continued and the Middle Grade Doctor

should be informed

If the CTG is suspicious or pathological, Propess should be removed and the

Middle Grade Doctor informed immediately.

Terbutaline 250micrograms subcutaneous should be considered, however due to

the short half-life of dinoprostone and the low dose released per hour, the

hyperstimulation should resolve spontaneously in 15 – 20 minutes.

3.42 Maternal reaction is suspected if there is

Nausea, vomiting, diarrhoea

Fever, hypotension

Vaginal irritation or oedema

Induction of Labour with Cervical Ripening Balloon (Cook Medical)

3.43 The Cervical Ripening Balloon (Cook Medical) CRB is a silicone double balloon

catheter. It is indicated in non-labouring women at term with a singleton pregnancy,

longitudinal lie, cephalic presentation, intact membranes, with an indication for

induction of labour and no contraindications (see below).

Appointment to M2 should be made for 18:00

3.44 Contraindications:

Fetal Pregnancy Maternal

Abnormal CTG Polyhydramnios Active genital herpes

Absent or

reversed End

Diastolic Flow

on Doppler

Placenta praevia

Vasa praevia

Previous hysterotomy, classical

caesarean section, cervical tear

Presenting part

above pelvic

inlet

Undiagnosed vaginal

bleeding in pregnancy

History of myomectomy where

there has been full thickness

uterine incision

Cephalo-pelvic

disproportion

Do not use if placenta was

low lying at 20 week scan

unless vasa praevia is

excluded at a 36 week scan

Pelvic structural abnormality


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Transverse lie Prelabour rupture of

membranes

Severe maternal

Hypertension

Oblique lie Any contraindication to IOL Invasive cervical cancer

Prior use of

Propess/prostaglandin Gel

Relative Contraindications

Severe FGR Multiple pregnancy Grand multi para >5

Active cardiac disease

3.45 Do not use balloon after/before Propess or Prostaglandin gel as this may

increase the risk of adverse events associated with prostaglandins including:

3.46 For women with history of previous Caesarean, CRB is the locally agreed

method of choice for induction, unless indicated otherwise by the Consultant.

3.47 Instructions for Use

Prior to use:

1) Confirm term, singleton, longitudinal lie, cephalic presentation, intact

membranes

2) CTG for 20-30 minutes

3) Maternal observations to include a MOEWS

Insertion of balloon:

1) Perform vaginal examination under aseptic conditions

2) Calculate Bishop’s score. Insert CRB if Bishops score is 6 or less.

3) Insert a Cusco’s speculum and visualise the cervical os.

Uterine hyperstimulation Amniotic fluid embolism

Impaired utero-placental circulation Pelvic pain

Tachysystole Retained placenta

Uterine rupture Severe genital bleeding

Placental abruption Fetal bradycardia


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4) Insert the catheter through the cervix until the vaginal balloon is in the cervical

canal.

5) Inflate the uterine balloon with 40ml normal saline through the red Check-Flo

valve (U)

6) Once inflated, pull back until the uterine balloon is against the internal cervical

os

7) The vaginal balloon is visible outside the external cervical os. Inflate with 10ml

normal saline through the green Check-Flo valve (V)

8) Once the balloons are situated on each side of the cervix, inflate the vaginal

balloon until a volume of 40ml is achieved. Then add 40ml to uterine balloon

so that 80ml is in this balloon and then do the same for the vaginal balloon

and thus each balloon contains 80ml.

DO NOT PUT MORE THAN 80ML IN EITHER BALLOON

9) Occasionally inflation of the vaginal balloon can cause discomfort in which

case can try removing 20ml fluid.

3.48 Alternatively:

If the cervix is very posterior or unfavourable, balloon insertion may be difficult:

1) Place the patient in lithotomy position

3-9) As above

3.49 After insertion:

1) Repeat CTG for 30 minutes after insertion

2) If reassuring, discontinue, allow woman to mobilise

3) The balloon may fall out as the cervix dilates. If not, remove after 12 hours

4) If the membranes rupture spontaneously whilst the balloon is in place, both

balloons should be deflated and the device removed

3.50 Post Cervical Ripening Balloon Monitoring - Maternal


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If there is rupture of the membranes with a balloon in situ the balloon should be

removed and there should be assessment of fetal lie and presentation as well as

auscultation of the fetal heart.

3.51 Post Cervical Ripening Balloon Monitoring - Fetal

Fetal heart should be auscultated at least every 12 hours for at least one minute.


uterine activity at anytime or if clinically indicated (SROM, APH etc)


3.52 After 12 hours:

Perform a CTG for at least 30 minutes

Remove the CRB

Perform a VE to assess suitability for ARM

If suitable for ARM, transfer to Central Delivery Suite for ARM and oxytocin

If unsuitable for ARM, further management should be discussed with Consultant

regarding Caesarean section

If there is a delay between the decision to perform LSCS and its execution,

the woman should be re-examined vaginally in case there have been

significant cervical changes in the interim.

Induction of Labour with Prostaglandin Gel


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3.53 Primigravida are given 2mg Prostaglandin E2 gel and multigravida 1 mg

Prostaglandin E2 gel if the Bishop’s score is < 6

3.54 Insertion of Prostaglandin Gel

Maternal observations to be performed before insertion to include Early

Warning Score (MOEWS)

Perform abdominal palpation to assess fetal lie, presentation and 5ths palpable

in the abdomen.

CTG for 20-30 minutes and continue for at least 30 minutes post insertion.


If CTG is reassuring and Bishop Score is 6 or less, insert Prostaglandin Gel as

per instructions

If Bishop Score is 7 or greater, arrange for transfer to CDS for ARM

Use Modified Bishops score sticker and document in the notes.

3.55 Post Prostaglandin Gel Monitoring - Maternal





If rupture of the membranes occurs there should be an assessment of lie and

presentation as well as auscultation of the fetal heart beat

Colour of liquor

3.56 Post Prostaglandin Gel Monitoring - Fetal

Fetal heart should be monitored by CTG, when the woman due for further

Prostaglandin Gel insertion, otherwise at least twice daily. 4 hourly auscultation

unless clear indication for continuous fetal monitoring


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uterine activity at anytime or if clinically indicated (SROM, APH, escalating

analgesia requirement etc)


3.57 Reassessment after initial Prostaglandin Gel

After six hours a CTG should be performed then the Bishop Score reassessed. If

it remains less than or equal to 6, a further dose of prostaglandin gel 1 mg is

administered. The CTG is continued as above.

If the Bishop Score is more than 6, the woman is to be transferred to Delivery

Suite for amniotomy and an oxytocin infusion.

If uterine activity or spontaneous rupture of membranes do not occur, no further

action is necessary until the following morning. If Bishop's Score remains less

than or equal to 6, 1 mg Prostaglandin E2 Gel should be given.

3.58 Three doses of prostaglandin gel is the maximum recommended dose. If further

doses are thought to be beneficial, this should only be prescribed after discussion

with the woman's Consultant or Consultant of the week.

Amniotomy (Induction On Central Delivery Suite)

3.59 This should not be used as a primary method of Induction of Labour and should

only be considered where there are relative contraindications to the use of all the 3

methods for induction of labour unless Bishop Score is equal to or more than 7

3.60 Women should be advised to attend M2 at the time specified at induction booking

so that they can be transferred to Delivery Suite for 0900 and be reviewed on the

Delivery Suite Obstetric Ward Round.

3.61 A 20-minute CTG is performed prior and immediately following amniotomy.

3.62 Intravenous access should be obtained and an oxytocin infusion commenced

straight after ARM, to obtain 4-5 contractions per ten minutes (see oxytocin

guideline).

Method Of Induction In High Risk Women Include:


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High Risk Factor Prostaglandin

Gel Propess

Cervical Ripening

Balloon

Severe FGR Yes No Yes

Previous Caesarean

Section Yes Relative CI Yes

Severe Pre-eclampsia Yes Yes Yes

Grand Multiparity > to 5 Yes No Relative CI

Polyhydramnios Yes Yes No

Pre-gestational or

Gestational Diabetes Yes Yes Yes

Multiple Pregnancy Relative CI Relative CI Relative CI

3.63 Women with either Pre-gestational Diabetes or Gestational Diabetes without any

evidence of fetal compromise should be considered low risk with respect to site for

IOL. These women can safely be induced on M2.

3.64 This list is not exhaustive

Individual Management Plan When Induction Of Labour Fails

3.65 If induction fails to start labour, the healthcare professionals should discuss this with

the woman and provide support. The woman’s condition and the pregnancy in

general should be fully reassessed. Electronic monitoring should be used to assess

fetal wellbeing. Discussions between the woman & her medical team should

determine the ongoing management

3.66 The individual management plan options include

1) A further attempt to induce labour

2) Waiting if there are no pressing maternal or fetal needs for delivery

3) Elective Caesarean Section

4) If in doubt, discuss with the woman’s Consultant or Consultant of the week

Individual Management Plan For Women Who Decline IOL

3.67 In some cases, women will decline IOL when recommended by the Medical team. In

these cases,

3.68 - the reason for the patient’s refusal should be clearly documented in the notes.

3.69 Arrangements should be made to increase fetal and maternal surveillance. This

should at least include an ultrasound scan, (frequency of scan at Consultant’s


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discretion) with a documented maximal pool depth, and CTG performed daily from

T+14 onwards.

3.70 A further offer of induction should be made if there is deterioration in the maternal or

fetal condition.

Linked guidelines

Oxytocin Use for Induction and Augmentation of Labour.

Prelabour Rupture of Membranes.

Guideline For The Management of Pregnant Women With Pre-existing &

Gestational Diabetes.

Induction Of Labour In Late Intra Uterine Fetal Death (IUFD).

Patient Observation Policy.

4. Duties and Responsibilities

4.1. All staff involved in the antenatal and intrapartum care of pregnant women at Royal

Bolton Hospital and within the community teams are required to familiarise with this

guideline to promote best practice when pregnancy is proceeding post-dates and

also where induction is considered for other indications.

5. Monitoring Compliance

5.1. Adherence to this policy will be audited at least once in every three year period. The

results of the audit will be considered by the Women’s Quality Forum. If deficiencies


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in care are identified the Women’s Quality Forum will agree an action plan to improve

care and be responsible for monitoring the implementation of the action plan.

5.2. These guidelines assume that all aspects of the woman's care will be discussed with

her and that she will be helped to make appropriate choices concerning her care. An

accurate contemporaneous record of all information given of progress made and

individual plans will be kept.

6. References

NICE Clinical Guideline 70 Induction of Labour - July 2008

NICE Guidance Induction of Labour Quality Standard 60, April 2014

NICE Clinical Guideline 62 Antenatal Care - March 2008

Kelly AJ, Kavanagh J, Thomas J. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003101. DOI: 10.1002/14651858.CD003101 Lyrenas Sven et al., In vivo controlled release of PGE2 from a vaginal insert (0.8mm, 10mg) during induction of labour, BJOG, February 2001,Vol. 108, pp169-178. El-Shawarby SA and Connell RJ Induction of labour at term with vaginal prostaglandins preparations: a randomised controlled trial of Prostin vs Propess. Journal of Obstetrics and Gynaecology 2006; 26 :( 7)627–30 Ferring Pharmaceuticals; https://www.medicines.org.uk/emc/medicine/16898/SPC/Propess+10mg+vaginal+delivery+system

Appendices

Appendix 1: Modified Bishop’s score


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Parameter\Score 0 1 2 3

Dilation (cm) < 1 1- 2 2 - 4 > 4

Length of Cervix (cm) > 4 2 – 4 1 – 2 < 1

Fetal station -3 -2 -1 / 0 +1 / +2

Consistency Firm Average Soft

Position Posterior Mid / Anterior

Total Score


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Appendix 2: RAG (red / amber / green) rating of priority of inductions

This list is not exhaustive and risk rating may change

Red

Immediate Induction Required

Amber

Induction within 24 hours of request

Green

May occur more than 24 hours after request

Uncontrolled hypertension Fetal growth restriction Post-dates (<T+14)

Fulminant Pre-eclampsia Non-fulminant Pre-eclampsia Pelvic Girdle Pain

SROM >24 hours Growth crossing the centiles Maternal Request

Obstetric Cholestasis

Poor Obstetric History

Previous Caesarean section

Polyhydramnios

Maternal Diabetes or gestational diabetes

IVF

Post Dates T+14

Previous precipitate labour

When multiple patients are awaiting transfer to CDS for augmentation the Shift Leader in consultation with the Obstetric Middle Grade or Consultant to decide priority for transfer to CDS.


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Appendix 3 – Patient information for women having out-patient induction of labour

Outpatient induction of labour- Information for women having an outpatient induction Who is offered outpatient induction of labour? We offer outpatient induction of labour to women with an uncomplicated pregnancy, who have not gone in to spontaneous labour by 40 weeks + 12 days, and for other low risk women who are undergoing induction. The process of inducing labour can take a long time, so enabling you to go home ensures that you are able to remain in the most familiar and relaxing environment possible. Outpatient induction of labour is safe for women who have uncomplicated pregnancies. Criteria for outpatient induction of labour:

Another adult will need to stay with you once you leave the hospital in case you

need to return quickly

You will need to live within a 30 minute drive to the hospital and have 24 hour

access to a telephone

Plan how you will travel to and from the hospital.

Before your induction of labour appointment: At your 40 /41 week antenatal appointment, the Midwife will discuss induction of labour. You will be offered a membrane sweep at this appointment, which is an internal examination allowing the Midwife to assess your cervix. If possible, the Midwife will insert a fingertip into the cervix and try to sweep around the membrane containing the water that the baby grows inside of. This can sometimes be a little uncomfortable, but membrane sweeping makes spontaneous labour more likely and may reduce the likelihood of you needing to have your labour induced. At the induction of labour appointment: When you arrive at the hospital, the Midwife will assess you are suitable for outpatient induction of labour.

Asking you about the pattern of your baby’s movements

Discussing what will happen , what to expect when your labour is induced and

when to return to the hospital

Feeling your abdomen to assess baby’s position and measuring your abdomen to

assess baby’s growth

Performing a 30 minutes monitoring of your baby’s heart beat to confirm well being

When the Midwife has completed the above assessment, she/ he will perform an internal examination, during which a Propess pessary is inserted. A Propess pessary contains artificial hormones which are designed to prepare your cervix for labour. The pessary has a small string, similar to a tampon, which allows for the pessary to be removed easily, should the need arise. Once the Propess pessary is in place, the Midwife will advise you to walk around the maternity department for a further 30 minutes. If you have any concerns during that time, please return to M2 immediately. At the end of 30 minutes return to M2 ward and if there have been no concerns that have been raised after 30 minutes, it is safe for you to leave the hospital.


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The Midwife will have arranged for you to be reassessed on M2 the following morning to monitor your baby’s well-being . What to expect after the Propess pessary has been administered: After the Propess pessary has been administered, it is common to experience some abdominal cramping or back pain, mucus discharge contractions and or nausea. Whilst you are outside of the hospital, you should continue to eat, drink, mobilise and rest as usual It is important to remember the pessary is in place and be careful not to accidently pull the Propess string; this may cause it to come out of place. If the Propess pessary falls out, please do not re-insert it. Please place the pessary into a sealed plastic bag and phone the hospital on 01204 390612 to arrange re insertion of the pessary. If you start to experience contractions at any point during the 24 hours after the Propess pessary was inserted please call Maternity Triage immediately where the Midwife will be happy to offer you advice and reassurance. Coping with the early stages of labour: Please call the maternity Triage telephone: 01204 390612 at any time for advice. You may find the following helpful in early labour:

Taking Paracetamol 500mg - 1gram, 4 – 6 hours apart Do not exceed more than 4

grams in 24hrs

Mobilising and using different positions

Breathing techniques and visualisation

Warm bath or warm compress over your lower back and or abdomen

TENS machine

What happens next? If you have contractions, call Maternity Triage on 01204 390612, the Midwife will arrange to assess you and your baby’s well being. If you are found to be in established labour and no risks have been identified the Midwife will arrange for you to go to the Birth Suite, or the Delivery Suite to birth your baby. If you do not have regular contractions and the Propess pessary has been in place for 24 hours we will arrange to review and assess you and your baby’s wellbeing on M2 ward the following day to continue the Induction process. If we find your cervix is favourable to have your waters broken you will be transferred to Delivery Suite when a bed becomes available which may not be that day. If we are unable to break your waters you will be given a 2nd Propess pessary and remain on M2 until you are in labour or the following morning when you will be reassessed and transferred to delivery suite to have your waters broken when a bed becomes available. In the rare event your cervix is unfavourable the Obstetrician will discuss your options with you and plan care on an individual basis Please note in exceptional busy times your transfer to the Delivery Suite may take up to 24 hours to continue the induction pathway. If contracting regularly no further intervention is required however if no or few contractions present once your waters have been broken a hormone infusion will be commenced to initiate contractions to help you birth your baby. When to contact us: If you are experiencing any of the following, please call maternity Triage immediately at Royal Bolton Hospital on 01204 390612

Regular contractions

You think you are in labour


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Any Bleeding

Change in the pattern of your baby’s movements

Your waters break

You have any concerns


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Documents

Induction of Labour Propess, Cervical Ripening Balloon, … · 2019-10-11 · Presentation other than cephalic Macrosomia and previous precipitate labour (Induction has not been shown