Queensland Clinical Guidelines Induction of Labour

8/12/2019 Queensland Clinical Guidelines Induction of Labour

1/26

Induction of labour


2/26

Queensland Maternity and Neonatal Clinical Guideline: Induction of labour

Refer to online version, destroy printed copies after use Page 2 of 26

Document title: Induction of labour

Publication date: September 2011

Document number: MN11.22-V3-R16

Documentsupplement:

The document supplement is integral to and should be read in conjunctionwith this guideline

Amendments Full version history is supplied in the document supplement

Amendment date January 2014

Replaces document: MN11.22-V2-R16

Author: Queensland Maternity and Neonatal Clinical Guidelines Program

Audience: Health professionals in Queensland public and private maternity services

Review date: September 2016

Endorsed by:

Queensland Maternity and Neonatal Clinical Guidelines Program

Statewide Maternity and Neonatal Clinical Network

Queensland Health Patient Safety and Quality Executive Committee

Contact:Email:[email protected]

URL:http://www.health.qld.gov.au/qcg

Disclaimer

These guidelines have been prepared to promote and facilitate standardisation and consistency ofpractice, using a multidisciplinary approach.

Information in this guideline is current at time of publication.

Queensland Health does not accept liability to any person for loss or damage incurred as a result ofreliance upon the material contained in this guideline.

Clinical material offered in this guideline does not replace or remove clinical judgement or theprofessional care and duty necessary for each specific patient case.

Clinical care carried out in accordance with this guideline should be provided within the context oflocally available resources and expertise.

This Guideline does not address all elements of standard practice and assumes that individualclinicians are responsible to:

Discuss care with consumers in an environment that is culturally appropriate and whichenables respectful confidential discussion. This includes the use of interpreter serviceswhere necessary

Advise consumers of their choice and ensure informed consent is obtained

Provide care within scope of practice, meet all legislative requirements and maintainstandards of professional conduct

Apply standard precautions and additional precautions as necessary, when delivering care

Document all care in accordance with mandatory and local requirements

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 2.5 Australia licence. To view a copy of thislicence, visit http://creativecommons.org/licenses/by-nc-nd/2.5/au/

State of Queensland (Queensland Health) 2010

In essence you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the authorsand abide by the licence terms. You may not alter or adapt the work in any way.

For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001,[email protected], phone (07) 3234 1479. For further information contact Queensland Maternity and Neonatal ClinicalGuidelines Program, RBWH Post Office, Herston Qld 4029, [email protected] phone (07) 3131 6777.
mailto:[email protected]:[email protected]:[email protected]://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcgmailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://creativecommons.org/licenses/by-nc-nd/2.5/au/http://www.health.qld.gov.au/qcgmailto:[email protected]


3/26



Flowchart: Summary of recommendations for Induction of labour

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

FGR

IUFD

Maternal request

Other maternal conditions

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

Cervix

Favourable:

o Bishop score > 6

Unfavourable:

o Bishop score 6

Declined indu ction

Offer increased antenatal

monitoring x 2/week:

o CTGo Ultrasound scan:

Amniotic fluid index

Umbilical arterial Doppler

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

Continuous CTG minimum

30 minutes Recumbent left lateral for 30

minutes post insertion

Temperature, BP, pulse,

monitor uterine activity and

PV loss hourly for 4 hours

VE reassess:

o Gel - after 6 hours

o Controlled release - after

12 hours

Prosta-

glandin

Queensland Maternity and Neonatal Clinical Guideline: MN11.22-V3-R16: Induction of labour

Indications

Favourable cervix

o If cervix unfavourable

consider Dinoprostone(PGE2)

Cautions

Not within 6 hours of

Dinoprostone gel

Not within 30 minutes of

removal of Dinoprostone

pessary(Cervidil)

Previous uterine surgery

High parity (>4)

One to one midwifery care

ARM prior to Oxytocin

Continuous CTG

Assess uterine contractions

for 10 minutes every 30

minutes

Temperature - 2 hourly

BP, Pulse, PV loss - hourly

Maintain fluid balance

Assess progress of labour

according to local guideline

Oxytocin

Indications

Unfavourable cervix

Contraindications

Hypersensitivity to

Prostaglandin

Grandmultiparity gel

High parity (>3) pessary

Previous uterine surgery

High presenting part

Malpresentation

Indications

Unfavourable cervix

Contraindication

Low lying placenta

Cautions

Antepartum bleeding

Rupture of membranes

Cervicitis

Monitor FHR appropriate to

clinical circumstances

If not spontaneously expelled

within 12 hours then obstetric

review

Trans-

cervical

Catheter

Indications

Favourable cervix

Cautions

Avoid with high head

Monitor FHR immediately

post procedure

Document liquor colour/

consistency

Mobilise

ARM

Indications

Offer at 39 - 40 weeks

Contraindications

Low lying placenta Elective caesarean section

is planned

Monitor FHR appropriate to

clinical circumstances

Advise may cause

discomfort, bleeding and

irregular contractions

Membrane

Sweep


4/26



Abbreviations

ARM Artificial rupture of membranes; amniotomy

CS Caesarean section

CTG Cardiotocography

FGR Fetal growth restriction

FHR Fetal heart rate

GBS Group B streptococcus

GDM Gestational Diabetes Mellitus

IOL Induction of labour

IUFD Intrauterine fetal death

NICU Neonatal intensive care unit

PGE2 Dinoprostone, Prostaglandin E2

PPROM Preterm prelabour rupture of membranes

PROM Prelabour rupture of membranes

PV Per vaginam

RCT Randomised controlled trial

VBAC Vaginal birth after caesareanVE Vaginal examination

Definition of Terms

Amniotomy Artificial rupture of membranes to initiate or speed up labour.1

Cervical ripening

A prelude to the onset of labour whereby the cervix becomes soft andcompliant. This allows its shape to change from being long andclosed, to being thinned out (effaced) and starting to open (dilate). Iteither occurs naturally or as a result of physical or pharmacologicalinterventions.

1

Dinoprostone Prostaglandin gel or pessary.

Expedited IOL PROMInduction of labour (IOL) commencing between 2 and 12 hours afterprelabour rupture of membranes (PROM).

1

Expectant ManagementNon-intervention at any particular point in the pregnancy, allowingprogress to a future gestational age. Intervention occurs only whenclinically indicated.

2

Favourable cervixThe cervix is said to be favourable when its characteristics suggestthere is a high chance of spontaneous onset of labour, or ofresponding to interventions made to induce labour.

1

Fetal growth restriction(FGR)

Also known as intrauterine growth restriction (IUGR). Fetal growthrestriction (FGR) indicates the presence of a pathophysiologicalprocess occurring in utero that inhibits fetal growth.

3

Induction of labour The process of artificial initiation of labour before its spontaneousonset.

4

Mechanical method Non-pharmacological method of inducing labour.1

Uterine hypercontractilityMore than 5 contractions in 10 minutes for two consecutive 10 minuteintervals or a contraction lasting more than 2 minutes.

1

Obstetrician

Local facilities may differentiate the roles and responsibilitiesassigned in this document to an Obstetrician according to theirspecific practitioner group requirements; for example to GeneralPractitioner Obstetricians, Specialist Obstetricians, Consultants,Senior Registrars, Obstetric Fellows or other members of the team asrequired.

Prolonged pregnancy A pregnancy past 42+0

weeks gestation.1


5/26



Table of Contents

1 Introduction ................................................................................................................................................... 61.1 Communication and information ............................................................ .............................................. 6 1.2 Indications ........................................................................................................................................... 61.3 Contraindications ............................................................. .................................................................. .. 61.4 Care if induction of labour declined ..................................................................................................... 61.5

Care if induction of labour postponed .................................................................................................. 7

1.6 Clinical standards ................................................................................................................................ 71.7 Membrane sweeping ........................................................................................................................... 7

2 Specific circumstances ................................................................................................................................. 82.1 Prolonged Pregnancy .......................................................................................................................... 82.2 Preterm prelabour rupture of membranes ........................................................................................... 82.3 Term prelabour rupture of membranes ........................................................... ..................................... 92.4 Previous caesarean section ...............................................................................................................102.5 Obstetric cholestasis ..........................................................................................................................102.6 Diabetes .............................................................................................................................................112.7 Hypertensive disorders of pregnancy .................................................................................................112.8 Twin pregnancy ..................................................................................................................................112.9

Suspected fetal macrosomia (>4000grams) ............................................................ ...........................12

2.10 Fetal growth restriction .......................................................................................................................122.11 Intrauterine fetal death........................................................................................................................132.12 Maternal request ................................................................................................................................132.13 Other maternal conditions ..................................................................................................................13

3 Pre induction of labour assessment .............................................................................................................143.1 Cervical assessment ..........................................................................................................................14

4 Methods of induction of labour ............................................................ .........................................................144.1 Dinoprostone ......................................................................................................................................15

4.1.1 Dinoprostone dose and administration ................................................................. ..........................164.2 Oxytocin infusion ................................................................................................................................17

4.2.1 Oxytocin administration ................................................................. .................................................184.2.2

Oxytocin regimens .........................................................................................................................18

4.3 Artificial rupture of membranes .......................................................... .................................................194.4 Transcervical catheters ......................................................................................................................20

5 Risks associated with induction of labour.....................................................................................................21References ..........................................................................................................................................................22

Acknowledgements ......................................................... .................................................................. ...................26List of Tables

Table 1. Membrane sweeping considerations ......................................................... ............................................... 7Table 2. Prolonged pregnancy .......................................................... .................................................................. ... 8Table 3. Preterm prelabour rupture of membranes ............................................................ .................................... 8Table 4. Term prelabour rupture of membranes ................................................................ .................................... 9Table 5. Previous caesarean section ............................................................ ....................................................... 10Table 6. Obstetric cholestasis ............................................................ .................................................................. 10Table 7. Gestational diabetes/diabetes mell itus .................................................................. ................................. 11Table 8. Hypertensive disorders of pregnancy ......................................................... ............................................ 11Table 9. Twin pregnancy ......................................................... .................................................................. ........... 11Table 10. Suspected fetal macrosomia ......................................................... ....................................................... 12Table 11. Fetal growth restriction .................................................................. ....................................................... 12Table 12. Intrauterine fetal death .................................................................. ....................................................... 13Table 13. Maternal request ...................................................................................... ............................................ 13Table 15. Modified Bishop score ........................................................ .................................................................. 14Table 16. Dinoprostone considerations ......................................................... ....................................................... 15Table 17. Dinoprostone administration ................................................................................................................ 16Table 18. Oxytocin considerations ................................................................ ....................................................... 17Table 19. Oxytocin administration ................................................................. ....................................................... 18Table 20. Oxytocin regimen ............................................................... .................................................................. 18Table 21. Artificial rupture of membranes considerations ......................................................................... ........... 19Table 22. Transcervical catheter considerations .................................................................. ................................ 20Table 23. Risk factors associated with IOL ..................................................................................... ..................... 21


6/26



1 IntroductionInduction of labour (IOL) is a relatively common procedure. In 2009 the IOL rate in Queensland was22.4%.

5The 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 IOLare included in this guideline.

1.1 Communication and information

Discuss the risks and benefits of IOL as they pertain to each individual woman to enable the womanto make an informed decision in consultation with her health care provider.

In Queensland, only 27.1% of women who had an IOL reported having made an informed decision6:

Provide women with information on the1,4

:

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

Consider the use of decision aids to assist the woman make informed choices7

1.2 Indications

IOL is indicated when the maternal and/or fetal risks of ongoing pregnancy outweigh the risks of IOLand 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 Care if induction of labour declined

Women who decline IOL should have their decision respected. Usually, these are women who havebeen offered IOL for prolonged pregnancy.

At 41 weeks or later gestation, it has been shown for those women who8:

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 associatedwith postterm pregnancy. However, it is recommended from 42 weeks, to offer increased antenatal

monitoring9consisting of twice weekly:

Cardiotocography (CTG)10

Ultrasound assessment of amniotic fluid volume using:

o Estimation of maximum amniotic pool depth10,11

,or

o Amniotic fluid index12,13

Umbilical arterial Doppler ultrasound12


7/26



1.5 Care if induction of labour postponed

Take into account the womans individual clinical circumstances and preferences, the indication forIOL and the local service capabilities and priorities when determining if a booked IOL can bepostponed (e.g. due to resourcing issues or as a result of maternal request). When a bookedinduction of labour is postponed:

Perform an assessment of maternal and fetal wellbeing

Involving the woman, develop a plan for continued care including, arrangements forongoing 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 ofher baby

1.6 Clinical standards

When offering IOL:

Consider the service capabilities of the facility

Ensure availability of health care professionals appropriate to the circumstances

Continuous electronic fetal heart monitoring and uterine contraction monitoring should be

available1

1.7 Membrane sweeping

Membrane sweeping refers to the digital separation of the fetal membranes from the lower uterinesegment during vaginal examination. This movement helps to separate the cervix from themembranes and helps to stimulate the release of prostaglandins.Table 1 outlines considerations formembrane sweeping.

Table 1. Membrane sweeping considerations

Membrane sweeping

Indication

Is not a method of IOL

Is used to reduce the need for formal IOL by encouraging spontaneouslabour

Risk/Benefit

From 38-40 weeks onwards, significantly reduced pregnancies beyond 41weeks

14

Repeated membrane sweeping has been found to decrease the proportionof postterm pregnancies

15

Reduced need for formal IOL16

,particularly in multiparous women15

Limited data on risk in Group B streptococcus (GBS) carriers17

No evidence of increased risk of maternal or neonatal infection14

Associated with discomfort14,15

,vaginal bleeding and irregularcontractions

14

Most women would choose membrane sweeping again15

Optimal frequency unknown. Practice varies from weekly to several times aweek

1,14

Recommendations

Consider offering membrane sweep at 39-40 weeks, especially to low riskmultiparous women

18

Advise of the benefits of repeated membrane sweeping

If the cervix is closed and membrane sweeping is not possible, cervicalmassage in vaginal fornices may achieve similar effect

1


8/26



2 Specific circumstancesConsiderations for specific IOL indications are outlined in the following sections.

2.1 Prolonged Pregnancy

Table 2. Prolonged pregnancy

Prolonged pregnancy

Risk/Benefit

The risk of fetal death increases significantly with gestational age19

:

o At 38 weeks gestation 0.25%o At 42 weeks gestation 1.55%

IOL at 41 weeks or beyond compared with awaiting spontaneous labourfor at least one week is associated with

13:

o Fewer perinatal deaths 1/3285 (0.03%) versus 11/3238 (0.34%)o No significant difference in the risk of caesarean section for women

induced at 41 and 42 weekso Lower risk of meconium aspiration syndrome at 42 weeks (3.0%

versus 4.7%), and significantly lower risk at 41 weeks (0.9% versus

3.3%) Most women prefer IOL at 41 weeks over serial antenatal monitoring

19

Recommendations

For women with uncomplicated pregnancies, recommend IOL between 41and 42 weeks

1,20

Waiting after 42 weeks is not recommended1,20,21

Exact timing depends on the womens preferences and localcircumstances

2.2 Preterm prelabour rupture of membranes

Table 3. Preterm prelabour rupture of membranes

Preterm prelabour rupture of membranes

Risk/Benefit

Gestation between 34+036

+6

IOL versus expectant management:

o Reduces chorioamnionitis22,23

o Reduces maternal length of stay

22

o Insufficiently sized studies to determine difference in: Neonatal sepsis

22,23

Respiratory distress23

Newborn intensive care resource use

23

Decreased neonatal intensive care unit (NICU) length of stay andhyperbilirubinaemia is demonstrated if delivery occurs after, rather than

before, 34 weeks

24

Gestation less than 34 weeks

Birth before 34 weeks is associated with increased neonatal mortality25

,adverse neonatal outcomes

25including respiratory distress syndrome

24,

intraventricular haemorrhage24

,necrotising enterocolitis24

and other longterm complications

25

Mortality and morbidity increase with decreasing gestational age25

Recommendations

Gestation between 34+036

+6

Decision should be based on discussion with the woman and her partnerand 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

indications1


9/26



2.3 Term prelabour rupture of membranes

Table 4. Term prelabour rupture of membranes

Term prelabour rupture o f membranes (PROM)

Risk/Benefit

Spontaneous labour commences26

o Within 24 hours in 70% of womeno Within 48 hours in 85% of womeno This may decrease the need for continuous fetal heart rate (FHR)

monitoring

IOL is perceived as being more painful. These women may have a greaterneed for epidural analgesia

27

A policy of expedited IOL compared to expectant managementdecreases

28:

o Admissions to the NICU from 17% to 12.6%o Chorioamnionitis from 9.9% to 6.8%o Postpartum endometritis from 8.3% to 2.3%o No differences in caesarean section (CS) rate

Waiting greater than 96 hours is associated with higher risk of neonatal

sepsis29

Women with planned management are more likely to view their care more

positively than expectantly managed women29

When associated with GBS:

o Compared to expectant management and IOL with Dinoprostone,IOL with Oxytocin is associated with lower rate of neonatal infection

2.5% versus greater than 8%30

Recommendations

To confirm PROM, offer sterile speculum vaginal examination (VE)

Discuss expectant management (provided a digital VE has not beenperformed) and expedited management

Recommend expedited IOL

If the woman wishes to await spontaneous labour:

o Digital VE should not be performed If a digital VE has been performed, the use of prophylactic

antibiotics while awaiting the onset of spontaneous labour isrecommended

o Waiting greater than 96 hours is not recommended

In the woman known to be GBS positive advise expedited IOL withOxytocin

30

Refer to Guideline: Early onset Group B streptococcal disease31


10/26



2.4 Previous caesarean section

Table 5. Previous caesarean section

Previous caesarean section

Risk/Benefit

Dinoprostone (Prostin, Prostaglandin E2) gel and pessary are widely used

in the UK, with good effect1 Data on risk of uterine rupture are mainly based on retrospective studies

32

The risk of uterine rupture with33

:

o Spontaneous labour is 4/1000o Augmentation with Oxytocin is 9/1000o Induction with Oxytocin is 11/1000o Induction with Prostaglandin with/without Oxytocin is 14/1000o Induction with mechanical methods with/without Oxytocin 9/1000

In a large study, neither induction nor augmentation of labour wasassociated with uterine rupture, compared to women who labourspontaneously. However risk of uterine rupture increased when bothOxytocin and Prostaglandin were used for labour induction

34

Recommendations

Taking into account individual circumstances, discuss IOL, CS andexpectant management

1

Inform women of the increased risk of CS and uterine rupturein IOL

1,35

Discuss decisions about care with the responsible obstetrician36

Refer to guideline: Vaginal birth after caesarean section (VBAC)37

2.5 Obstetric cholestasis

Table 6. Obstetric cholestasis

Obstetric cholestasis

Risk/Benefit

There is no quality evidence to recommend best management38

Is associated with increased risk of39:o Intrauterine fetal death (IUFD) 2%o Preterm birth 44%o Meconium staining of liquor 25-45%

90% of fetal deaths occur after 37 weeks39

A correlation has been shown between serum bile acid levels and fetalcomplication rates

39,40:

o Bile acids of less than 40 micromol/L were associated with noincrease in fetal risk

o Ursodeoxycholic acid has been shown to reduce serum bile acidlevels. It is uncertain if this translates to reduced perinatal risk

41,42

o Poor fetal outcome is associated with43

:

Deteriorating biochemical tests Unresponsiveness to Ursodeoxycholic acid

CTG and Doppler surveillance have no role in the prediction of perinatalrisk

40

IOL at 37 weeks or at time of diagnosis, before or after 37 weeks, had adecreased risk of IUFD:

o 0/218 (0%) compared to 14/888 (1.6%) for historical controls in theliterature

44

Recommendations

Decision to deliver should be made on an individual basis

Based on weak evidence, IOL may be recommended at 37 weeks

Consider IOL at 35-37 weeks for severe cases with jaundice39

,progressive elevations in serum bile acids

39and liver enzymes, and

suspected fetal compromise

39


11/26



2.6 Diabetes

Table 7. Gestational diabetes/diabetes mellitus

Gestational diabetes (GDM)/diabetes mellitus

Risk/Benefit

27% of non-malformed stillbirths in women with pre-existing diabetesoccur after 37 completed weeks

45

In women with GDM on insulin, comparing IOL in the 38thweek withexpectant management

,showed

46:

o Reduced macrosomia in the IOL group, 10% versus 23%o No difference in caesarean section rateso A non-significant increase in shoulder dystocia in the expectant

group

Diet controlled, mild GDM is associated with good pregnancy outcome47

o No data on risk of perinatal mortality after 40 weeks

Recommendations

Until quality evidence becomes available, offer delivery at 38 weeks towomen with diabetes requiring insulin

46

Advise women with well-controlled, diet controlled GDM, and no fetalmacrosomia or other complications, to await spontaneous labour unless

there are other indications for IOL

2.7 Hypertensive disorders of pregnancy

Table 8. Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy

Risk/Benefit

The only cure for pre eclampsia is birth1,14,48

In non-severe hypertension, compared to IOL, expectant managementshowed increased poor maternal outcome, using a composite measure:

o 44% compared to 31% in IOL groupo No differences in composite neonatal outcome

Recommendations

Consider individual circumstances when determining timing of birth Consider delivery where hypertension initially diagnosed after 37 weeks

Consider vaginal birth unless a caesarean section is required for otherobstetric indications

4,49

Refer to Guideline: Hypertensive disorders of pregnancy50

2.8 Twin pregnancy

Table 9. Twin pregnancy

Twin pregnancy

Risk/Benefit

Optimal timing for uncomplicated twin pregnancy is uncertain51

Retrospective studies demonstrate:o Perinatal mortality rate is lowest for birth at 37 weeks gestation

52

o An increase in stillbirth, particularly from 38 weeks53

o An underpowered randomised controlled trial (RCT) comparing

expectant management with IOL at 37 weeks showed no statisticaldifference in CS, CS for fetal distress or perinatal death

54

In uncomplicated twin pregnancy there is insufficient data to support thepractice of planned birth from 37 weeks

51

The main determinant of risk in a multiple pregnancy is chorionicity andthis may influence decisions regarding the timing of delivery in individualcases

Recommendations

Taking into account individual circumstances, plan birth soon after 38+0

weeks

53

Refer for specialist consultation when risk factors, such as twin-to-twin

transfusion syndrome, indicate the need


12/26



2.9 Suspected fetal macrosomia (>4000grams)

Table 10. Suspected fetal macrosomia

Suspected fetal macrosomia

Risk/Benefit

Accuracy of estimating fetal weight varies55

:

o From 15-79% using ultrasoundo From 40-52% using clinical judgement

Comparing IOL and expectant management there are no significantdifferences in

56:

o CS rateo Instrumental birtho Perinatal morbidity although 6/189 cases of brachial plexus injury

or fractured clavicle were found in the expectant group and 0/183 inthe IOL group, the difference was not statistically different

Recommendations

In the absence of other indications, IOL should not be recommendedsimply on suspicion that a baby is macrosomic

1,21,56

However, it is important to discuss and consider maternal concerns

2.10 Fetal growth restriction

Table 11. Fetal growth restriction

Fetal growth restriction

Risk/Benefit

There are no clear guidelines supported by strong evidence on timing ofdelivery when fetal growth restriction (FGR) has been diagnosed

57

Use of umbilical artery and ductus venosus Doppler has been shown toassist in improving perinatal outcome

57

Preterm FGR

The GRIT study comparing expectant versus immediate birth (IOL andCS) between 24-36 weeks showed:

o Expectant group58

Prolonged pregnancy by 4 days Decreased CS rate (79% versus 91%) Increased stillbirth rate (3.1% versus 0.7%) Decreased post birth death rate, prior to discharge (6.2%

versus 9.1%)o At two years

59:

Similar rates of mortality More severe disability noted in immediate birth group if less

than 31 weeks at birthTerm FGR

Small pilot RCT, with a total of only 33 cases, comparing expectantversus immediate birth at term, showed no significant difference in

60:

o Obstetric interventions, for example CSo Neonatal morbidity

Recommendations

In term and preterm pregnancies with FGR there is little evidence to guidetiming of birth

1

Timing of birth will depend on gestational age, severity of FGR and resultsof tests of fetal well being

Recommend expedited birth for a woman with FGR diagnosed at term61

Severity affects the decision of the most appropriate mode of birth58


13/26



2.11 Intrauterine fetal death

Table 12. Intrauterine fetal death

Intrauterine fetal death

Risk/Benefit

There is no evidence addressing immediate versus delayed IOL1

Many women go into spontaneous labour within 2-3 weeks of IUFD

Risk of coagulopathy is usually only of concern after 4 weeks62

Recommendations

Support the woman's preferences regarding timing of IOL:

o Delaying IOL for a few days should be supported, if desired,provided:

Membranes are intact No evidence of infection

1

2.12 Maternal request

Table 13. Maternal request

Maternal request

Risk/Benefit There are no studies that address this group specifically

1

In uncomplicated pregnancies consider the risk of neonatal respiratorydistress syndrome and related adverse effects

13

Recommendations Consider IOL based on exceptionalcircumstances of the woman and her

family

2.13 Other maternal conditions

Table 14. Other maternal conditions

Anti coagulant therapy and maternal card iac cond it ion

Risk/Benefit

For a woman on anticoagulant therapy, IOL is timed around themedication protocol63

For maternal cardiac conditions, the objective of care is to minimise theadditional load on the cardiovascular system, ideally through spontaneousonset of labour

63

Recommendations

A multidisciplinary team, consisting of an obstetrician, cardiologist orphysician as appropriate, anaesthetist, and midwife is essential

Involve an intensivist and neonatologist as required63

Develop a plan for peripartum management of anticoagulant therapy(prophylactic or therapeutic)

64

If receiving anticoagulant therapy, wean and cease prior to IOL

For a woman with a maternal cardiac condition, plan for an IOL when

required

63

:o Anticoagulant therapy protocolo Availability of medical staffo Deteriorating maternal cardiac function

Refer to Guideline: Venous thromboembolism (VTE) prophylaxis inpregnancy and the puerperium

64


14/26



3 Pre induction of labour assessmentPrior to IOL an assessment of the woman should include:

Review of maternal history

Confirmation of gestation

o Reliable menstrual dates supported by early ultrasound examination

o Ultrasound scan may be more reliable even in women who are sure of last menstrualperiod

12

Abdominal palpation to confirm presentation and engagement

Assessment of membrane status (ruptured or intact)4

Vaginal examination to assess the cervix

o Refer to Section 3.1

Assessment of fetal wellbeing

o A normal fetal heart rate pattern should be confirmed using electronic fetalmonitoring

1

o Consult an obstetrician if cardiotocograph (CTG) is abnormal

Assessment of contraindications

Consideration of urgency of IOL

3.1 Cervical assessment

The Bishop score is commonly used to assess the cervix. Each feature of the cervix is scored andthen the scores are summed.Table 15 provides an example of a modified Bishop score

65.

The state of the cervix is one of the important predictors of successful IOL4

The cervix is unfavourable if the score is 6 or less4

Table 15. Modified Bishop score

Cervical featureScore

0 1 2 3

Dilation (cm) < 1 1-2 3-4 > 4

Length of cervix (cm) > 3 2 1 < 1

Station (relative to ischial spines) -3 -2 -1 / 0 +1 / +2

Consistency Firm Medium Soft

Position Posterior Mid Anterior

4 Methods of induction of labour

Methods used for IOL include: Medical methods

o Dinoprostone preparations (Prostaglandin E2, PGE2, PG gel, Prostin E2, Cervidil)

o Oxytocin infusion

Surgical methods

o Artificial rupture of membranes (ARM)

Mechanical methods

o Transcervical catheter (Foley or Atad)


15/26



4.1 Dinoprostone

Dinoprostone (vaginal Prostaglandin E2) promotes cervical ripening and stimulates uterinecontractions. [refer toTable 16 andTable 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 Unfavourable cervix

Contraindications

Known hypersensitivity to Dinoprostone or other constituents66,67

Ruptured membranes pessary contraindicated67,68

Multiple pregnancies68

High parity

o Gel - parity greater than 466

ando Pessary - parity greater than 3

67

Previous CS or any uterine surgery66,67,68

Malpresentation / high presenting part66

Unexplained vaginal discharge and / or uterine bleeding during current

pregnancy66,67,68

Cautions

Use caution in women with asthma due to potential bronchoconstriction68

Ruptured membranes use gel with caution68

Oxytocin administration66,67,68

Epilepsy68

Cardiovascular disease68

Raised intraocular pressure, glaucoma68

Risk/Benefit

Nausea, vomiting and diarrhoea may occur soon after insertion68

Increased risk of hyperstimulation with or without FHR abnormality in

approximately 4% of women

69

Incidence of CS is not increased

69

The risk of hyperstimulation is higher with the pessary than with the gel(4.5% versus 2.4%)

70

Risk of hyperstimulation is higher if Oxytocin is also used71

Compared to IOL with Oxytocin refer toTable 18

For a woman with an unfavourable cervix, the pessary may be moreappropriate as it will avoid repeated application of the gel. Conversely,the gel may be more appropriate for a woman with a favourable cervix

1

Monitoring

Prior to insertion, encourage voiding

Perform CTG to confirm fetal well being

Remain recumbent (to retain gel) left lateral (to prevent supine

hypotension) for 30 minutes after insertion Perform CTG after insertion (minimum 30 minutes)

Temperature, BP, pulse, per vaginam (PV) loss, uterine activity - hourlyfor 4 hours

Advise the woman to inform staff as soon as contractions commence

When contractions commence, confirm fetal wellbeing with continuousCTG

1for 30 minutes:

o If applicable, remove pessaryo Intermittent FHR auscultation may be used as in normal

spontaneous labour unless concerns are identified1

Assessment ofprogress

If contractions do not commence, reassess the modified Bishop score:

o Dinoprostone gel 6 hours after insertion68

o Dinoprostone pessary 12 hours after insertion68


16/26



4.1.1 Dinoprostone dose and administration

Table 17. Dinoprostone administration

Aspec t Dinoprostone administration

Dose

Dinoprostone gel

Initial dose:

o Nulliparous 2 mg PV72o Multiparous 1 mg PV

Repeat dose, after 6 hours:

o Nulliparous 2 mgo Multiparous 1-2 mg

Dinoprostone pessary

10 mg PV (released at a rate of approximately 4 mg in 12 hours)69

Maximum dose

Dinoprostone gel

Maximum 3 mg over 6 hours68


4 mg (12 hours after insertion)67

There is no information on the use of Dinoprostone if no cervical changeafter pessary insertion

67

To avoid hyperstimulation, the gel should not be inserted within 6 hoursof pessary removal

Administ rat ion

Dinoprostone gel

Use water soluble lubricants (not obstetric cream)

Remove from refrigeration and stand at room temperature for at least 30minutes prior to use

66

Insert into the posterior fornix of the vagina66

Not for intracervical administration66

Advise recumbent and left lateral position for 30 minutes after insertion

66

to facilitate absorption


Remove from freezer or fridge immediately prior to use67

Can be stored in the fridge for up to one month after removal from thefreezer

67

Warming is not required67

Open the foil only after decision has been made to use it

Use water soluble lubricants (not obstetric cream)

Insert into the posterior fornix of the vagina68

in transverse position67

Ensure sufficient tape outside vagina to allow removal67

Remain recumbent for 30 minutes67

Advise women to avoid inadvertent removal of pessary and to report if

pessary falls out

Side effects Uterine hypercontractility [For management: refer Section 5]

Indications forRemoval


Onset of regular uterine contractions

Membranes rupture (spontaneous or ARM)

Fetal distress

Uterine hypercontractility

Insufficient cervical ripening after 12 hours

o At the obstetricians discretion, Dinoprostone gel 2 mg may beinserted 30 minutes after removal of the Dinoprostone pessary


17/26



4.2 Oxytocin infusion

Oxytocin stimulates the smooth muscle of the uterus producing rhythmic contractions. Syntocinon issynthetic Oxytocin [refer toTable 18].

Table 18. Oxytocin considerations

Consideration Clinical practice point

Indications IOL using ARM and intravenous Oxytocin infusion is the preferred method

once the cervix is favourable73

Cautions

Should not be started within 6 hours of administration of vaginalProstaglandin gel administration

Should not be used with Dinoprostone pessary insitu or within 30 minutesof its removal

67

If not already ruptured, perform ARM prior to initiation of Oxytocin infusion

Oxytocin should be used with caution in women with previous uterine scaror high parity (greater than 4).

71Discuss with an obstetrician prior to

commencement

Risk/Benefit

Compared to IOL with vaginal Prostaglandin:

o Is associated with more failures to achieve vaginal birth within 24hours

74

o Shows no significant difference in caesarean birth rates74

o Increased the need for epidural

74

o Mobility is restricted1

o Refer toTable 16 for Dinoprostone considerations

Is associated with lower infection rates in both mother and baby whenmembranes are ruptured at the time of IOL

74

Oxytocin induced contractions may be perceived as more painful

Monitoring

Provide one-to-one midwifery care4

Use continuous electronic FHR monitoring once Oxytocin infusioncommenced

75,71

Titrate dose to achieve 3-4 strong regular contractions in 10 minutes

Assess maternal observations and FHR prior to any increase in theinfusion rate

Maternal observations (more frequently if clinically indicated)

o Temperature 2 hourlyo BP hourlyo Pulse hourlyo Vaginal loss hourly

Maintain fluid balance as water intoxication may result from prolongedinfusion

71(rare with the use of isotonic solutions)

Assess pain relief requirements

Assessment ofprogress

Commence the partogram or intrapartum record with the start of theinfusion

When labour established, consider the use of alert and action lines tomonitor progress


18/26



4.2.1 Oxytocin administ ration

Table 19. Oxytocin administration

Consideration Oxytocin administ ration

Administ rat ion

Use a volumetric pump to ensure an accurate rate of infusion4,71

o Consider the need for sideline/secondary IV access as per localprotocols

A standard dilution of Oxytocin should always be used

Individual protocols should specify maximum doses

The dose should be titrated against uterine contractions

o Titration should occur at 30 minute or greater intervals4

o Aim for 3-4 contractions in a 10 minute period with duration of 40-60seconds and resting period not less than 60 seconds

Use the minimum dose required to establish and maintain active labour4

Record the dose in milliunits per minute

Mark changes to dose clearly and contemporaneously on the CTG and / orintrapartum record

Maximum dose Review by an obstetrician should occur before exceeding a dose of 20

milliunits per minute

Side effects

Cardiovascular disturbances (e.g. bradycardia, tachycardia)71

Headache71

Gastrointestinal disorders (e.g. nausea, vomiting)71

Cease infus ion if:

Uterine activity becomes hypertonic71

Resting uterine tone increases71

Fetal compromise occurs (any concerning FHR abnormality)71

Consult with an obstetrician before recommencing infusion

4.2.2 Oxytocin regimens

The ideal dosing regime of Oxytocin is unknown.4Suggested regimens are outlined inTable 20.

Table 20. Oxytocin regimen

Time afterstarting

(minutes)

Oxytocin dose(milliunits per

minute)

Volume infused (mL/hour)

10 IU in500 mL

20 IU in1000 mL

30 IU in500 mL

0 1 3 3 130 2 6 6 260 4 12 12 490 8 24 24 8

120 12 36 36 12

150 16 48 48 16180 20 60 60 20Obstetrician review prior to exceeding 20 milliunits per minute

210 24 72 72 24240 28 84 84 28270 32 96 96 32


19/26



4.3 Artificial rupture of membranes

Table 21. Artificial rupture of membranes considerations

Ar ti fi cial rupture of membranes (ARM)

Indications

Favourable cervix Bishop score 7 or more76

May be used alone especially in a multiparous woman (may initiatecontractions) or in combination with Oxytocin infusion

76

Cautions Caution should be exercised where the head is high due to the risk of

cord prolapse1[refer to Section5]

Risk/Benefit

Risk of pain, discomfort, bleeding76

May shorten length of labour by speeding up contractions77

Nulliparous women with ARM and immediate Oxytocin compared todelayed Oxytocin (commenced 4 hours post ARM) showed

78:

o Increased rate of established labour 4 hours after ARMo Shorter ARM to birth intervalo Increased rate of vaginal birth within 12 hourso Increased satisfaction with the induction process and the duration

of labour

Monitoring

Before ARM:

o Explain the procedure to the woman79

o Abdominal palpation to determine descent

80

o Assess for possible cord presentationo Consult obstetrician if the head is not engaged

80or with possible

cord presentation

Immediately after ARM, examine to ensure there is no cord prolapse

Refer toTable 23 for risk factors associated with IOL including cordprolapse

Monitor FHR immediately following procedure75

preferably by continuouselectronic monitoring. Confirm normal CTG before discontinuing

Document liquor colour and consistency Encourage mobilisation to promote onset of uterine contractions

Following ARM, consider Oxytocin in:

o Multiparous women: if no contractions after 2 hourso Nulliparous women: immediately following ARM as few women will

commence contractions spontaneously unless the cervical score is7 or more

73


20/26



4.4 Transcervical catheters

Transcervical catheters (e.g. Foley, Atad) are used to ripen the cervix through:

Direct dilatation of the canal or

Indirectly by increasing prostaglandin and/or oxytocin secretion81

Table 22. Transcervical catheter considerations

Consideration Comment

Indications

May be particularly useful where the cervix is unfavourable

May be used where Dinoprostone has had no effect on cervical ripening

May be considered in women with previous CS

Cautions

Contraindication:

o Low lying placenta81

Cautions:

o Antepartum bleeding4

o Rupture of membranes4

o Cervicitis4

Risk/Benefit

Low cost and no specific storage or temperature requirements81

No evidence of an increased risk of chorioamnionitis or endometritis

although data is limited81

May be associated with slight vaginal bleeding

In women with a very unfavourable cervix, use seems to reduce failedIOL when compared to IOL with Oxytocin alone

81

Monitoring

Monitor FHR as appropriate to individual clinical circumstances

If after 12 hours, the catheter has not spontaneously fallen out, obstetricreview is indicated


21/26



5 Risks associated with induction of labourIOL may increase the risk of the following conditions outlined inTable 23.

Table 23. Risk factors associated with IOL

Risk Good Practice Point

Failed IOL

The criteria for failed IOL are not generally agreed1

Recommended care options include1:

o Review the individual clinical circumstanceso Assess fetal wellbeing using CTGo Discuss options for care with the womano If appropriate consider discharging home for 24 hours followed by

second attempt at IOLo Caesarean section

Uterinehypercontractility

Attempt removal of any remaining Dinoprostone gel82

Remove Dinoprostone pessary if still in situ82

Stop Oxytocin infusion1while reassessing labour and fetal state

Position woman left lateral

Assess BP and FHR

Commence intravenous hydration if not contraindicated by maternalcondition

Pelvic exam to assess cervical dilation

If persists use tocolytics1:

o Terbutaline 250 micrograms subcutaneously73

o Salbutamol 100 micrograms by slow intravenous (IV) injection

75

o *Sublingual Glyceryl Trinitrate (GTN) spray 400 micrograms75

If clinically indicated perform emergency CS1

Cord prolapse

Is a potential risk at the time of membrane rupture especially with ARM1

Is an obstetric emergency1

Precautions should include1

:o Assessment of engagement of the presenting parto Caution during ARM if the babys head is high

Uterine rupture

Uterine rupture is an uncommon event with IOL1

Uterine rupture is a life-threatening event for mother and baby

If suspected, prepare for an emergency CS,1uterine repair or

hysterectomy*Not currently listed on the Queensland Health List of Approved Medications (LAM)Not TGA approved for this purpose


22/26



References

1. National Collaborating Centre for Women's and Children's Health. Induction of labour. Clinical Guideline. July 2008 [cited2011 February 4]. Available from:http://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdf.

2. Caughey A, Sundaram V, Kaimal A, Cheng Y, Gienger A, Little S, et al. Maternal and neonatal outcomes of electiveinduction of labor. Evidence report/technology assessment no. 176. AHRQ Publication No. 09-E005. Rockville, MD.: Agencyfor Healthcare Research and Quality. Mar 2009 [cited 2010 December 16]. Available from:

http://www.ncbi.nlm.nih.gov/books/NBK38683/.

3. Queensland Maternity and Neonatal Clinical Guidelines Program. Term small for gestational age baby. Guideline No:MN10.16-V2-R15. 2010. Available from:www.health.qld.gov.au/qcg.

4. Society of Obstetricians and Gynaecologists of Canada. SOGC clinical practice guideline. Induction of labour at term. No.107. J Obstet Gynaecol Can. 2001; August:1-12.

5. Queensland Health, Health Statistics Centre. Perinatal Statistics Queensland 2009. 2010 [cited 2011 March 18]. Availablefrom:http://www.health.qld.gov.au/hic/peri2009/6_Lab&del_2009.pdf.

6. Miller Y, Thompson R, Porter J, Prosser S. Findings from the having a baby in Queensland survey, 2010. QueenslandCentre for Mothers and Babies, the University of Queensland. 2011.

7. University of Queensland, Queensland Centre for Mothers and Babies. The having a baby in Queensland book: yourchoices during pregnancy and birth. 2010 [cited 2011 March 16]. Available from:http://www.havingababy.org.au/media/pdf/habiqbook.pdf.

8. Heimstad R, Romundstad P, Hyett J, Mattsson L, Salvesen K. Women's experiences and attitudes towards expectantmanagement and induction of labor for post-term pregnancy. Acta Obstetricia et Gynecologica Scandinavica. 2007; 86(8):950-6.

9. Heimstad R, Skogvoll E, Mattson L, Johansen O, Eik-Nes S, Salvesen K. Induction of labour or serial antenatal fetalmonitoring in postterm pregnancy: a randomized controlled trial. Obstetrics & Gynecology. 2007; 109(3):609-17.

10. National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the healthy pregnantwoman. Clinical Guideline 62. March 2008 [cited 2011 February 4]. Available from:http://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdf.

11. Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single deepest vertical pocket: a meta-analysis of randomizedcontrolled trials. International Journal of Gynaecology and Obstetrics. 2009; 104(3):184-8.

12. Mandruzzato G, Alfirevic Z, Chervenak F, Gruenebaum A, Heimstad R, Heinonen S, et al. Guidelines for the managementof postterm pregnancy. Journal of Perinatal Medicine. 2010; 38(2):111-9.

13. Glmezoglu A, Crowther C, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term.Cochrane Database of Systematic Reviews. 2006; Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2.

14. Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews.2005 Issue 1. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub2:[Edited 2010 (no change to conclusions), contentassessed as up-to-date: 8 November 2004].

15. de Miranda E, van der Bam J, Bonsel G, Bleker O, Rosendaal F. Membrane sweeping and prevention of post-termpregnancy in low risk pregnancies: a randomised controlled trial. British Journal of Obstetrics and Gynaecology: an

International Journal of Obstetrics and Gynaecology. 2006; 113(4):402-408.

16. Boulvain M, Fraser W, Marcoux S, Fontaine J, Bazin S, Pinault J, et al. Does sweeping of the membranes reduce theneed for formal induction of labour? A randomised control trial. British Journal of Obstetrics and Gynaecology. 1998; 105:34-40.

17. Netta D, Visitainer P, Bayliss P. Does cervical membrane stripping increase maternal colonization of Group Bstreptococcus? American Journal of Obstetrics and Gynecology. 2002; 187(6):S221.

18. Yildirim G, Gungorduk K, Karadag OI, Aslan H, Turhan E, Ceylan Y. Membrane sweeping to induce labor in low-riskpatients at term pregnancy: A randomised controlled trial. The Journal of Maternal-Fetal and Neonatal Medicine. 2010;23(7):681-7.

19. Heimstad R, Romundstad P, Eik-Nes S, Salvesen K. Outcomes of pregnancy beyond 37 weeks of gestation. Obstetricsand Gynecology. 2006; 108(3 Pt1):500-8.

20. Hermus MA, Verhoeven CJ, Mol BW, de Wolf GS, Fiedeldeij CA. Comparison of induction of labour and expectantmanagement in postterm pregnancy: a matched cohort study. J Midwifery Womens Health. 2009; 54(5):351-6.
http://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdfhttp://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdfhttp://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdfhttp://www.ncbi.nlm.nih.gov/books/NBK38683/http://www.ncbi.nlm.nih.gov/books/NBK38683/http://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/hic/peri2009/6_Lab&del_2009.pdfhttp://www.health.qld.gov.au/hic/peri2009/6_Lab&del_2009.pdfhttp://www.health.qld.gov.au/hic/peri2009/6_Lab&del_2009.pdfhttp://www.havingababy.org.au/media/pdf/habiqbook.pdfhttp://www.havingababy.org.au/media/pdf/habiqbook.pdfhttp://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdfhttp://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdfhttp://www.nice.org.uk/nicemedia/live/11947/40145/40145.pdfhttp://www.havingababy.org.au/media/pdf/habiqbook.pdfhttp://www.health.qld.gov.au/hic/peri2009/6_Lab&del_2009.pdfhttp://www.health.qld.gov.au/qcghttp://www.ncbi.nlm.nih.gov/books/NBK38683/http://www.nice.org.uk/nicemedia/live/12012/41255/41255.pdf


23/26



21. Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King VJ. Indications for induction of labour: A best-evidence review.BJOG. 2009; 116:626-636.

22. Hartling L, Chari R, Friesen C, Vandermeer B, Lacaze-Masmonteil T. A systematic review of intentional delivery in womenwith preterm prelabor rupture of membranes. Journal of Maternal-Fetal and Neonatal Medicine. 2006; 19(3):177-87.

23. Buchanan S, Crowther C, Levett K, Middleton P, Morris J. Planned early birth versus expectant management for womenwith preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome. CochraneDatabase of Systematic Reviews. 2010; Issue 3. Art.:CD004735. DOI: 10.1002/14651858.CD004735.pub3.

24. Neerhof M. Timing of labor induction after premature rupture of membranes between 32 and 36 weeks' gestation.American Journal of Obstetrics and Gynecology. 1999; 180(2 Pt1):349-52.

25. Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes. Preterm birth:causes, consequences, and prevention. Washington (DC): National Academies Press (US); 2007.

26. Keirse M, Ottervanger H, Smit W. Controversies: Prelabor rupture of the membranes at term: the case for expectantmanagement. Journal of Perinatal Medicine. 1996; 24(6):563-72.

27. Capogna G, Parpaglioni R, Lyons G, Columb M, Celleno D. Minimum analgesic dose of epidural sufentanil for first-stagelabor analgesia: a comparison between spontaneous and prostaglandin-induced labors in nulliparous women. Anesthesiology.2001; 94(5):740-4.

28. Dare M, Middleton P, Crowther C, Flenady V, Varatharaju B. Planned early birth versus expectant management (waiting)for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database of Systematic Reviews 2006; Issue 1.

Art. No.:CD005302. DOI: 10.1002/14651858.CD005302.pub2.

29. Hannah M, Ohlsson A, Farine D, Hewson S, Hodnett E, Myhr T, et al. Induction of labor compared with expectantmanagement for prelabor rupture of the membranes at term. TERMPROM Study Group. The New England Journal ofMedicine. 1996; 334(16):1005-1010.

30. Hannah ME, Ohlsson A, Wang EEL, Matlow A, Foster GA, Willan AR, et al. Maternal colonization with group BStreptococcus and prelabor rupture of membranes at term: The role of induction of labor. American Journal of Obstetrics andGynecology. 1997; 177(4):780-5.

31. Queensland Maternity and Neonatal Clinical Guideline Program. Early onset Group B streptococcal disease. GuidelineNo. MN10.20-V2-R15. 2010. Available from:www.health.qld.gov.au/qcg.

32. Cahill AG, Macones GA. Vaginal birth after cesarean delivery: evidence-based practice. Clinical Obstetrics andGynecology. 2007; 50(2):518-25.

33. Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomesassociated with a trial of labor after prior cesarean delivery. New England Journal of Medicine. 2004; 351:2581-9.

34. Macones GA, Peipert J, Nelson DB, Odibo A, Stevens EJ, Stamilio DM, et al. Maternal complications with vaginal birthafter cesarean delivery: a multicenter study American Journal of Obstetrics and Gynecology. 2005; 193(5):1656-62.

35. McDonagh MS, Osterweil P, Guise J-M. The benefits and risks of inducing labour in patients with prior caesarean delivery:a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology. 2005; 112(8):1007-15.

36. Royal College of Obstetricians and Gynaecologists. Birth after previous caesarean birth. Guideline No.45. 2007.

37. Queensland Maternity and Neonatal Clinical Guideline Program. Vaginal birth after caesarean section (VBAC). 2009;

MN09.12-V3-R14. Available from:www.health.qld.gov.au/qcg.

38. Royal College of Obstetricians and Gynaecologists. Obstetric cholestasis. Guideline No. 43. 2006 [cited 2011 March 18].Available from:http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT43ObstetricCholestasis2006.pdf.

39. Saleh M, Abdo K. Intrahepatic cholestasis of pregnancy: review of the literature and evaluation of current evidence. JWomen's Health. 2007 Jul-Aug; 16(6):833-41.

40. Glantz A, Marschall H, Mattsson L. Intrahepatic cholestasis of pregnancy: relationships between bile acid levels and fetalcomplication rates. Hepatology. 2004; Aug 40(2):467-74.

41. Kenyon A, Shennan A. Obstetric cholestasis. Fetal and Maternal Medicine Review 2009; 20(2):119-42.

42. Pathak B, Sheibani L, Lee R. Cholestasis of pregnancy. Obstetrics and Gynecology Clinics of North America. 2010;

37(2):269-82.

43. Heinonen S, Kirkinen P. Pregnancy outcome with intrahepatic cholestasis. Obstet Gynecol. 1999; 94(2):189-93.
http://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT43ObstetricCholestasis2006.pdfhttp://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT43ObstetricCholestasis2006.pdfhttp://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT43ObstetricCholestasis2006.pdfhttp://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT43ObstetricCholestasis2006.pdfhttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcg


24/26



44. Roncaglia N, Arreghini A, Locatelli A, Bellini P, Andreotti C, Ghidini A. Obstetric cholestasis: outcome with activemanagement. Eur J Obstet Gynecol Reprodu Biol. 2002; Jan 100(2):167-70.

45. Confidential Enquiry into Maternal and Child Health. Pregnancy in Women with Type 1 and Type 2 Diabetes in 200203,England, Wales and Northern Ireland. London. 2005 [cited 2011 February 3]. Available from:http://www.cemach.org.uk/getattachment/8af39ba1-1cab-476b-ad8e-b9393fd35aed/Pregnancy-in-women-with-type-1-and-type-2-diab-(1).aspx.

46. Kjos S, Henry O, Montoro M, Buchanan T, Mestman J. Insulin requiring diabetes in pregnancy: a randomised trial ofactive induction of labor and expectant management. American Journal of Obstetrics and Gynecology. 1993; 169:611-5.

47. Lucas M. Diabetes complicating pregnancy. Obstetrics and Gynecology Clinics of North America. 2001 [cited 17/12/2010];28(3):513-6.

48. Koopmans C, Zwart J, Groen H, Bloemenkamp K, Mol B, Van Pampus M, et al. Risk indicators for eclampsia ingestational hypertension or mild preeclampsia at term. Hypertension in Pregnancy. 2010 [cited 15/12/2010]; (Sept 7 [epubahead of print]):1-14.

49. SOGC clinical practice guideline. Diagnosis, evaluation and management of the hypertensive disorders of pregnancy.Journal of Obstetric and Gynaecology Canada. 2008; 30(3):Supplement 1.

50. Queensland Maternity and Neonatal Clinical Guidelines Program. Hypertensive disorders of pregnancy. Guideline No:MN10.13-V2-R15. 2010. Available from:http://www.health.qld.gov.au/qcg.

51. Dodd J, Crowther C. Elective delivery of women with twin pregnancy from 37 weeks' gestation. Cochrane Database ofSystematic Reviews 2003, Issue 1. Art. No.: CD003582. updated 2010 [cited 15/12/2010].

52. Hartley R, Emanuel I, J H. Perinatal mortality and neonatal morbidity rates among twin pairs at different gestational ages:optimal delivery timing at 37 to 38 weeks' gestation. American Journal of Obstetrics and Gynecology. 2001; 184(3):451-8.

53. Dodd J, Robinson J, Crowther C, Chan A. Stillbirth and neonatal outcomes in South Australia, 1991-2000. AmericanJournal of Obstetrics and Gynecology. 2003; 189(6):1731-6.

54. Suzuki S, Otsubo Y, Sawa R, Yoneyama Y, T A. Clinical trial of induction of labor versus expectant management in twinpregnancy. Gynecologic and Obstetric Investigation. 2000; 49:24-7.

55. Chauhan S, Grobman W, Gherman R, Chauhan V, Chang G, Magann E, et al. Suspicion and treatment of themacrosomic fetus: a review. American Journal of Obstetrics and Gynecology. 2005; 193(2):332-46.

56. Irion O, Boulvain M. Induction of labour for suspected fetal macrosomia. Cochrane Database of Systematic Reviews. 1998(Last assessed as up-to-date 29 September 2007); Issue 2. Art. No.: CD000938. DOI: 10.1002/14651858.CD000938.

57. Alfirevic Z, Stampalija T, Gyte GM. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Databaseof Systematic Reviews. 2010; Issue 1. Art. No.: CD007529. DOI: 10.1002/14651858.CD007529.pub2.

58. GRIT Study Group. A randomised trial of timed delivery for the compromised preterm fetus: short term outcomes andBayesian interpretation. British Journal of Obstetrics and Gynaecology. 2003; 110(1):27-32.

59. Thornton J, Hornbuckle J, Vail A, Spiegelhalter D, Levene M, group. Gs. Infant wellbeing at 2 years of age in the GrowthRestriction Intervention Trial (GRIT): multicentred randomised controlled trial. Lancet. 2004; 364(9433):513-20.

60. van den Hove M, Willekes C, Roumen J, Scherjon S. Intrauterine growth restriction at term: Induction or spontaneouslabour? Disproportionate intrauterine growth intervention trial at term (DIGITAT): a pilot study. European Journal of Obstetrics,

Gynecology, and Reproductive Biology. 2006; 125 (1).

61. Figueras F, Gardosi J. Intrauterine growth restriction: new concepts in antenatal surveillance, diagnosis, andmanagement. American Journal of Obstetrics and Gynecology. 2010; Article in press (doi:10.1016/j.ajog.2010.08.055).

62. American College of Obstetricians and Gynaecologists. Diagnosis and management of fetal death. ACOG TechnicalBulletin Number 176 - January. International Journal of Gynaecology and Obstetrics. 1993; 42(3):291-9.

63. Royal College of Obstetricians and Gynaecologists. Heart Disease and Pregnancy - study group statement. Consensusviews arising from the 51st Study Group: Heart Disease and Pregnancy. 2006 [cited 2011 March 18]. Available from:http://www.rcog.org.uk/print/womens-health/clinical-guidance/heart-disease-and-pregnancy-study-group-statement.

64. Queensland Maternity and Neonatal Clinical Guidelines Program. Venous thromboembolism (VTE) prophylaxis inpregnancy and the puerperium. Guideline No. MN09.9-V3-R14. 2009. Available from:www.health.qld.gov.au/qcg.

65. Lange A, Secher N, Westergaard J, Skovgrd I. Prelabor evaluation of inducibility. Obstetrics and Gynecology. 1982;60(2):137-47.
http://www.cemach.org.uk/getattachment/8af39ba1-1cab-476b-ad8e-b9393fd35aed/Pregnancy-in-women-with-type-1-and-type-2-diab-(1).aspxhttp://www.cemach.org.uk/getattachment/8af39ba1-1cab-476b-ad8e-b9393fd35aed/Pregnancy-in-women-with-type-1-and-type-2-diab-(1).aspxhttp://www.cemach.org.uk/getattachment/8af39ba1-1cab-476b-ad8e-b9393fd35aed/Pregnancy-in-women-with-type-1-and-type-2-diab-(1).aspxhttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.rcog.org.uk/print/womens-health/clinical-guidance/heart-disease-and-pregnancy-study-group-statementhttp://www.rcog.org.uk/print/womens-health/clinical-guidance/heart-disease-and-pregnancy-study-group-statementhttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.health.qld.gov.au/qcghttp://www.rcog.org.uk/print/womens-health/clinical-guidance/heart-disease-and-pregnancy-study-group-statementhttp://www.health.qld.gov.au/qcghttp://www.cemach.org.uk/getattachment/8af39ba1-1cab-476b-ad8e-b9393fd35aed/Pregnancy-in-women-with-type-1-and-type-2-diab-(1).aspxhttp://www.cemach.org.uk/getattachment/8af39ba1-1cab-476b-ad8e-b9393fd35aed/Pregnancy-in-women-with-type-1-and-type-2-diab-(1).aspx


25/26



66. MIMS Online. Prostin E2 Vaginal Gel [Pfizer]. 2008 [cited 2011 June 6]. Available from: https://www-mimsonline-com-au.cknservices.dotsec.com/Search/FullPI.aspx?ModuleName=Product%20Info&searchKeyword=Dinoprostone&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=8110001_2.

67. MIMS Online. Cervidil Pessary [CSL]. 2006 [cited 2011 June 6]. Available from: https://www-mimsonline-com-au.cknservices.dotsec.com/Search/FullPI.aspx?ModuleName=Product%20Info&searchKeyword=Dinoprostone&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=67730001_2.

68. Australian Medicines Handbook. Dinoprostone. 2010 [cited 2010 December 9]. Available from: https://www-amh-net-au.cknservices.dotsec.com/online/view.php?page=chapter17/monographdinoprostone.html#dinoprostone.

69. Kelly AJ, Malik S, Smith L, Kavanagh J, Thomas J. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour atterm. Cochrane Database of Systematic Reviews. 2009; Issue 4. Art. No.: CD003101. DOI:10.1002/14651858.CD003101.pub2.

70. Kho E, Sadler L, McCowan L. Induction of labour: a comparison between controlled-release dinoprostone vaginal pessary(Cervidil) and dinoprostone intravaginal gel (Prostin E2). Australian and New Zealand Journal of Obstetrics and Gynaecology.2008 Oct; 48(5):473-7.

71. MIMS Online. Syntocinon solution for injection [Novartis]. 2009 [cited 2011 June 6]. Available from: https://www-mimsonline-com-au.cknservices.dotsec.com/Search/FullPI.aspx?ModuleName=Product%20Info&searchKeyword=Oxytocin&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=8130001_2.

72. Sanchez-Ramos L, Bernstein S, Kaunitz A. Expectant management versus labor induction for suspected fetalmacrosomia: a systematic review. Obstetrics and Gynecology. 2002; 100(5 Pt 1):997-1002.

73. Subramanian D, Penna L. Induction of labour. In: Arulkumaran, S & Warren R, editors. Best practice labour and delivery.Cambridge (UK): Cambridge University Press 2009. p. 195-206.

74. Alfirevic Z, Kelly AJ, Dowswell T. Intravenous oxytocin alone for cervical ripening and induction of labour. CochraneDatabase of Systematic Reviews. 2009; Issue 4. Art. No.: CD003246. DOI: 10.1002/14651858.CD003246.pub2.

75. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Intrapartum fetal surveillance.Clinical Guidelines - Second edition. 2009 [cited 2012 February 7]. Available from:http://www.ranzcog.edu.au/publications/womens-health-publications/intrapartum-fetal-surveillance-clinical-guidelines.html.

76. Howarth GR, Botha DJ. Amniotomy plus intravenous oxytocin for induction of labour. Cochrane Database of Systematic

Reviews. 2001; Issue 3. Art. No.: CD003250. DOI: 10.1002/14651858.CD003250.

77. Smyth R, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour (Review). Cochrane Database ofSystematic Reviews. 2007; Issue 4. Art. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub2.

78. Selo-Ojeme D, Pisal P, Lawal O, Rogers C, Shah A, Sinha S. A randomised controlled trial of amniotomy and immediateoxytocin infusion versus amniotomy and delayed oxytocin infusion for induction of labour at term. Archives of Gynecology andObstetrics. 2009; 279(6):813-20.

79. National Collaborating Centre for Women's and Children's Health. Intrapartum care: care of healthy women and theirbabies during childbirth Clinical Guideline [online]. 2007 (corrected June 2008) [cited 2011 March 7]. Available from:http://publications.nice.org.uk/intrapartum-care-cg55.

80. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Routine intrapartum care in theabsence of pregnancy complications. College statement:C-Obs 31. 2010 [cited 2013 December 3]. Available from:

http://www.ranzcog.edu.au/college-statements-guidelines.html.

81. Boulvain M, Kelly A, Lohse C, Stan C, Irion O. Mechanical methods for induction of labour. Cochrane Database ofSystematic Reviews. 2001; Issue 4. Art. No.: CD001233. DOI: 10.1002/14651858.CD001233.

82. Australian Medicines Handbook. 2009 [cited 2009 August 10]. Available from: https://www-mimsonline-com-au.cknservices.dotsec.com/Search/Search.aspx
http://www.ranzcog.edu.au/publications/womens-health-publications/intrapartum-fetal-surveillance-clinical-guidelines.htmlhttp://www.ranzcog.edu.au/publications/womens-health-publications/intrapartum-fetal-surveillance-clinical-guidelines.htmlhttp://publications.nice.org.uk/intrapartum-care-cg55http://publications.nice.org.uk/intrapartum-care-cg55http://www.ranzcog.edu.au/college-statements-guidelines.htmlhttp://www.ranzcog.edu.au/college-statements-guidelines.htmlhttp://www.ranzcog.edu.au/college-statements-guidelines.htmlhttp://publications.nice.org.uk/intrapartum-care-cg55http://www.ranzcog.edu.au/publications/womens-health-publications/intrapartum-fetal-surveillance-clinical-guidelines.html


26/26


AcknowledgementsThe Queensland Maternity and Neonatal Clinical Guidelines Program gratefully acknowledge thecontribution of Queensland clinicians and other stakeholders who participated throughout theguideline development process particularly:

Working Party Clinical Lead

Associate Professor Kassam Mahomed, Senior Staff Specialist, Obstetrics and Gynaecology,Ipswich Hospital and University of Queensland

Working Party Members

Dr Michael Beckman, Director Obstetrics and Gynaecology, Mater Health Services, Brisbane

Dr Lindsay Cochrane, Staff Specialist, Caboolture Hospital

Ms Jennifer Fry, A/Midwife Educator, Womens Health, Darling Downs West Moreton District HealthService

Professor Michael Humphrey, Clinical Adviser, Office of Rural and Remote Health

Associate Professor Rebecca Kimble, Clinical Director, Obstetric Services, Royal Brisbane and

Womens HospitalMs Sarah Kirby, Midwifery Unit Manager, Royal Brisbane and Womens Hospital

Associate Professor Alka Kothari, Obstetrician, Redcliffe Hospital

Dr David Moore, Obstetric Registrar, Ipswich Hospital

Ms Gloria OConnor, Clinical Midwife, Redcliffe Hospital

Ms Jessie Offer, Consumer, Home Midwifery Association

Ms Pamela Sepulveda, Clinical Midwifery Consultant, Logan Hospital

Ms Rachel Thompson, Health Psychology Academic, Queensland Centre for Mothers and Babies

Ms Mary Tredinnick, Pharmacist, Royal Brisbane and Womens Hospital

Ms Robin Turnbull, Network Coordinator, South Queensland and Maternity and Neonatal ClinicalNetwork

Program Team

Associate Professor Rebecca Kimble, Program Director, Queensland Maternity and Neonatal ClinicalGuidelines Program

Ms Jacinta Lee, A/Manager, Queensland Maternity and Neonatal Clinical Guidelines Program

Ms Jackie Doolan, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program

Ms Lyndel Gray, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program

Mr Keppel Schafer, Program Officer, Queensland Maternity and Neonatal Clinical GuidelinesProgram

Steering Committee, Queensland Maternity and Neonatal Clinical Guidelines Program

Funding

This clinical guideline was supported by funding from Centre of Healthcare Improvement,Queensland Health