Queensland maternity and Neonatal clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use. These guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Information in This Guideline is current at time of publication.
Queensland maternity and Neonatal clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use. These guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Information in This Guideline is current at time of publication.
Queensland maternity and Neonatal clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use. These guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Information in This Guideline is current at time of publication.
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 Document supplement: The document supplement is integral to and should be read in conjunction with this guideline Amendments Full version history is supplied in the document supplement Amendment date J anuary 2014 Replaces document: MN11.22-V2-R16 Author: Queensland Maternity and Neonatal Clinical Guidelines Program Audi ence: 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: MN-Guidelines@health.qld.gov.au URL: http://www.health.qld.gov.au/qcg
Discl aimer
These guidelines have been prepared to promote and facilitate standardisation and consistency of practice, 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 of reliance upon the material contained in this guideline.
Clinical material offered in this guideline does not replace or remove clinical judgement or the professional care and duty necessary for each specific patient case.
Clinical care carried out in accordance with this guideline should be provided within the context of locally available resources and expertise.
This Guideline does not address all elements of standard practice and assumes that individual clinicians are responsible to: Discuss care with consumers in an environment that is culturally appropriate and which enables respectful confidential discussion. This includes the use of interpreter services where necessary Advise consumers of their choice and ensure informed consent is obtained Provide care within scope of practice, meet all legislative requirements and maintain standards 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 this licence, 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 authors and 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 ip_officer@health.qld.gov.au , phone (07) 3234 1479. For further information contact Queensland Maternity and Neonatal Clinical Guidelines Program, RBWH Post Office, Herston Qld 4029, email MN-Guidelines@health.qld.gov.au phone (07) 3131 6777. Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 3 of 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 induction Offer increased antenatal monitoring x 2/week: o CTG o 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 (PGE 2 ) 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
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 4 of 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 PGE 2 Dinoprostone, Prostaglandin E 2
PPROM Preterm prelabour rupture of membranes PROM Prelabour rupture of membranes PV Per vaginam RCT Randomised controlled trial VBAC Vaginal birth after caesarean VE 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 and compliant. This allows its shape to change from being long and closed, to being thinned out (effaced) and starting to open (dilate). It either occurs naturally or as a result of physical or pharmacological interventions. 1
Dinoprostone Prostaglandin gel or pessary. Expedited IOL PROM Induction of labour (IOL) commencing between 2 and 12 hours after prelabour rupture of membranes (PROM). 1
Expectant Management Non-intervention at any particular point in the pregnancy, allowing progress to a future gestational age. Intervention occurs only when clinically indicated. 2
Favourable cervix The cervix is said to be favourable when its characteristics suggest there is a high chance of spontaneous onset of labour, or of responding to interventions made to induce labour. 1
Fetal growth restriction (FGR) Also known as intrauterine growth restriction (IUGR). Fetal growth restriction (FGR) indicates the presence of a pathophysiological process occurring in utero that inhibits fetal growth. 3
Induction of labour The process of artificial initiation of labour before its spontaneous onset. 4
Mechanical method Non-pharmacological method of inducing labour. 1
Uterine hypercontractility More than 5 contractions in 10 minutes for two consecutive 10 minute intervals or a contraction lasting more than 2 minutes. 1
Obstetrician Local facilities may differentiate the roles and responsibilities assigned in this document to an Obstetrician according to their specific practitioner group requirements; for example to General Practitioner Obstetricians, Specialist Obstetricians, Consultants, Senior Registrars, Obstetric Fellows or other members of the team as required. Prolonged pregnancy A pregnancy past 42 +0 weeks gestation. 1
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 5 of 26 Table of Contents 1 Introduction ................................................................................................................................................... 6 1.1 Communication and information .......................................................................................................... 6 1.2 Indications ........................................................................................................................................... 6 1.3 Contraindications ................................................................................................................................. 6 1.4 Care if induction of labour declined ..................................................................................................... 6 1.5 Care if induction of labour postponed .................................................................................................. 7 1.6 Clinical standards ................................................................................................................................ 7 1.7 Membrane sweeping ........................................................................................................................... 7 2 Specific circumstances ................................................................................................................................. 8 2.1 Prolonged Pregnancy .......................................................................................................................... 8 2.2 Preterm prelabour rupture of membranes ........................................................................................... 8 2.3 Term prelabour rupture of membranes ................................................................................................ 9 2.4 Previous caesarean section ...............................................................................................................10 2.5 Obstetric cholestasis ..........................................................................................................................10 2.6 Diabetes .............................................................................................................................................11 2.7 Hypertensive disorders of pregnancy .................................................................................................11 2.8 Twin pregnancy ..................................................................................................................................11 2.9 Suspected fetal macrosomia (>4000grams) .......................................................................................12 2.10 Fetal growth restriction .......................................................................................................................12 2.11 Intrauterine fetal death........................................................................................................................13 2.12 Maternal request ................................................................................................................................13 2.13 Other maternal conditions ..................................................................................................................13 3 Pre induction of labour assessment .............................................................................................................14 3.1 Cervical assessment ..........................................................................................................................14 4 Methods of induction of labour .....................................................................................................................14 4.1 Dinoprostone ......................................................................................................................................15 4.1.1 Dinoprostone dose and administration ...........................................................................................16 4.2 Oxytocin infusion ................................................................................................................................17 4.2.1 Oxytocin administration ..................................................................................................................18 4.2.2 Oxytocin regimens .........................................................................................................................18 4.3 Artificial rupture of membranes ...........................................................................................................19 4.4 Transcervical catheters ......................................................................................................................20 5 Risks associated with induction of labour.....................................................................................................21 References ..........................................................................................................................................................22 Acknowledgements ..............................................................................................................................................26
List of Tables Table 1. Membrane sweeping considerations ........................................................................................................ 7 Table 2. Prolonged pregnancy ............................................................................................................................... 8 Table 3. Preterm prelabour rupture of membranes ................................................................................................ 8 Table 4. Term prelabour rupture of membranes .................................................................................................... 9 Table 5. Previous caesarean section ................................................................................................................... 10 Table 6. Obstetric cholestasis .............................................................................................................................. 10 Table 7. Gestational diabetes/diabetes mellitus ................................................................................................... 11 Table 8. Hypertensive disorders of pregnancy ..................................................................................................... 11 Table 9. Twin pregnancy ...................................................................................................................................... 11 Table 10. Suspected fetal macrosomia ................................................................................................................ 12 Table 11. Fetal growth restriction ......................................................................................................................... 12 Table 12. Intrauterine fetal death ......................................................................................................................... 13 Table 13. Maternal request .................................................................................................................................. 13 Table 15. Modified Bishop score .......................................................................................................................... 14 Table 16. Dinoprostone considerations ................................................................................................................ 15 Table 17. Dinoprostone administration ................................................................................................................ 16 Table 18. Oxytocin considerations ....................................................................................................................... 17 Table 19. Oxytocin administration ........................................................................................................................ 18 Table 20. Oxytocin regimen ................................................................................................................................. 18 Table 21. Artificial rupture of membranes considerations .................................................................................... 19 Table 22. Transcervical catheter considerations .................................................................................................. 20 Table 23. Risk factors associated with IOL .......................................................................................................... 21 Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 6 of 26 1 Introduction Induction of labour (IOL) is a relatively common procedure. In 2009 the IOL rate in Queensland was 22.4%. 5 The 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 IOL are 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 woman to 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 decision 6 : Provide women with information on the 1,4 : 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 choices 7
1.2 Indications IOL is indicated when the maternal and/or fetal risks of ongoing pregnancy outweigh the risks of IOL and 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 have been offered IOL for prolonged pregnancy.
At 41 weeks or later gestation, it has been shown for those women who 8 : 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 associated with postterm pregnancy. However, it is recommended from 42 weeks, to offer increased antenatal monitoring 9 consisting of twice weekly: Cardiotocography (CTG) 10
Ultrasound assessment of amniotic fluid volume using: o Estimation of maximum amniotic pool depth 10,11 , or o Amniotic fluid index 12,13
Umbilical arterial Doppler ultrasound 12
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 7 of 26 1.5 Care if induction of labour postponed Take into account the womans individual clinical circumstances and preferences, the indication for IOL and the local service capabilities and priorities when determining if a booked IOL can be postponed (e.g. due to resourcing issues or as a result of maternal request). When a booked induction of labour is postponed: Perform an assessment of maternal and fetal wellbeing Involving the woman, develop a plan for continued care including, arrangements for ongoing 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 of her 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 available 1
1.7 Membrane sweeping Membrane sweeping refers to the digital separation of the fetal membranes from the lower uterine segment during vaginal examination. This movement helps to separate the cervix from the membranes and helps to stimulate the release of prostaglandins. Table 1 outlines considerations for membrane 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 spontaneous labour Risk/Benefit From 38-40 weeks onwards, significantly reduced pregnancies beyond 41 weeks 14
Repeated membrane sweeping has been found to decrease the proportion of postterm pregnancies 15
Reduced need for formal IOL 16 , particularly in multiparous women 15
Limited data on risk in Group B streptococcus (GBS) carriers 17
No evidence of increased risk of maternal or neonatal infection 14
Associated with discomfort 14,15 , vaginal bleeding and irregular contractions 14
Most women would choose membrane sweeping again 15
Optimal frequency unknown. Practice varies from weekly to several times a week 1,14
Recommendations Consider offering membrane sweep at 39-40 weeks, especially to low risk multiparous women 18
Advise of the benefits of repeated membrane sweeping If the cervix is closed and membrane sweeping is not possible, cervical massage in vaginal fornices may achieve similar effect 1
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 8 of 26 2 Specific circumstances Considerations 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 age 19 : o At 38 weeks gestation 0.25% o At 42 weeks gestation 1.55% IOL at 41 weeks or beyond compared with awaiting spontaneous labour for 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 weeks o 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 41 and 42 weeks 1,20
Waiting after 42 weeks is not recommended 1,20,21
Exact timing depends on the womens preferences and local circumstances
2.2 Preterm prelabour rupture of membranes Table 3. Preterm prelabour rupture of membranes Preterm prelabour rupture of membranes Risk/Benefit Gestation between 34 +0 36 +6
IOL versus expectant management: o Reduces chorioamnionitis 22,23
o Reduces maternal length of stay 22
o Insufficiently sized studies to determine difference in: Neonatal sepsis 22,23
Respiratory distress 23
Newborn intensive care resource use 23
Decreased neonatal intensive care unit (NICU) length of stay and hyperbilirubinaemia 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 mortality 25 , adverse neonatal outcomes 25 including respiratory distress syndrome 24 , intraventricular haemorrhage 24 , necrotising enterocolitis 24 and other long term complications 25
Mortality and morbidity increase with decreasing gestational age 25
Recommendations Gestation between 34 +0 36 +6
Decision should be based on discussion with the woman and her partner and 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 indications 1
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 9 of 26 2.3 Term prelabour rupture of membranes Table 4. Term prelabour rupture of membranes Term prelabour rupture of membranes (PROM) Risk/Benefit Spontaneous labour commences 26
o Within 24 hours in 70% of women o Within 48 hours in 85% of women o This may decrease the need for continuous fetal heart rate (FHR) monitoring IOL is perceived as being more painful. These women may have a greater need for epidural analgesia 27
A policy of expedited IOL compared to expectant management decreases 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 sepsis 29
Women with planned management are more likely to view their care more positively than expectantly managed women 29
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 been performed) 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 is recommended o Waiting greater than 96 hours is not recommended In the woman known to be GBS positive advise expedited IOL with Oxytocin 30
Refer to Guideline: Early onset Group B streptococcal disease 31
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 10 of 26 2.4 Previous caesarean section Table 5. Previous caesarean section Previous caesarean secti on Risk/Benefit Dinoprostone (Prostin, Prostaglandin E 2 ) gel and pessary are widely used in the UK, with good effect 1
Data on risk of uterine rupture are mainly based on retrospective studies 32
The risk of uterine rupture with 33 : o Spontaneous labour is 4/1000 o Augmentation with Oxytocin is 9/1000 o Induction with Oxytocin is 11/1000 o Induction with Prostaglandin with/without Oxytocin is 14/1000 o Induction with mechanical methods with/without Oxytocin 9/1000 In a large study, neither induction nor augmentation of labour was associated with uterine rupture, compared to women who labour spontaneously. However risk of uterine rupture increased when both Oxytocin and Prostaglandin were used for labour induction 34
Recommendations Taking into account individual circumstances, discuss IOL, CS and expectant management 1
Inform women of the increased risk of CS and uterine rupture
in IOL 1,35
Discuss decisions about care with the responsible obstetrician 36
Refer to guideline: Vaginal birth after caesarean section (VBAC) 37
2.5 Obstetric cholestasis Table 6. Obstetric cholestasis Obstetric chol estasis Risk/Benefit There is no quality evidence to recommend best management 38
Is associated with increased risk of 39 : o Intrauterine fetal death (IUFD) 2% o Preterm birth 44% o Meconium staining of liquor 25-45% 90% of fetal deaths occur after 37 weeks 39
A correlation has been shown between serum bile acid levels and fetal complication rates 39,40 : o Bile acids of less than 40 micromol/L were associated with no increase in fetal risk o Ursodeoxycholic acid has been shown to reduce serum bile acid levels. It is uncertain if this translates to reduced perinatal risk 41,42
o Poor fetal outcome is associated with 43 : Deteriorating biochemical tests Unresponsiveness to Ursodeoxycholic acid CTG and Doppler surveillance have no role in the prediction of perinatal risk 40
IOL at 37 weeks or at time of diagnosis, before or after 37 weeks, had a decreased risk of IUFD: o 0/218 (0%) compared to 14/888 (1.6%) for historical controls in the literature 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 jaundice 39 , progressive elevations in serum bile acids 39 and liver enzymes, and suspected fetal compromise 39
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 11 of 26 2.6 Diabetes Table 7. Gestational diabetes/diabetes mellitus Gestational diabetes (GDM)/diabetes mell itus Risk/Benefit 27% of non-malformed stillbirths in women with pre-existing diabetes occur after 37 completed weeks 45
In women with GDM on insulin, comparing IOL in the 38 th week with expectant management , showed 46 : o Reduced macrosomia in the IOL group, 10% versus 23% o No difference in caesarean section rates o A non-significant increase in shoulder dystocia in the expectant group Diet controlled, mild GDM is associated with good pregnancy outcome 47
o No data on risk of perinatal mortality after 40 weeks Recommendations Until quality evidence becomes available, offer delivery at 38 weeks to women with diabetes requiring insulin 46
Advise women with well-controlled, diet controlled GDM, and no fetal macrosomia 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 birth 1,14,48
In non-severe hypertension, compared to IOL, expectant management showed increased poor maternal outcome, using a composite measure: o 44% compared to 31% in IOL group o 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 other obstetric indications 4,49
Refer to Guideline: Hypertensive disorders of pregnancy 50
2.8 Twin pregnancy Table 9. Twin pregnancy Twin pregnancy Risk/Benefit Optimal timing for uncomplicated twin pregnancy is uncertain 51
Retrospective studies demonstrate: o Perinatal mortality rate is lowest for birth at 37 weeks gestation 52
o An increase in stillbirth, particularly from 38 weeks 53
o An underpowered randomised controlled trial (RCT) comparing expectant management with IOL at 37 weeks showed no statistical difference in CS, CS for fetal distress or perinatal death 54
In uncomplicated twin pregnancy there is insufficient data to support the practice of planned birth from 37 weeks 51
The main determinant of risk in a multiple pregnancy is chorionicity and this may influence decisions regarding the timing of delivery in individual cases 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
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 12 of 26 2.9 Suspected fetal macrosomia (>4000grams) Table 10. Suspected fetal macrosomia Suspected fetal macrosomia Risk/Benefit Accuracy of estimating fetal weight varies 55 : o From 15-79% using ultrasound o From 40-52% using clinical judgement Comparing IOL and expectant management there are no significant differences in 56 : o CS rate o Instrumental birth o Perinatal morbidity although 6/189 cases of brachial plexus injury or fractured clavicle were found in the expectant group and 0/183 in the IOL group, the difference was not statistically different Recommendations In the absence of other indications, IOL should not be recommended simply 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 of delivery when fetal growth restriction (FGR) has been diagnosed 57
Use of umbilical artery and ductus venosus Doppler has been shown to assist in improving perinatal outcome 57
Preterm FGR The GRIT study comparing expectant versus immediate birth (IOL and CS) between 24-36 weeks showed: o Expectant group 58
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 birth Term FGR Small pilot RCT, with a total of only 33 cases, comparing expectant versus immediate birth at term, showed no significant difference in 60 : o Obstetric interventions, for example CS o Neonatal morbidity Recommendations In term and preterm pregnancies with FGR there is little evidence to guide timing of birth 1
Timing of birth will depend on gestational age, severity of FGR and results of tests of fetal well being Recommend expedited birth for a woman with FGR diagnosed at term 61
Severity affects the decision of the most appropriate mode of birth 58
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 13 of 26 2.11 Intrauterine fetal death Table 12. Intrauterine fetal death Intrauterine fetal death Risk/Benefit There is no evidence addressing immediate versus delayed IOL 1
Many women go into spontaneous labour within 2-3 weeks of IUFD Risk of coagulopathy is usually only of concern after 4 weeks 62
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 respiratory distress syndrome and related adverse effects 13
Recommendations Consider IOL based on exceptional circumstances of the woman and her family 2.13 Other maternal conditions Table 14. Other maternal conditions Anticoagulant therapy and maternal cardiac condition Risk/Benefit For a woman on anticoagulant therapy, IOL is timed around the medication protocol 63
For maternal cardiac conditions, the objective of care is to minimise the additional load on the cardiovascular system, ideally through spontaneous onset of labour 63
Recommendations A multidisciplinary team, consisting of an obstetrician, cardiologist or physician as appropriate, anaesthetist, and midwife is essential Involve an intensivist and neonatologist as required 63
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 protocol o Availability of medical staff o Deteriorating maternal cardiac function Refer to Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium 64
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 14 of 26 3 Pre induction of labour assessment Prior 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 menstrual period 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 fetal monitoring 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 and then 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 IOL 4
The cervix is unfavourable if the score is 6 or less 4
Table 15. Modified Bishop score Cervical feature Score 0 1 2 3 Dilation (cm) <1 1-2 3-4 >4 Length of cervix (cm) >3 2 1 <1 Station (rel ative 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 E 2 , PGE 2 , PG gel, Prostin E 2 , Cervidil) o Oxytocin infusion Surgical methods o Artificial rupture of membranes (ARM) Mechanical methods o Transcervical catheter (Foley or Atad) Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 15 of 26 4.1 Dinoprostone Dinoprostone (vaginal Prostaglandin E 2 ) promotes cervical ripening and stimulates uterine contractions. [refer to Table 16 and Table 17]. Dinoprostone preparations include: Vaginal gel (Prostaglandin E 2 , PGE 2 , PG gel, Prostin E 2, , 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 constituents 66,67
Ruptured membranes pessary contraindicated 67,68
Multiple pregnancies 68
High parity o Gel - parity greater than 4 66 and o Pessary - parity greater than 3 67
Previous CS or any uterine surgery 66,67,68
Malpresentation / high presenting part 66
Unexplained vaginal discharge and / or uterine bleeding during current pregnancy 66,67,68
Cautions Use caution in women with asthma due to potential bronchoconstriction 68
Ruptured membranes use gel with caution 68
Oxytocin administration 66,67,68
Epilepsy 68
Cardiovascular disease 68
Raised intraocular pressure, glaucoma 68
Risk/Benefit Nausea, vomiting and diarrhoea may occur soon after insertion 68
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 used 71
Compared to IOL with Oxytocin refer to Table 18 For a woman with an unfavourable cervix, the pessary may be more appropriate 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 - hourly for 4 hours Advise the woman to inform staff as soon as contractions commence When contractions commence, confirm fetal wellbeing with continuous CTG 1 for 30 minutes: o If applicable, remove pessary o Intermittent FHR auscultation may be used as in normal spontaneous labour unless concerns are identified 1
Assessment of progress If contractions do not commence, reassess the modified Bishop score: o Dinoprostone gel 6 hours after insertion 68
o Dinoprostone pessary 12 hours after insertion 68
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 16 of 26 4.1.1 Dinoprostone dose and administration Table 17. Dinoprostone administration Aspect Dinoprostone admini stration Dose Dinoprostone gel Initial dose: o Nulliparous 2 mg PV 72
o Multiparous 1 mg PV Repeat dose, after 6 hours: o Nulliparous 2 mg o 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 hours 68
Dinoprostone pessary 4 mg (12 hours after insertion) 67
There is no information on the use of Dinoprostone if no cervical change after pessary insertion 67
To avoid hyperstimulation, the gel should not be inserted within 6 hours of pessary removal Admini stration Dinoprostone gel Use water soluble lubricants (not obstetric cream) Remove from refrigeration and stand at room temperature for at least 30 minutes prior to use 66
Insert into the posterior fornix of the vagina 66
Not for intracervical administration 66
Advise recumbent and left lateral position for 30 minutes after insertion 66
to facilitate absorption
Dinoprostone pessary Remove from freezer or fridge immediately prior to use 67
Can be stored in the fridge for up to one month after removal from the freezer 67
Warming is not required 67
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 vagina 68 in transverse position 67
Ensure sufficient tape outside vagina to allow removal 67
Remain recumbent for 30 minutes 67
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 for Removal Dinoprostone pessary 67
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 be inserted 30 minutes after removal of the Dinoprostone pessary
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 17 of 26 4.2 Oxytocin infusion Oxytocin stimulates the smooth muscle of the uterus producing rhythmic contractions. Syntocinon is synthetic Oxytocin [refer to Table 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 favourable 73
Cautions Should not be started within 6 hours of administration of vaginal Prostaglandin gel administration Should not be used with Dinoprostone pessary insitu or within 30 minutes of 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 scar or high parity (greater than 4). 71 Discuss 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 24 hours 74
o Shows no significant difference in caesarean birth rates 74
o Increased the need for epidural 74
o Mobility is restricted 1
o Refer to Table 16 for Dinoprostone considerations Is associated with lower infection rates in both mother and baby when membranes are ruptured at the time of IOL 74
Oxytocin induced contractions may be perceived as more painful Monitoring Provide one-to-one midwifery care 4
Use continuous electronic FHR monitoring once Oxytocin infusion commenced 75,71
Titrate dose to achieve 3-4 strong regular contractions in 10 minutes Assess maternal observations and FHR prior to any increase in the infusion rate Maternal observations (more frequently if clinically indicated) o Temperature 2 hourly o BP hourly o Pulse hourly o Vaginal loss hourly Maintain fluid balance as water intoxication may result from prolonged infusion 71 (rare with the use of isotonic solutions) Assess pain relief requirements Assessment of progress Commence the partogram or intrapartum record with the start of the infusion When labour established, consider the use of alert and action lines to monitor progress
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 18 of 26 4.2.1 Oxytocin admini stration Table 19. Oxytocin administration Consideration Oxytocin admini stration Admini stration Use a volumetric pump to ensure an accurate rate of infusion 4,71
o Consider the need for sideline/secondary IV access as per local protocols 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 intervals 4
o Aim for 3-4 contractions in a 10 minute period with duration of 40-60 seconds and resting period not less than 60 seconds Use the minimum dose required to establish and maintain active labour 4
Record the dose in milliunits per minute Mark changes to dose clearly and contemporaneously on the CTG and / or intrapartum 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
Consult with an obstetrician before recommencing infusion
4.2.2 Oxytocin regimens The ideal dosing regime of Oxytocin is unknown. 4 Suggested regimens are outlined in Table 20. Table 20. Oxytocin regimen Time after starting (minutes) Oxytocin dose (milliunits per minute) Volume infused (mL/hour) 10 IU in 500 mL 20 IU in 1000 mL 30 IU in 500 mL 0 1 3 3 1 30 2 6 6 2 60 4 12 12 4 90 8 24 24 8 120 12 36 36 12 150 16 48 48 16 180 20 60 60 20 Obstetrician review prior to exceeding 20 milliunits per minute 210 24 72 72 24 240 28 84 84 28 270 32 96 96 32
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 19 of 26 4.3 Arti ficial rupture of membranes Table 21. Artificial rupture of membranes considerations Artificial rupture of membranes (ARM) Indications Favourable cervix Bishop score 7 or more 76
May be used alone especially in a multiparous woman (may initiate contractions) or in combination with Oxytocin infusion 76
Cautions Caution should be exercised where the head is high due to the risk of cord prolapse 1 [refer to Section 5] Risk/Benefit Risk of pain, discomfort, bleeding 76
May shorten length of labour by speeding up contractions 77
Nulliparous women with ARM and immediate Oxytocin compared to delayed Oxytocin (commenced 4 hours post ARM) showed 78 : o Increased rate of established labour 4 hours after ARM o Shorter ARM to birth interval o Increased rate of vaginal birth within 12 hours o Increased satisfaction with the induction process and the duration of labour Monitoring Before ARM: o Explain the procedure to the woman 79
o Abdominal palpation to determine descent 80
o Assess for possible cord presentation o Consult obstetrician if the head is not engaged 80 or with possible cord presentation Immediately after ARM, examine to ensure there is no cord prolapse Refer to Table 23 for risk factors associated with IOL including cord prolapse Monitor FHR immediately following procedure 75 preferably by continuous electronic 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 hours o Nulliparous women: immediately following ARM as few women will commence contractions spontaneously unless the cervical score is 7 or more 73
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 20 of 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 secretion 81
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 placenta 81
Cautions: o Antepartum bleeding 4
o Rupture of membranes 4
o Cervicitis 4
Risk/Benefit Low cost and no specific storage or temperature requirements 81
No evidence of an increased risk of chorioamnionitis or endometritis although data is limited 81
May be associated with slight vaginal bleeding In women with a very unfavourable cervix, use seems to reduce failed IOL 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, obstetric review is indicated Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 21 of 26 5 Risks associated with induction of labour IOL may increase the risk of the following conditions outlined in Table 23. Table 23. Risk factors associated with IOL Risk Good Practi ce Point Failed IOL The criteria for failed IOL are not generally agreed 1
Recommended care options include 1 : o Review the individual clinical circumstances o Assess fetal wellbeing using CTG o Discuss options for care with the woman o If appropriate consider discharging home for 24 hours followed by second attempt at IOL o Caesarean section Uterine hypercontractility Attempt removal of any remaining Dinoprostone gel 82
Remove Dinoprostone pessary if still in situ 82
Stop Oxytocin infusion 1 while reassessing labour and fetal state Position woman left lateral Assess BP and FHR Commence intravenous hydration if not contraindicated by maternal condition Pelvic exam to assess cervical dilation If persists use tocolytics 1 : o Terbutaline 250 micrograms subcutaneously 73
o Salbutamol 100 micrograms by slow intravenous (IV) injection 75
o *Sublingual Glyceryl Trinitrate (GTN) spray 400 micrograms 75
If clinically indicated perform emergency CS 1
Cord prolapse Is a potential risk at the time of membrane rupture especially with ARM 1
Is an obstetric emergency 1
Precautions should include 1 : o Assessment of engagement of the presenting part o Caution during ARM if the babys head is high Uterine rupture Uterine rupture is an uncommon event with IOL 1
Uterine rupture is a life-threatening event for mother and baby If suspected, prepare for an emergency CS, 1 uterine repair or hysterectomy *Not currently listed on the Queensland Health List of Approved Medications (LAM) Not TGA approved for this purpose Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 22 of 26 References
1. National Collaborating Centre for Women's and Children's Health. Induction of labour. Clinical Guideline. J uly 2008 [cited 2011 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 elective induction of labor. Evidence report/technology assessment no. 176. AHRQ Publication No. 09-E005. Rockville, MD.: Agency for 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]. Available from: 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. Queensland Centre 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: your choices 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 expectant management 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, J ohansen O, Eik-Nes S, Salvesen K. Induction of labour or serial antenatal fetal monitoring 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 pregnant woman. 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 randomized controlled trials. International J ournal 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 management of postterm pregnancy. J ournal 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), content assessed 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-term pregnancy in low risk pregnancies: a randomised controlled trial. British J ournal of Obstetrics and Gynaecology: an International J ournal 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 the need for formal induction of labour? A randomised control trial. British J ournal of Obstetrics and Gynaecology. 1998; 105:34- 40. 17. Netta D, Visitainer P, Bayliss P. Does cervical membrane stripping increase maternal colonization of Group B streptococcus? American J ournal 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-risk patients at term pregnancy: A randomised controlled trial. The J ournal 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. Obstetrics and 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 expectant management in postterm pregnancy: a matched cohort study. J Midwifery Womens Health. 2009; 54(5):351-6. Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 23 of 26 21. Mozurkewich E, Chilimigras J , Koepke E, Keeton K, King VJ . Indications for induction of labour: A best-evidence review. BJ OG. 2009; 116:626-636. 22. Hartling L, Chari R, Friesen C, Vandermeer B, Lacaze-Masmonteil T. A systematic review of intentional delivery in women with preterm prelabor rupture of membranes. J ournal 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 women with preterm prelabour rupture of membranes prior to 37 weeks' gestation for improving pregnancy outcome. Cochrane Database 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 J ournal 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 expectant management. J ournal 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-stage labor 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 expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. The New England J ournal of Medicine. 1996; 334(16):1005-1010. 30. Hannah ME, Ohlsson A, Wang EEL, Matlow A, Foster GA, Willan AR, et al. Maternal colonization with group B Streptococcus and prelabor rupture of membranes at term: The role of induction of labor. American J ournal of Obstetrics and Gynecology. 1997; 177(4):780-5. 31. Queensland Maternity and Neonatal Clinical Guideline Program. Early onset Group B streptococcal disease. Guideline No. 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 and Gynecology. 2007; 50(2):518-25. 33. Landon MB, Hauth J C, Leveno KJ , Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. New England J ournal 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 birth after cesarean delivery: a multicenter study American J ournal 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. BJ OG: An International J ournal 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. J Women's Health. 2007 J ul-Aug; 16(6):833-41. 40. Glantz A, Marschall H, Mattsson L. Intrahepatic cholestasis of pregnancy: relationships between bile acid levels and fetal complication 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. Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 24 of 26 44. Roncaglia N, Arreghini A, Locatelli A, Bellini P, Andreotti C, Ghidini A. Obstetric cholestasis: outcome with active management. Eur J Obstet Gynecol Reprodu Biol. 2002; J an 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 of active induction of labor and expectant management. American J ournal 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 in gestational hypertension or mild preeclampsia at term. Hypertension in Pregnancy. 2010 [cited 15/12/2010]; (Sept 7 [epub ahead of print]):1-14. 49. SOGC clinical practice guideline. Diagnosis, evaluation and management of the hypertensive disorders of pregnancy. J ournal 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 of Systematic 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 J ournal 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. American J ournal 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 twin pregnancy. 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 the macrosomic fetus: a review. American J ournal 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 Database of 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 and Bayesian interpretation. British J ournal 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 Growth Restriction 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 spontaneous labour? Disproportionate intrauterine growth intervention trial at term (DIGITAT): a pilot study. European J ournal of Obstetrics, Gynecology, and Reproductive Biology. 2006; 125 (1). 61. Figueras F, Gardosi J . Intrauterine growth restriction: new concepts in antenatal surveillance, diagnosis, and management. American J ournal 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 Technical Bulletin Number 176 - J anuary. International J ournal of Gynaecology and Obstetrics. 1993; 42(3):291-9. 63. Royal College of Obstetricians and Gynaecologists. Heart Disease and Pregnancy - study group statement. Consensus views 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 in pregnancy 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. Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 25 of 26 66. MIMS Online. Prostin E2 Vaginal Gel [Pfizer]. 2008 [cited 2011 J une 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 J une 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 at term. 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 J ournal of Obstetrics and Gynaecology. 2008 Oct; 48(5):473-7. 71. MIMS Online. Syntocinon solution for injection [Novartis]. 2009 [cited 2011 J une 6]. Available from: https://www- mimsonline-com- au.cknservices.dotsec.com/Search/FullPI.aspx?ModuleName=Product%20Info&searchKeyword=Oxytocin&PreviousPage=~/S earch/QuickSearch.aspx&SearchType=&ID=8130001_2. 72. Sanchez-Ramos L, Bernstein S, Kaunitz A. Expectant management versus labor induction for suspected fetal macrosomia: 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. Cochrane Database 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 of Systematic 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 immediate oxytocin infusion versus amniotomy and delayed oxytocin infusion for induction of labour at term. Archives of Gynecology and Obstetrics. 2009; 279(6):813-20. 79. National Collaborating Centre for Women's and Children's Health. Intrapartum care: care of healthy women and their babies during childbirth Clinical Guideline [online]. 2007 (corrected J une 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 the absence 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 of Systematic 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
Queensland Maternity and Neonatal Clinical Guideline: Induction of labour Refer to online version, destroy printed copies after use Page 26 of 26 Acknowledgements The Queensland Maternity and Neonatal Clinical Guidelines Program gratefully acknowledge the contribution of Queensland clinicians and other stakeholders who participated throughout the guideline development process particularly:
Working Party Cl inical 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 J ennifer Fry, A/Midwife Educator, Womens Health, Darling Downs West Moreton District Health Service Professor Michael Humphrey, Clinical Adviser, Office of Rural and Remote Health Associate Professor Rebecca Kimble, Clinical Director, Obstetric Services, Royal Brisbane and Womens Hospital Ms 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 J essie 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 Clinical Network
Program Team Associate Professor Rebecca Kimble, Program Director, Queensland Maternity and Neonatal Clinical Guidelines Program Ms J acinta Lee, A/Manager, Queensland Maternity and Neonatal Clinical Guidelines Program Ms J ackie 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 Guidelines Program Steering Committee, Queensland Maternity and Neonatal Clinical Guidelines Program
Funding This clinical guideline was supported by funding from Centre of Healthcare Improvement, Queensland Health