Induction of Labour Audit
Muhammad Uthman KhanFY2 in Obstetrics
Airedale General HospitalApril-August 2011
Aim
• To look at the indications, process and outcome of induction of labour at Airedale
• To determine whether this meets the CNST Maternity Standards 2011 and NICE Guidance (clinical guideline 70 – Induction of labour, July 2008)
Aim
• To gain an appreciation of the efficacy of single-dose Propess® (vaginal PGE2 controlled-release pessary), the most commonly used agent at Airedale, in inducing labour
• To determine the caesarean section and assisted delivery rates of inductions and review the indications both for inducing and mode of delivery in these instances
PurposeAudit will aim to benefit patients and the Trust by:• Ensuring induction is carried out only when
indicated to encourage normality in the labouring process
• Ensuring where induction is indicated, that the process meets specified standards, and where this falls short, changes made in the induction process that result in improved patient care, better outcomes and maternal satisfaction
Background
• Definition An intervention to of IOL:stimulate uterine contractions in
pregnancy prior to labour beginning spontaneously
• Reason: Deemed that early delivery is safer for the mother and/or foetus than allowing the pregnancy to continue its natural course
Background
• Around 1/5 deliveries in the UK induced1
• Induced labour may be less efficient and more painful than spontaneous labour2
• Associated with higher rates of assisted delivery (17-19%) compared to 12% with spontaneous labour1
1. Hospital Episode Statistics, Maternity data 2009-102. NICE clinical guideline 70, Induction of labour, July 2008
Methodology• Sample of 60 patients from those induced at
Airedale Hospital between January-March 2011• Used both hand-held + hospital maternity records
to gather data• Defined as those administered vaginal
prostaglandin (in either pessary, gel or tablet form) and/or those in whom amniotomy was performed when the woman was not in labour
Results
Maternal demographics
Age
Ethnicity
Parity
Parity
24
19
7 6
20 0
2
0
5
10
15
20
25
30
0 1 2 3 4 5 6 7
Previous C-Section
Induction information
Gestation at Induction (weeks)
Reason for Inducing
‘Other’ reasons
• Foetal tachycardia, reduced movements
• Hughes syndrome (antiphospholipid syndrome)
• Severe symphysis pubis dysfunction
• Suspicious CTG after presenting in query labour
Induction in specific circumstances
PROMLabour ward busy
Woman returning >24 hours later
Post-dates
Information provision and time of induction
Treatment and care to be offeredNo documentation
Time of induction
PROM
Admitted from clinic
Labour ward busy
Maternofoetal assessment & monitoring prior to and during
induction, before the establishment of labour
Prior to induction
• EFM to assess foetal wellbeing, performed in all (100%) cases
Modified Bishop Score
Information in notes but not formally calculated
Vaginal PGE2 used
Repeat CTG performed in all (100%) women who developed
contractions
Intermittent auscultation following normal CTG?
Laboured prior or CTG not normal
EFM
Maternal observations
Laboured prior
6-hourly
Propess®: duration in-situ
Time to labour:
Modified Bishop score reassessed in all (100%) women
who did not labour 24hrs following Propess® insertion
Prostin™
Outcome of Induction
Instrumental deliveries – reasons for induction
Indication for instrumental delivery
Caesarean sections – reasons for induction
Indication for caesarean section
Maternal complications
• A total of 3 women (6% of those receiving Propess®) suffered from uterine hyperstimulation
• 2/3 given Terbutaline
Failed Inductions
• Both induced for post-dates• Both had 24 hours of Propess®• One was a previous C-section therefore no
Prostin™ → C-section• The other woman had 2x Prostin™ 6 hours
apart, amniotomy performed after but did not labour → C-section
• Both had EFM following failed induction
Previous C-section managementReason for induction
All women had Propess®
None had Prostin™
Previous C-section managementOutcome of induction
Findings
• Single-dose Propess® (controlled-release vaginal prostaglandin E2 pessary) is effective as an induction agent in the majority of women (88%)
• Lower instrumental delivery (12%) and C-section rates (16%) in this audit compared to national average (England: 16-19% and 21-23% respectively)1
1. Hospital Episode Statistics, Maternity data 2009-10
Main Recommendations
• Scope for reducing intensity of foetal monitoring in low-risk women prior to establishment of labour to promote normality
• To review local guidelines on frequency of maternal observations during induction, prior to establishment of labour
• To re-audit in the near future after implementation of the new Induction of Labour proforma to determine effects
Areas for development
• To record timing of P/PROM from induction to delivery
• To identify whether epidural analgesia was administered
• Recording of actual bishop scores to allow analysis of correlation amongst successful and failed inductions
Thank you for listening
Any Questions?