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SDMS ID: P2010/0483-0012.8/09WACS

Title: Prostaglandin E2 (PE2 gel) Cervical RipeningReplaces: Prostaglandin E2 (PE2 gel) Cervical Ripening

WACSClinProc2.8/06Description: Induction of labour using Prostaglandin E2 (PE2 gel)

Target Audience: Midwifery and Medical Staff, Queen Victoria Maternity UnitKey Words: PE2 gel

Policy Supported: P2010/0321-001 Induction of Labour for Post Maturity

P2010/0486-001 Intrapartum Fetal Monitoring

P2010/0528-001 Uterine Hyperstimulation

Purpose:

Vaginal prostaglandin E2 (PE2 gel) has been shown to be efficacious in ripening thecervix prior to the induction of labour. The likelihood of delivery within 24 hours isincreased although there appears to be no significant change in the Caesareansection rate. There is however evidence for increased rates of uterinehyperstimulation with fetal heart rate change.

Indication for Prostaglandin

PE2 gel is used where induction of labour is indicated and the Bishops score is

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Abnormal fetal heart trace Ruptured membranes

DosageThe recommended dose is: Primiparous women 2mg PE2 gel Multiparous women 1 to 2mg PE2 gel

In the absence of significant uterine activity the dose maybe repeated in six hours. Thedecision to administer a second or third dose of PE2 gel must be made by the obstetricregistrar or consultant. The maximum dose of PE2 gel vaginal gel must not exceed 3mgover a six hour period.

Administ rat ion

Woman for cervical ripening should be admitted to 4B between 3 and 4 pm (or at atime convenient to the labour ward and clinician inserting the gel). The first dose ofPE2 gel will be administered at 4pm and the second dose given at 10pm. Thewoman will then be reviewed the following morning with a view to ARM andSyntocinon infusion.

Prostaglandin should be removed from the fridge 30 minutes prior to administration. A CTG must be performed prior to the administration. The CTG must be reassuring

prior to the administration of the PE2 gel. A consultant obstetrician may administerPE2 gel in the presence of a non-reassuring CTG after appropriate discussion andcounselling with the woman.

The PE2 gel maybe administered by midwifery staff when Bishops scoring has beendocumented and the PE2 gel has been ordered on the medication chart by themedical officer.

The gel should be inserted high into the posterior fornix of the vagina, avoidingadministration into the cervical canal.

It should be given using a water based lubricant only. The woman should remain recumbent for one hour following administration of PE2

gel. Because of the risk of hyperstimulation when used in conjunction with oxytocin, there

should be a delay of an absolute minimum of six hours after the PE2 gel has beenadministered and the commencement of intravenous oxytocin.

Clinical Observations

A CTG must be performed for one hour following the administration of PE2 gel. Maternal observations should be recorded prior to the insertion of PE2 gel, one hour

after the insertion of PE2 gel and thereafter, every four hours. Continuous fetal heart rate monitoring should be repeated 30 minutes prior to the

insertion of another dose.A reassuring CTG should be obtained once contractions are established and continuousCTG should be commenced when risk factors for fetal compromise have been detectedantenatally or are detected at the onset of labour or develop during labour (P2010/0486-001 Intrapartum Fetal Monitoring)

Indications for Removal of PE2 gel

Uterine hyperstimulation or hypertonic uterine contractions Fetal distress

Should this occur: Reposition women left lateral Consider Terbutaline 0.25mg subcutaneously Swab the vagina with a dry swab to remove residual prostaglandin gel. Notify midwife in charge and obstetric registrar/consultant.

http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0486-001http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0486-001http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0486-001http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0486-001http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0486-001

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Attachments

N/A

Performance Indicators: Evaluation of compliance with guideline to be achieved throughmedical record audit.

Review Date: Annually verified for currency or as changes occur, andreviewed every 3 years.

Stakeholders: Midwives and medical staff WACS

Developed by: Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director(Nursing & Midwifery) Womens & Childrens Services

Dr A Dennis Sue McBeathCo-Director (Medical) Co-Director (Nursing & Midwifery)Womens & Childrens Services Womens & Childrens Services

Date: 30 J une 2010

REFERNCES

Kelly AJ , Kavanagh J , Thomas J . Vaginal prostaglandin (PE2 GEL and PGF2a) forinduction of labour at term. Cochrane Database of Systematic Reviews 2003, Issue4. art. No.: CD003101. DOI: 10.1002/14651858.CD003101.

Royal Australian and New Zealand College of Obstetricians and Gynaecologist 2009College Statement Use of prostaglandins for cervical ripening prior to induction oflabour. Online:http://www.ranzcog.edu.au/publications/collegestatements.shtml

Mims Online Prescribing Information 2008 Prostin E2 Vaginal Gel viewed 14September 2009 .

National Institute for Clinical Excellence Clinical Guideline D 2008 Induction oflabour. Onlinehttp://www.nice.org.uk/guidance/index.jsp?action=byID&o=12012

http://www.ranzcog.edu.au/publications/collegestatements.shtmlhttp://www.ranzcog.edu.au/publications/collegestatements.shtmlhttp://www.ranzcog.edu.au/publications/collegestatements.shtmlhttp://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=811&product_name=Prostin+E%3csub%3e2%3c%2fsub%3e+Vaginal+Gelhttp://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=811&product_name=Prostin+E%3csub%3e2%3c%2fsub%3e+Vaginal+Gelhttp://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=811&product_name=Prostin+E%3csub%3e2%3c%2fsub%3e+Vaginal+Gelhttp://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=811&product_name=Prostin+E%3csub%3e2%3c%2fsub%3e+Vaginal+Gelhttp://www.nice.org.uk/guidance/index.jsp?action=byID&o=12012http://www.nice.org.uk/guidance/index.jsp?action=byID&o=12012http://www.nice.org.uk/guidance/index.jsp?action=byID&o=12012http://www.nice.org.uk/guidance/index.jsp?action=byID&o=12012http://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=811&product_name=Prostin+E%3csub%3e2%3c%2fsub%3e+Vaginal+Gelhttp://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=811&product_name=Prostin+E%3csub%3e2%3c%2fsub%3e+Vaginal+Gelhttp://proxy8.use.hcn.com.au/ifmx-nsapi/mims-data/?MIval=2MIMS_abbr_pi&product_code=811&product_name=Prostin+E%3csub%3e2%3c%2fsub%3e+Vaginal+Gelhttp://www.ranzcog.edu.au/publications/collegestatements.shtml