provincial clinical knowledge topic induction of labour, adult – … · 2018-06-11 · document...

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Provincial Clinical Knowledge Topic Induction of Labour, Adult – Inpatient

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Induction of Labour, Adult – Inpatient V 1.3 of 39

Document History Version

No. Date Description of Revision Completed By /

Revised By 1.0 Feb. 2017 Document completed Dr. Wynne Leung

1.1 Oct. 2017 Minor abbreviation changes Modified Bishop score updated Dr. Wynne Leung

1.2 Dec. 2017 Table #4 Misoprostol considerations updated Dr. Wynne Leung 1.3 Jan. 2018 Order Sets revised to include option for other

medication Dr. Wynne Leung


Important Information Before you Begin The recommendations contained in this knowledge topic have been provincially adjudicated in order to support best practice and based on available evidence. Clinicians applying these guidelines should, in consultation with the patient, use independent medical judgment in the context of individual clinical circumstances to direct care. This knowledge topic will be reviewed periodically and updated as best practice evidence and practice change. The information in this topic strives to adhere to Institute for Safe Medication Practices (ISMP) safety standards and align with Quality and Safety initiatives and accreditation requirements. Some examples of these initiatives or groups are: Health Quality Council Alberta (HQCA), Choosing Wisely campaign, Safer Healthcare Now campaign etc.

This knowledge topic is based on the following guidelines:

• SOGC Clinical Practice Guideline – Induction of Labour • MORE OB – Induction of Labour


Rationale For induction of labour to be considered and to be offered, there must be evidence that such an intervention carries benefits for the mother and/or her baby and this requires careful consideration of the clinical evidence in discussion with the woman. In all cases, there is a clear need for the provision of information to allow women to make a fully informed choice. It is also important that the most accurate information is obtained concerning the gestational age of the pregnancy. In most instances there will be reliable menstrual data supported by evidence from an ultrasound examination made in the early weeks of pregnancy.3

In Canada the rates of induction have remained steady at around 21.8% since 2005. In Alberta the induction of labour rate among all women giving birth in 2014 was 30.1% representing an increase from 28.4% in 2012.1 The table below demonstrates zone comparison by facility by birth for 2014 and the rates of induction

Table 1 Zone Comparison by Birth 4 South

Zone Calgary

Zone Central Zone

Edmonton Zone

North Zone

Midwifery (Out of

Hospital)

Provincial Total

Maternal Indicator Count %

total Count %

total Count %

total Count %

total Count %

total Count %

total

Count %

total

No. of Deliveries 4167 19361 5851 18970 6330 1188* 55822

Induction of Labour 1059 25.4 6602 34.2 1487 25.4 5915 31.2 1674 26.4 50* 4.2 16787 30.1

From Alberta Perinatal Health Program Provincial Perinatal Data Report 2014

*In-patient statistics for Midwifery are included within the Site induction of labour numbers


Analytics

Baseline Analytic – Outcome Measure Name of Measure

Order set usage for Cervical Ripening and Induction of Labour

Definition For all patients admitted for cervical ripening and induction of labour, the number of times the order sets are utilized. Overall capture the following: • Patient demographics, region • Site and Zone identifiers • Unit/area • Method of cervical ripening • Method of induction • Documented Bishop Score • Laboratory investigations

Rationale These order sets are intended to standardize the process for cervical ripening and induction across the province based on the Society of Obstetricians and Gynecologists and MOREOB guidelines. This is intended to measure if the order sets are being utilized and what percentage of the time. This is also to potentially decrease the number of inductions within the province and improve outcomes. This may also indicate areas where there are potentially adoption issues or gaps in the knowledge provided.

Notes for Interpretation

This will increase access to knowledge in rural areas and improve access across the province.

Cited References

1. Society of Obstetricians and Gynecologists. Induction of Labour Review. http://www.jogc.com/article/pdf 2013; Sept. Reviewed 2015; Mar. (Clinical Practice Guideline no. 296) Accessed June 2016

2. MOREOB. Induction of Labour. https://secure.moreob.com 2016; Sept. Accessed Sept. 2016

http://www.jogc.com/article/S1701-2163(15)30842-2/pdf

https://secure.moreob.com/


Clinical Analytics – Outcome Measure #1 Name of Measure

For all patients undergoing induction of labour an appropriate indication for induction is identified

Definition Based on SOGC1 and MOREOB 2 guidelines and clinical assessment an appropriate indication for all patients undergoing induction of labour has been documented. When performed for the correct reasons and in the correct way, induction is useful and confers benefit2. The indication for induction has been discussed with the patient and an informed consent has been obtained

Rationale Studies have shown that by having appropriate indications for labour that there is a significant reduction in the number of elective inductions, unplanned Caesarean sections and decreased risk to maternal/fetal well-being. Medical induction of labour should only be carried out in a level one facility utilizing the appropriate indication(s) and also a plan for medical transfer to a facility with caesarean section capabilities if required.


Consideration is required for those patients with a history of rapid labour, logistical concerns such as distance from the hospital

Cited References

1. Society of Obstetricians and Gynecologists. Induction of Labour Review. http://www.jogc.com/article/pdf 2013; Sept. Reviewed 2015 Mar. (Clinical Practice Guideline no. 296) Accessed June 2016

2. MOREOB. Induction of Labour. https://secure.moreob.com 2016 Sept. Accessed Sept. 2016




Clinical Analytics – Outcome Measure #2 Name of Measure

Pre-induction assessment is performed by the clinician(s) prior to cervical ripening/induction of labour as a predictor of a positive outcome and determination of the appropriate method of cervical ripening/induction

Definition Based on the SOGC and MOREOB guidelines clinical assessment to confirm vertex presentation and an adequate Bishop score must be performed prior to cervical ripening and induction of labour. This is to assist in the determination method of cervical ripening and medical induction. Prior to initiation of oxytocin infusion fetal well-being should ascertained, an adequate Bishop score and fetal presentation and well-being confirmed.

Rationale The method of cervical ripening whether mechanical or pharmacological are considerations for: • Patient acceptance and preference • Cost considerations for the organization. This also is a consideration

when considering the choice of prostaglandin if the pharmacological method of cervical ripening is chosen.

Prior to initiation of oxytocin administration consideration is given to the favorability of the cervix, fetal well-being and adequate resources are in place. A protocol should be in place for the administration of oxytocin for all areas that provide induction of labour.


Disposition planning must be in place prior to initiation of cervical ripening and medical induction of labour. This should include a plan for transfer of patient to a facility capable of performing a Caesarean section if required. This should be included as part of the pre-induction assessment.

Cited References

1. Society of Obstetricians and Gynecologists. Induction of Labour Review. http://www.jogc.com/article/pdf 2013: Sept. Reviewed 2015; Mar. (Clinical Practice Guideline no. 296) Accessed June 2016

2. MOREOB. Induction of Labour. https://secure.moreob.com 2016; Sept. Accessed Sept. 2016




Goals of Management

1. The well-being of the woman and the fetus are the focus of care. 2. Treatment and care should takes into account the women’s individual needs and

preferences. 3. Treatment and care is culturally appropriate.

Key Principles

1. All women are offered information about the risks and benefits associated with induction of labour, and the proposed method of induction, to ensure documented informed consent.

2. Arrangements and support for pain relief options are discussed. 3. A plan for non-progressive or unsuccessful induction is discussed and options provided

for the patient. 4. Alternative options should be explored if the woman chooses not to have an induction.


Clinical Decision Support Modified Bishop Score

Assist: The Bishop score is a widely used tool to assess the status of a woman’s cervix. The physician is required to document and make decisions based on this score for women requiring induction.

Table 1 Modified Bishop Score 2

Score 0 1 2

Dilation (cm) Less than 1 1 - 2 3 - 4

Length (cm) Greater than 3 1 - 3 Less than 1

Consistency Firm Medium Soft

Position Posterior Mid Anterior

Station Spines - 3 Spines - 2 Spines -1 or lower

Total Bishop Score:

Date: Time:

Signature: Print Name:


Decision Making

Decision Path

Figure 1 Decision Path – Induction of Labour 2

Assess Bishop Score

Unfavorable Bishop Score less

than 6

FavorableBishop Score greater

or equal to 6

Cervical Ripening: • Balloon Devices• Prostaglandin

Induction of Labour:• Amniotomy• Prostaglandin• Oxytocin

Prioritize Urgent Less urgent

Consent Obtained

Adapted from MORE OB

Discuss Options

Pregnant Women or Fetus who may benefit from

induction

Acceptable Indication

Contraindication

Avoid Induction

YES NO

Yes No

Discuss Options

YES No


Prevention of Induction

• Routine early ultrasound for confirmation of expected date of delivery has been shown to reduce induction rates.

• Routine membrane sweeping or cervical massage promotes the onset of labour and decreases the rates of induction. When membrane sweeping is used the subsequent need for other induction methods needs to be balanced against women's discomfort and other adverse effects.2

• Clinician, maternal or unit preference should not be a consideration for induction

Table 1 Membrane Sweeping Considerations 1, 2 3

Consideration Comment Indications • Measure used to prevent induction of labour Risk/ Benefit • Repeated membrane sweeping has been found to significantly

reduce the number of post term pregnancies • The need for formal induction of labour is reduced • There is no evidence of increased risk of maternal or neonatal

infection • Some associated discomfort, potential vaginal bleeding and

irregular contractions has been reported Recommendations • Consider offering membrane sweeping at 38-40 weeks especially

to low risk women • Advise of the benefits of membrane sweeping • If the cervix is not dilated enough for membrane sweeping

cervical massage may be considered

Indications for Induction

High Priority • Suspected fetal compromise • Severe pre-eclampsia, eclampsia • Significant maternal disease not responding to therapy • Significant but stable antepartum hemorrhage • Chorioamnionitis • Term rupture of membranes with maternal GBS culture positive

Other Indications

• Postdates greater than 41 weeks • Uncomplicated twin pregnancy equal to or greater than 38 weeks • Diabetes Mellitus – level of glucose control may determine urgency or other

maternal/fetal co-morbidities (Clinical Question & Recommendations - Clinical Question # 1)

• Alloimmune disease at or near term • Intrauterine growth restriction • Oligiohydramnious • Gestational Hypertension greater than or equal to 38 weeks


• Intrauterine fetal death • Premature rupture of membranes at or near term – Group B Strep Negative • Logistical problems – history of rapid labour, distance to hospital • Intrauterine fetal death in prior pregnancy

Contraindications to Induction

• Placenta Previa, Vasa Previa • Cord presentation confirmed with Maternal Fetal Medicine consultation • Abnormal fetal lie or non-vertex presentation • Prior classical Caesarean section or inverted T uterine incision • Significant previous uterine surgery or uterine rupture • Active genital herpes • Pelvic structural deformities • Invasive cervical carcinoma

Situations where the benefit of Induction are uncertain

• Induction on the sole basis of suspected fetal macrosomia(large for gestational age) is not recommended (Clinical Questions & Recommendations - Clinical Question #2)

• Advanced maternal age – greater than 40 years of age, may be an indication for induction of labour at 39-40 weeks if concurrent medical co-morbidities exist and the woman is nulliparous (Clinical Questions & Recommendations - Clinical Question #3)

• Maternal obesity – BMI greater than 40, is not an indication for induction of labour unless concurrent medical co-morbidities exist or there are other indications that induction of labour is required. (Clinical Questions & Recommendations – Clinical Question # 7)

General Risks associated with Induction of Labour Predictors of successful induction include Bishop score equal to or greater than 6, and parity (prior vaginal delivery); and factors that may contribute to failure of induction include BMI greater than 40, later maternal age, estimated fetal weight greater than 4 kg, and diabetes

• Failure to achieve labor. An associated plan must be in place and documented. • Risk of uterine rupture increased in scarred uterus and maybe in an unscarred uterus • Chorioamnionitis • Cord prolapse with artificial rupture of membranes (ARM) • Inadvertent delivery of preterm infant in the case of inadequate dating • Uterine tachysystole (greater than 5 contractions in 10 minutes) • Operative vaginal delivery


Induction Process

Pre-induction Assessment • Review of maternal history including parity, (prior vaginal delivery), BMI, maternal

age, estimated fetal weight and history of diabetes • Vaginal examination to assess cervix and complete Bishop Score. Predictors of

successful induction include a Bishop Score greater than or equal to 6 • Confirmation of gestation • Confirmation of vertex presentation • Baseline temperature, pulse, blood pressure and fetal heart rate measurements • Perform urinalysis if the woman has diabetes, hypertension or if there has been

previous proteinuria • For women with pre-eclampsia, other medical conditions and other medical

complications of pregnancy, ensure that appropriate blood work is taken on day of induction of labour and results are available

Methods of Induction of Labour

1. Options for cervical ripening – unfavourable cervix (Bishop Score of less than 6) • Mechanical options

o Balloon devices

Table 2 Balloon Device Considerations 1, 2, 3

Consideration Comment Indications • Recommended where the cervix is unfavourable

• Prostaglandin has had no effect on cervical ripening Cautions Contraindication –

• Any contraindication to induction of labour (see contraindications) Caution – • For those women with latex allergies, latex free balloon devices

must be available on site • Care should be taken If this is provided on an outpatient basis

appropriate patient education and community support follow-up has been arranged

Risk/ Benefit • Low cost and no specific storage or temperature requirements e.g. foley catheter

• No evidence of an increased risk of chorioamnionitis or endometritis although data is limited

• Shortest induction to delivery interval • May be associated with slight vaginal bleeding • In women with a very unfavourable cervix, reduces unsuccessful

induction when compared to induction with oxytocin alone Assessment of Progress

• Notify the primary physician when/if the catheter falls out • Monitor fetal heart rate and uterine activity by auscultation and

palpation • Pharmacological options

o dinoprostone (PGE2)


Table 3 dinoprostone Considerations 1, 2, 3

Consideration Comment Indications • Unfavourable cervix Cautions Contraindication –

• Any contraindication to induction of labour (see contraindications) • Previous Caesarean section • Known hypersensitivity to dinoprostone (prostaglandin) or other constituents • Less than 35 weeks gestation • Abnormal fetal heart rate • Regular or painful uterine contractions Caution – • High parity • Fetal malpresentation • Multiple pregnancy • Ruptured membranes • Fetal growth restriction or oligiohydramnios • Maternal fever • Care should be taken, if this is provided on an outpatient basis, that regular

monitoring for uterine tachysystole is occurring , patient education and community support follow-up is arranged

Route & Dose Vaginal – available in gel preparation or vaginal insert • PGE2 Gel (Prostin E2®) 1 or 2 mg into the posterior fornix • PGE2 vaginal insert (Cervidil®) 10 mg into the posterior fornix and placed

transversely Risk/ Benefit • A lower operative rate than oxytocin, and less need for oxytocin augmentation

when used with an unfavourable cervix • Nausea, vomiting and diarrhea may occur soon after administration • Increased risk of uterine tachysystole with or without fetal heart rate (FHR)

abnormality (See Electronic Fetal Monitoring Guidelines: http://insite.electronic-fetal-monitoring.pdf ). Risk of uterine tachysystole is higher if oxytocin is used.

• Lower operative delivery rate Assessment of Progress

• Monitor FHR and uterine activity electronically, generally for periods of one to two hours post administration

• If contractions do not commence reassess the Bishop score 24 hour post dinoprostone insertion

• Consider removing the vaginal insert(Cervidil®): o When a patient is in established labour o When it has been 24 hours since administration o When membranes rupture o In cases of uterine tachystyole (greater than 5 contractions in 10 minutes

over 30 minutes) o In the presence of adverse maternal/fetal response

• If there is no response to dinoprostone consideration for repeat dose of dinoprostone should include evaluation of alternate form of induction

• In the case of uterine tachysystole ensure the vaginal insert or recently applied vaginal gel has been removed. Follow the management outlined in MOREOB

https://secure.moreob.com

o misoprostol (PGE1)

http://insite.albertahealthservices.ca/assets/scn/tms-scn-mncy-electronic-fetal-monitoring.pdf




Table 4 misoprostol Considerations 1, 2, 3

Consideration Comment Indications • MOREOB /SOGC support the use of misoprostol as an effective method of

labour induction, with intact membranes and when used on an inpatient basis.

• Recommended for use in the case of fetal demise. Cautions Contraindications:

• Any contraindication to Induction of Labour – (see contraindications) • Known hypersensitivity to misoprostol or other constituents • Should not be used in the setting of vaginal birth after Caesarean section • Multiple pregnancies • Ruptured Membranes • Concurrent oxytocin administration • Cardiovascular disease • Unexplained vaginal discharge and/or uterine bleeding during current pregnancy Caution: • Fetal well-being is required before administration of misoprostol. Electronic fetal

monitoring should be performed for 30 minutes after administration • Immediate Caesarean section availability is a pre-requisite Misoprostol is only available in 100 or 200 microgram tablets. This does not enable the health care provider to correctly guarantee the recommended dosage of 50 micrograms without manipulating the tablet (unless provided by Pharmacy). Manipulating the tablet requires precautions when handling. (See handling pre-cautions below.)

Handling Pre-Cautions

• Misoprostol is classified as a ‘hazardous medication’ (Reproductive Hazard) • Workers who are actively trying to conceive, women who are pregnant or may

become pregnant, or are breastfeeding, must exercise caution if manipulation of a dosage form is required.

Risk/ Benefit • Risk of uterine tachysystole • Uterine rupture • Meconium stained liquor • Stability at room temperature • Rapid onset of action • Can be administered oral, buccal, sublingual, vaginal, rectal

Route & Dose All doses of misoprostol can cause uterine tachystole. The oral and vaginal routes have a similar reduction of Caesarean section rates. The oral route requires more oxytocin stimulation but the vaginal route will have more tachysystole. The lower vaginal dose (25 mcg) tends to need more oxytocin stimulation and the higher vaginal dose (50 mcg) tends to have more uterine tachysystole. • Oral – 50 micrograms (mcg) *** (see cautions) every 4 hours as needed • Vaginal – 50 micrograms (mcg) *** (see cautions) every 4 hours as needed • In the case of fetal demise – Vaginal – 400 micrograms (mcg) every 4 hours

as needed Assessment of Progress

• No oxytocin should be started earlier than 4 hours after the last dose of misoprostol

• Continuous fetal monitoring for 30 minutes post any misoprostol dose (unless in the case of fetal demise)

Options for cervical ripening – favourable cervix (Bishop Score of greater or equal to 6)


• Artificial Rupture of Membranes

Table 5 Artificial Rupture of Membranes 1, 2, 3 (ARM)

Consideration Comment Indications • Favourable cervix – Bishop score greater than or equal to 6 or more

• May be used alone or in combination with oxytocin infusion Cautions Contraindication –

• Any contraindication to iInduction of labour (see contraindications) • Active genital infection Caution – • Cord prolapse • After the membranes are ruptured the care provider should continue to

palpate presenting part until it rests against the cervix to ensure there is no cord prolapse

• Group B prophylaxis should be provided if colonization is documented Risk/ Benefit • May not initiate labour

• May shorten length of labour by speeding up contractions • Nulliparous women with ARM and immediate oxytocin compared with

delayed oxytocin (commenced 4 hours post ARM) showed o Increased rate of established labour 4 hours post ARM o Shorter ARM to birth interval o Increased rate of vaginal birth within 12 hours

• Increased satisfaction with the induction process and the duration of labour Monitoring • Assess for possible cord presentation to ensure there is no cord prolapse

• Document liquor and consistency • Encourage mobilization to promote onset of contractions • Following ARM recommend initiating oxytocin in:

o Multiparous women if regular contractions have not been established after 1 hour

o Nulliparous women immediately following ARM Assessment of Progress

• Monitor fetal heart rate and uterine activity by auscultation and palpation • Monitor amount, color of amniotic fluid • Monitor vital signs at least every 4 hours

• oxytocin

Table 6 oxytocin Infusion Administration 1, 2, 3

Consideration Comment Indications • Favourable cervix – Bishop score greater or equal to 6 or more

• May be used alone especially in a multiparous woman (may initiate contractions)

Cautions Contraindication – • Contraindications to induction of labour (see contraindications) Caution – • It is preferable to undertake ARM prior to initiation of oxytocin if

membranes have not already ruptured


• It is recommended with intact membranes in the presence of HIV and/or Hepatitis B and/or C infection only after obstetric review and documented management plan

• If membranes have ruptured consider the number of digital examinations to decrease the risk of infections (Clinical Questions & Recommendations - Clinical Question #5)

• Previous uterine scar or high parity • oxytocin should not be administered, within 6 hours of dinoprostone gel

administration (Prostin E2®), within 30 minutes of removal of dinoprostone vaginal insert (Cervidil®), or within 4 hours of misoprostol dose (see misoprostol considerations)

Risk/Benefit Compared to induction of labour (IOL) with vaginal dinoprostone • oxytocin induction alone is associated with more failures to achieve

vaginal birth within 24 hours • No significant difference in Caesarean section birth rates • Increased need for epidural • Restricts mobility • Fetal heart rate disturbances (bradycardia, tachycardia) • Maternal gastrointestinal disorders (nausea/vomiting) • Water intoxication is possible with high dose oxytocin

Preparation • Mix 20 units of oxytocin in 1000 ml of lacated ringers or sodium choloride 0.9% solution. Complete independent double check prior to adding oxytocin to the infusion bag. http://insite.ahs.ca/independent-double-check-guideline

• IV delivery titrated through infusion pump by a secondary infusion line attached to control IV line as close to the venipuncture site as possible

Administration • Complete independent check when setting the initial infusion rate with the infusion pump medication program calculator prior to initiating IV infusion

• Set the initial oxytocin infusion rate at one to two milliunits per minute (low dose)

• Increase the infusion rate by one to two milliunits every 30 minutes, until adequate uterine response is obtained to achieve active labour to a maximum rate of 20 milliunits.

• For term healthy women, consider discontinuation or holding of oxytocin administration when contracting regularly and greater than 5 cm dilation (Clinical Questions & Recommendations – Clinical Question #9)

• Administration of oxytocin above 20 milliunits should be used with caution and close evaluation of progress of labour

Monitoring • Continuous external fetal monitoring (EFM) upon initiation of oxytocin.

(See Electronic Fetal Monitoring Guidelines http://insite.electronic-fetal-monitoring.pdf )

• EFM may be interupted for 30 minutes to facilitate ambulation and position changes after oxytocin rate is no longer being increased

• Titrate dose to achieve 3-4 strong regular contractions in 10 minutes • Assess the maternal blood pressure and pulse with each increase in the

oxytocin rate or more frequently if clinically indicated • Maternal observations (more frequently if clinically indicated)

o Temperature q 2 hourly o BP hourly o Pulse hourly o Vaginal loss hourly

• Maintain fluid balance

http://insite.albertahealthservices.ca/assets/policy/clp-provincial-med-mgmt-independent-double-check-guideline.pdf

http://insite.albertahealthservices.ca/assets/policy/clp-provincial-med-mgmt-independent-double-check-guideline.pdf




• Assess pain relief requirements Assessment of progress

• Assess the number, strength and timing of contractions • Chart progress, such as contraction pattern, cervical dilation, on the

partogram starting with initiation of the oxytocin infusion • Cease infusion if:

o Uterine activity becomes hypertonic – contractions less than 2 minutes apart from beginning of one contraction to the next or greater than 5 contractions in 10 minutes

o Contractions are lasting longer than 90 seconds o Resting uterine tone increases o Abnormal electronic fetal monitoring (EFM)

• In the case of uterine tachysystole ensure the oxytocin infusion is discontinued. Ensure assessment by the attending physician. Follow the management outlined in MOREOB https://secure.moreob.com

Methods that are not recommended for induction of labour

The following are methods not recommended for induction of labour: • Oral PGE2 • Intravenous PGE2 • Extra amniotic PGE2 • Intracervical PGE2 • Hylauronidase • Corticosteroids • Estrogen • Vaginal nitric oxide donors

Clinical Documentation

Nursing Interventions Prior to Induction/Cervical Ripening

• Review maternal history including gestational age, fetal presentation, Bishop score • Review current and past obstetrical history • Review understanding of process for induction of labour and ensure informed

consent has been obtained and documented including alternatives to treatment and any adverse events that could occur

• Ensure that no contraindications to induction are present (see contraindications) and the indication for induction documented

• Provide initial and ongoing patient teaching • Complete a maternal and fetal assessment including maternal vital signs

(temperature, pulse, respirations and blood pressure, and uterine activity) • Complete a fetal assessment that includes:

o A minimum of 20 minutes of electronic fetal monitoring to determine fetal well-being. Notify the physician of any fetal heart rate concerns

• Assess fetal response to cervical ripening • Assess for pain relief management • Notify responsible physician of progress of induction of labour



Pre Initiation of oxytocin

• Ensure Bishop score has been repeated by the physician • Physician order on the patient record • dinoprostone vaginal insertion (Cervidil®) has been removed if utilized for cervical

ripening • IV access has been initiated • Complete a maternal assessment including maternal vital signs (temperature, pulse,

respirations and blood pressure, and uterine activity • Complete a fetal assessment that includes:

o A minimum of 20 minutes of electronic fetal monitoring prior to initiation of oxytocin to ensure fetal well-being

• oxytocin dosage double checked • oxytocin not initiated until 30 minutes after dinoprostone vaginal insertion (Cervidil®)

has been removed, 4 hours after oral misoprostol administration and 6 hours after dinoprostone vaginal gel (Prostin E2®) administration

During oxytocin Induction • Initiate the partogram with onset of oxytocin administration • Assess response to oxytocin including uterine contractions, strength, time and length • Notify the physician if there are greater than 5 contractions in 10 minutes averaged

over 30 minutes, contractions less than 2 minutes apart from beginning of one contraction to the next

• Notify the physician if 20 milliunits/minute of oxytocin has been reached • Continuous electronic fetal heart rate monitoring with initiation of oxytocin. EFM may

be interrupted for 30 minutes for purposes of ambulation and position changes

• Assess fetal response to oxytocin administration. Notify the physician if there is an atypical tracing (See Electronic Fetal Monitoring Guidelines: http://insite.electronic-fetal-monitoring.pdf ) • Appropriate pain relief management as required. Notify physician if there is

inadequate pain control • Monitoring of maternal vital signs throughout the induction

Documentation

• Document on the patient record prior to initiating cervical ripening, prior to initiating oxytocin and during the induction process

• Initiate a partogram to document progress of induction, once oxytocin infusion is started

• Document the following parameters on the patient record: o Informed documented consent signed for induction of labour o Maternal observations and assessments including blood pressure, pulse,

respirations and temperature o Fetal heart rate, characteristics, and classification o Maternal and fetal responses to interventions o Initiation of cervical ripening and response o Initiation of oxytocin infusion, rate changes, uterine activity (frequency,

duration, contraction strength and resting tone). oxytocin infusion rates should always be documented in milliunits/minute




o Patient education provided Physician Assessment and Documentation Assessment This section contains specific considerations related to this topic. Standard assessment and documentation practices should still be followed. 1. History

• Review of maternal history • Confirmation of gestational age • Any co-morbidities such as obesity, hypertension, diabetes

2. Past History • Previous labour history • Previous complications of pregnancy • Previous uterine surgery

3. Medications & Allergies • Current medication regimen • Allergies documented

4. Review of Systems • Assess factors that contribute to failure of induction include BMI greater than 40,

maternal age greater than 35, estimated fetal weight greater than 4kg and diabetes • Baseline measurement of vital signs temperature, pulse, blood pressure and fetal

heart rate • Confirmation of vertex presentation

5. Family History

• Adverse reaction to anesthetic

• Any history of bleeding disorders 6. Scoring Tools / Risk Scores

• Consider prevention strategies to prevent induction for postdates – early ultrasound to determine accurate dating of the pregnancy, membrane sweeping and cervical massage

• Bishop Score Documentation 1. Pre-assessment carried out prior to induction documented on the patient record 2. Informed consent obtained and documented 3. The indication for induction must be documented and should include:

• Indication for induction • Bishop Score • Confirmation of vertex presentation • Method of induction • Risks including failure to achieve labour • Possible increased risk of Caesarean section

4. Documentation of absence of contraindications to induction of labour


Order Set: Cervical Ripening Order Set Components Order Set Key words: Induction, Labour, Cervix Order Set Requirements:

• Documented Bishop Score on patient record • Confirmation of vertex presentation

Diet

Maternal Diet NPO – when in active labour NPO – may take oral medications Clear Fluids – when in active labour Other __________

Activity

Bedrest Bedrest with Bathroom privileges Ambulate with assist Activity as tolerated

Monitoring

Vital Signs: These orders need to be re-evaluated based on progression of labour. Vital signs to include: respiratory rate (RR), pulse rate (P), blood pressure (BP), temperature (T), and oxygen saturation (O2 sat) with options to include:

As per local standards Every _____ minutes Every _____ hour

External Fetal Monitoring • Nonstress test (NST) immediately prior to dinoprostone or balloon catheter

insertion to determine fetal well being • Notify the primary clinician based on the Electronic Fetal Heart Rate Guidelines • Monitor fetal heart rate for at least 60 minutes post dinoprostone gel or

dinoprostone vaginal insertion

Laboratory Investigations

Ensure completed prior to decision to proceed with cervical ripening and induction of labour Hematology

Complete Blood Count (CBC) Microbiology

Group B Strep Vaginal/Rectal Swab (if status unknown)

Urine Tests Urine dipstick (Point of care testing) Urinalysis Random


Intravenous Therapy Intravenous Cannula – Insert: Initiate IV IV Peripheral Saline Flush/Lock: Insert Saline Lock 0.9% NaCl infusion IV at _____ mL/hour lactated ringers infusion IV at ____ mL/hour

Medications

dinoprostone vaginal insert 10 mg INTRA VAGINALLY once. (dinoprostone may be left insitu for up to 24 hours)

dinoprostone vaginal insert (remove upon onset of active labour, rupture of membranes or 24 hours after insertion)

Remove dinoprostone vaginal insert

dinoprostone vaginal gel ____ mg INTRA VAGINALLY once May repeat dinoprostone vaginal gel ___ mg INTRA VAGINALLY after 6 hours Other: ________________ Dose ______ mg Route _______ Frequency ______ hours

PRN Analgesics morphine _____ mg IM every 3 hours PRN morphine 2.5 mg DIRECT IV PRN every 10 minutes PRN (Maximum dose of 10 mg)

fentaNYL _____ mcg DIRECT IV PRN every 10 minutes PRN, (Recommended

fentaNYL dose: 0.5 mcg/kg). Maximum 50 mcg per dose. Maximum cumulative dose of 2 mcg/kg in 1 hour. Maximum total cumulative dose of 4 mcg/kg.

Entonox® Inhalation PRN during contractions

PRN Antinauseants dimenhyDRINATE ____ mg IVPB every ___hours PRN dimenhyDRINATE ____ mg IM every ___hours PRN

Transitions and Referrals

Consult Anesthesia Consultant Contacted Yes Not Required Consult Obstetrician on call Consultant Contacted Yes Not Required Consult Endocrinology Consultant Contacted Yes Not Required Consult Neonatology Consultant Contacted Yes Not Required Consult _________ Consultant Contacted Yes Not Required


Order Set: Induction of Labour Order Set Components Order Set Keywords: Induction, Labour, oxytocin Order Set Requirements:

• Documented Bishop Score on patient record • Confirmation of vertex presentation

Diet

Maternal Diet NPO – when in active labour NPO – may take oral medications Clear Fluids Other __________

Activity

Bedrest Bedrest with Bathroom privileges Ambulate with assist Activity as tolerated

Monitoring

Vital Signs: These orders need to be re-evaluated based on progression of labour. Vital signs to include: respiratory rate (RR), pulse rate (P), blood pressure (BP), temperature (T), and oxygen saturation (O2 sat) with options to include:

As per local standards Every _____ minutes Every _____ hour

External Fetal Monitoring • Continuous external fetal monitoring (EFM) upon initiation of oxytocin • May interrupt external fetal monitoring (EFM) tracing for 30 minutes to facilitate

periods of ambulation, bathing or position changes after oxytocin rate is no longer being increased

• Notify the primary clinician based on the fetal heart rate guidelines

Laboratory Investigations Ensure completed prior to decision to proceeding with cervical ripening and induction of labour

Hematology

Complete Blood Count (CBC) Type and Screen (consider if high risk patient only)


Microbiology Syphilis Antibody Test – Blood

Urine Tests

Urine dipstick (Point of care testing) Urinalysis Random

Intravenous Therapy

Intravenous Cannula – Insert: Initiate IV IV Peripheral Saline Flush/Lock: Insert Saline Lock 0.9% NaCl infusion IV at _____ mL/hour lactated ringers infusion IV at ______ mL/hour

Medications

oxytocin Infusion – oxytocin should not be administered, within 6 hours of dinoprostone gel administration (Prostin E2®), within 30 minutes of removal of dinoprostone vaginal insert (Cervidil®), or within 4 hours of misoprostol dose • oxytocin 20 units in _______ (0.9% NaCl OR lactated ringers infusion) IV 1000 mL • Administer oxytocin 1 to 2 milliunits/minute. Increase the infusion rate by one to two

milliunits every 30 minutes, until adequate uterine response is obtained to achieve active labour to a maximum rate of 20 milliunits/minute as per protocol

• Notify the primary clinician for assessment prior to increasing beyond 20 milliunits/minute

• For term health women, consider discontinuation or holding of oxytocin administration when contracting regularly and greater than 5 cm dilation

oxytocin 5 units DIRECT IV with delivery of anterior shoulder oxytocin 10 units IM with delivery of anterior shoulder if no IV access Other: ________________ Dose ______ mg Route _______ Frequency ______ hours

PRN Analgesics

morphine ____ mg IM every 3 hours PRN morphine 2.5 mg DIRECT IV PRN every 10 minutes to a maximum of 10 mg

fentaNYL _____ mcg DIRECT IV PRN every 10 minutes PRN, (Recommended fentaNYL dose: 0.5 mcg/kg). Maximum 50 mcg per dose. Maximum cumulative dose of 2 mcg/kg in 1 hour. Maximum total cumulative dose of 4 mcg/kg.

Entonox® Inhalation PRN during contractions PRN Antinauseants

dimenhyDRINATE ____ mg IV every 3 hours PRN dimenhyDRINATE ____ mg IM every 3 hours PRN


Group B Strep Positive/Status Unknown

• No Known allergy to Penicillin penicillin G sodium 5 million units IV once and then penicillin G sodium 2.5 million

units IV every 4 hours until delivery (no known allergy to penicillin)

• Allergy to Penicillin (no evidence/risk of anaphylaxis) ceFAZolin 2 g IV once and then ceFAZolin 1 g IV every 8 hours IV until delivery

(allergy to penicillin with no evidence/risk of anaphylaxis)

• Allergy to Penicillin (with evidence/risk of anaphylaxis) Isolate susceptible to clindamycin

clindamycin 900 mg IV every 8 hours until delivery(Group B isolate susceptible to clindamycin)

Isolate resistant to clindamycin (including inducible resistance or when susceptibilities) vancomycin 1 g IV every 12 hours until delivery (15mg/kg based on actual body

weight to maximum of 2 g [Group B isolate resistant to clindamycin, including inducible resistance])

Transitions and Referrals Consult Anesthesia Consultant Contacted Yes Not Required Consult Obstetrician on-call Consultant Contacted Yes Not Required Consult Endocrinology Consultant Contacted Yes Not Required Consult Neonatology Consultant Contacted Yes Not Required Consult __________ Consultant Contacted Yes Not Required


Disposition Planning 1. Considerations for Transfer1

• Medical induction by labour by oxytocin infusion is not recommended at a level 1A facility unless the following circumstances recognized to be conducive to a favourable outcome exsit:

a. Gestational age of greater than 38 weeks o Priminpara (primip) or o Multipara (multip) with previous uncomplicated vaginal delivery

b. Singleton fetus c. Bishop Score of equal to or greater than six d. A low antepartum risk score e. A back up plan has been established with a level 1B or higher hospital; f. The patient understands the risks associated with induction of labour and there

is a documented informed consent

Note: Membrane sweeping, cervical ripening by dinoprostine vaginal insertion (Cervidil®) or prostaglandin gel (Prostin E2 ®), insertion of cervical balloon and augmentation of already established labor is not included in the description of induction in this policy.

Acute Care Levels of Service for Obstetrical Patients

Table 1 Acute Care Service Levels 5

Acute Care Level

Sub Levels

Obstetrical Workforce Support Description of Service

Level Zero • No Health Services Level One • No obstetrical services. Triage and

transport to nearest obstetrical facility

Level One A

Required Support: • 24/7 maternity care providers • Obstetrical consults available

within 45 min for non-urgent. 30 m minutes or less for emergent inquires

• 1:1 nursing care, triage support

• Intrapartum care provided at facility 24/7 o Normal birth o Antepartum/postpartum

outpatient • Nursery

o Care for term newborns (37 weeks and greater)

o Triage and transport according to AHS obstetrical and transfer of care policy

Level One B

Required Support: • 24/7 maternity care providers • 24/7 on-call general practitioner

with enhanced skills includes surgery and anesthetists

• Obstetrical consults available within 45 minutes for non-urgent.

• Obstetrical Intrapartum care provided at facility 24/7 o Normal birth, epidurals,

inductions o Antepartum/Post-partum

outpatient and inpatient o Bereavement program:

stillbirth/neonatal death


30 minutes or less for emergent inquires

• 1:1 nursing care, triage support, bereavement support, and 24/7 OR support team

• Laboratory/Diagnostic Imaging/Pharmacy

• Transfusion Medicine

o 24/7 emergent surgical access: caesarean section

• Nursery o Care for term newborns (37

weeks and greater) o Triage and transport according to

AHS Obstetrical consult and transfer of care policy

o Triage and transport baby according to AHS care of late preterm infant policy

Level One C

Required Support: • 24/7 on-call obstetrician • 24/7 on-call anesthesia Multidisciplinary team for mother and newborn: • Family Medicine • Midwives • On-call medical and surgical

specialist • 1:1 nursing care, triage support,

bereavement support, and 24/7 OR support team

• 24/7 on-call Laboratory/Diagnostic Imaging/Pharmacy

• Transfusion Medicine

• Specialty of Obstetrics provided at facility 24/7 o Normal birth, epidurals,

inductions o Antepartum/ medial outpatient

and medical inpatient o Antepartum surgical outpatient

and surgical inpatient support o Post-partum outpatient and

inpatient support o Bereavement program:

stillbirth/neonatal death o 24/7 emergent surgical access:

Caesarean section • Nursery

o Care for term newborns (37 weeks and greater)

o Triage and transport according to AHS obstetrical consult and transfer of care policy

Level Two

Required support: • 24/7 obstetrician • 24/7 paediatrician • 24/7 anaesthetist Multidisciplinary team for mother and newborn: • Family Medicine • Midwives • On-call medical and surgical

specialist • 1:1 nursing care, bereavement

support, triage support and 24/7 OR support team

• 24/7 on call Laboratory/Diagnostic Imaging/Pharmacy/

• Transfusion medicine

Specialty of Obstetrics provided at facility 24/7: • Normal birth, epidurals, inductions • Antepartum medical outpatient and

medical inpatient, • Antepartum surgical outpatient and

surgical inpatient support • Postpartum outpatient and inpatient

support • Bereavement program:

stillbirth/neonatal death • 24/7 emergent surgical access:

caesarean section Nursery: • Accepts 32-35 weeks preterm

infants • Multiples over 34 weeks • Care for abnormal or ill preterm and

term newborns • Triage and transport according to

AHS obstetrical consult and transfer of care policy


Level Three

Required support: • 24/7 onsite obstetrician • 24/7 paediatrician • 24/7onsite neonatologist • 24/7 anaesthetist • perinatologist Multidisciplinary team for mother and newborn: • On-call medical specialist • 1:1 nursing care during labour,

antepartum unit support, bereavement support, triage support

• 24/7 OR support team • Social workers • 24/7 on-call

Laboratory/Diagnostic Imaging/Pharmacy

• Transfusion medicine

Specialty of Obstetrics provided at facility 24/7: • Normal birth, epidurals, inductions • Antepartum medical outpatient and

medical inpatient, • Antepartum surgical outpatient and

surgical inpatient support • Critical care antepartum support • Postpartum outpatient and inpatient

support • Postpartum critical care support • Bereavement program:

stillbirth/neonatal death • 24/7 emergent surgical access:

caesarean section Nursery: • Accepts less than 32 weeks preterm

infants • Care for abnormal or ill preterm and

term newborns • Multiples under 34 weeks


References 1. Society of Obstetricians and Gynecologists. Induction of Labour Review. http://sogc.org/wp-

content/uploads 2013; Sept. Reviewed 2015 Mar. (Clinical Practice Guideline no. 296) Accessed June 2016

2. MOREOB. Induction of Labour. https://secure.moreob.com 2016; Sept. Accessed Sept. 2016 3. Canterbury District Health Board. Induction of Labour. http://www.cdhb.health.nz/maternity-

care-guidelines 2014; Apr. (Clinical Practice Guideline no.GLM0035). Accessed June 2016. 4. Data provided by Alberta Perinatal Health Program. Provincial Data Report. 2014. Accessed

June 2016 5. AHS Practice Guideline. Obstetrical Criteria to Support Appropriate Level of Obstetrical

Care. 2017: Feb. 6. AHS Provincial and Rural Maternal Care Steering Committee. AHS Acute Care Service

Levels 2016; Dec.

http://sogc.org/wp-content/uploads%20%202013

http://sogc.org/wp-content/uploads%20%202013


http://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/maternity-care-guidelines/Documents/GLM0035-Induction-of-Labour.pdf

http://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/maternity-care-guidelines/Documents/GLM0035-Induction-of-Labour.pdf


Clinical Questions & Recommendations Key components of high quality and trustworthy clinical guidance include: i) recommendations that are clearly stated and based on scientific evidence of benefits, harms and where possible, costs, and ii) a guideline rating system that is used to communicate quality and reliability of both the evidence and the strength of its recommendations. The GRADE terminology is used to address the questions regarding Quality of Evidence and Strength of Recommendations and components are described below. GRADE Methodology Whenever possible answers are identified from recent high quality guidelines or high quality systematic reviews and recommendations provided are based on GRADE definitions. Where guidelines or systematic reviews are not available to answer certain questions rapid reviews are undertaken and/or a consensus approach used to try to answer clinically relevant questions. Only where the evidence is supportive and the benefits clearly outweigh the harm is “we recommend” strength of recommendation applied.

Table 1. GRADE Quality of Evidence1 High GRADE A

We have high confidence that the true effect lies close to that of the estimate of the effect.

Moderate GRADE B

We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Low GRADE C

Our confidence in the effect estimate is low: The true effect may be substantially different from the estimate of the effect.

Very low GRADE D

We have very low confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

Table 2. GRADE Strength of Recommendations1 Strong GRADE 1

Strong recommendation, with desirable effects clearly outweighing undesirable effects/burdens (or vice versa). Wording of Recommendation: We recommend in favor of / We recommend against…..

Weak GRADE 2

Weak recommendation, with desirable effects closely balanced with undesirable effects. Wording of Recommendation: We suggest in favor of / We suggest against …..

Insufficient evidence or no consensus

Wording of Recommendation: There is insufficient evidence or the confidence in the effect estimates is so low that the panel is unable to make a recommendation regarding….

1. Guyatt GH, Oxman AD, Vist GE, et al; for the GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008; 336(7650):924-926.


Clinical Recommendations Clinical Question #1: What is the most appropriate gestational age to induce women with diabetes (gestational, Type I or Type II)? Summary of Findings:

1. If gestational diabetes is the only complication, induction of labour can be offered at 39 +6

weeks so delivery could take place in the early part of the 40th week up to 40+6 (based on primary outcome: avoidance of stillbirth)

Quality of Evidence: Low – Grade C

Strength of Recommendation: Weak – Grade 2

2. If gestational diabetes is accompanied by other maternal or fetal complications, consider induction of labour before 40+6 weeks Quality of Evidence: Low – Grade C Strength of Recommendation: Weak – Grade 2

3. If Type I or Type II diabetes is the only complication, induction of labour should be offered between 37+0 weeks and 38+6 weeks

Quality of Evidence:

Low – Grade C

Strength of Recommendation: Weak – Grade 2

4. If Type I or Type II diabetes is accompanied by other maternal or fetal complications, consider induction of labour before 37+6 weeks Quality of Evidence: Low – Grade C Strength of Recommendation: Weak – Grade 2

References 1. Society of Obstetricians and Gynecologists. Induction of Labour. SOGC; 2013 Sept.

Reviewed 2015 Mar. (Clinical Practice Guideline no. 296). 2. National Institute for Health and Care Excellence Diabetes in Pregnancy. London (UK):

NICE; 2015 Feb. (Clinical Guideline no.3) 3. Melamed N, Ray J, Geary M, Bedard D, Yang C. Induction of labor before 40 weeks is

associated with lower rate of caesarean delivery in women with gestational diabetes mellitus. Am J Obstet Gynecol 2016; 214:364 e1-8

4. Martis R, Brown J, Alsweiler J, Crawford T, Crowther C. Different intensities of glycaemic control for women with gestational diabetes mellitus. Cochrane Database Syst Rev. 2016 Apr 7; 4:CD011624. doi: 10.1002/14651858.CD011624.pub2

5. Auckland Consensus Guideline on Induction of Labour. Published June 2014 6. World Health Organization. Recommendations for Induction of Labour. Geneva,

Switzerland. World Health Organization; 2011


Clinical Question #2: What are the recommendations for induction of labour for suspected large for gestational age fetuses (LGA)? Summary of Findings: We suggest against induction of labour on the sole basis of macrosomia/large for gestational age fetus. Quality of Evidence: Low – Grade C Strength of Recommendation: Weak – Grade 2

References 1. World Health Organization. Recommendations for Induction of Labour. Geneva,

Switzerland. World Health Organization; 2011 2. Boulvain M, Senat M, Perrotin F, Winer N, Beucher G et al. Induction of labour versus

expectant management for large-for-date fetuses: a randomized controlled trial. Lancet 2015; 385: 2600–05

3. Boulvain M, Irion O, Dowswell T, Thornton JG Induction of labour at or near term for suspected fetal macrosomia (Review) Cochrane Database of Systematic Reviews 2016 (5) CD000938. DOI: 10.1002/14651858

4. Queensland Health Clinical Guidelines. Induction of Labour 2011. Maternity and Neonatal Clinical Guideline. Queensland Government.

5. National Institute for Health and Care Excellence. Inducing Labour. London (UK): NICE; 2008 Jul. (Clinical Guideline no.70)

6. American College of Obstetricians and Gynecologists. Practice Bulletin: Fetal Macrosomia. ACOG: 2016; Nov. American College of Obstetricians and Gynecologists. Washington. D.C. (Practice Bulletin No. 173)

Clinical Question #3: Is advanced maternal age an indication for induction of labour? Summary of Findings: We suggest advanced maternal age may be an indication for induction of labour at 39–40 weeks if concurrent medical co-morbidities exist and the women is nulliparous or over 40 years of age Quality of Evidence: Low – Grade C Strength of Recommendation: Weak – Grade 2


Reviewed 2015 Mar. (Clinical Practice Guideline no. 296). 2. Walker K, Bugg J, Macpherson M, McCormick C, et al. Randomized Trial of Labor Induction

in Women 35 Years of Age or Older. N Engl Med 2016: 374(9): 813-822 3. Royal College of Obstetricians and Gynecologists. Induction of Labour at term in older

mothers Scientific Impact Paper. No. 34. 2013. Feb.

Clinical Question #4: Is maternal pain, discomfort with pregnancy, psychological distress an indication for induction of labour? Summary of Findings: There is insufficient evidence to make a recommendation Quality of Evidence: There is insufficient evidence to make a recommendation Strength of Recommendation: Weak – Grade 2. NICE suggests a dialogue between the woman and the clinician



Reviewed 2015 Mar. (Clinical Practice Guideline no. 296). 2. World Health Organization, Recommendations for Induction of Labour. Geneva,

Switzerland. World Health Organization; 2011 3. Queensland Health Clinical Guidelines. Induction of Labour 2011. Maternity and Neonatal

Clinical Guideline. Queensland Government. 4. National Institute for Health and Care Excellence. Inducing Labour. London (UK): NICE;

2008 Jul. (Clinical Guideline no.70) 5. National Institute for Health and Care Excellence. Intrapartum Care for Healthy Women and

Babies. London (UK): NICE; 2014 Dec. (Clinical Guideline no. 190) 6. Miquelutti M, Cecatti J, Makuch M. Evaluation of a birth preparation program on lumbopelvic

pain, urinary incontinence, anxiety and exercise: a randomized controlled trial. BMC Pregnancy and Childbirth 2013; 13:154-173

Clinical Question #5: Does cervical examination following PROM/PPROM increase the risk of maternal or neonatal infection or other adverse outcomes? Summary of Findings:

• For women with PROM, we suggest limiting, to two or less, or avoiding cervical examinations prior to the onset of active labour

• For women with PPROM, we suggest avoiding cervical examinations to reduce the risk of decreasing the latent period

Quality of Evidence: Moderate – Grade B Strength of Recommendation: Strong – Grade 1 unless there is some benefit to cervical examination References 1. National Institute for Health and Care Excellence Intrapartum Care for Healthy Women and

Babies. London (UK): NICE; 2014 Dec. (Clinical Guideline no. 190) 2. Wagner M, Chin V, Peters C, Drexler B, Newman L. A Comparison of Early and Delayed

Induction of Labor with Spontaneous Rupture of Membranes at Term. AM J Obstet Gynecol 1989; 74(1): 93-97

3. Shalev E, Peleg D, Eliyahu S, Nahum Z. Comparison of 12- and 72-Hour Expectant Management of Premature Rupture of Membranes in Term Pregnancies. AM J Obstet Gynecol. 1995; 85(5): 766-768

4. Ladfors L, Mattson L, Eriksson M, Fall O. A randomised trial of two expectant managements of prelabour rupture of the membranes at 34 to 42 weeks. BJOG. 1996 103: 755-762

5. Seawood G, Hannah M, Myhr T, Farine D, et al. International Multicentre Term Prelabor Rupture of Membranes Study: Evaluation of predictors of clinical Chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. AM J Obstet Gynecol. 1997; 177(5):1024-1029

6. Royal College of Obstetricians and Gynecologists. Premature Rupture of Membranes. London (UK); 2006 Nov. Updated 2010 Oct. (Guideline 44)

7. Registered Nurses Association of Ontario. Management of Prelabour Rupture of Membranes at Term. 2010. (Clinical Practice Guideline no.13)

8. Cahill A, Duffy C, Odibo A, Roehl A, Zhao Q, et al. Number of Cervical Examinations and Risk of Intrapartum Maternal Fever. AM J Obstet Gynecol . 2012; 119(6): 1096-1101

9. Reiter E, Nielsen K, Fedder J. Digital examination and transvaginal scan – competing or complementary for predicting preterm birth? Acta Obstet Gynecol Scand. 2012; 91:428–438.


Clinical Question #6: What are the effects of delaying oxytocin initiation following cervical ripening? Summary of Findings: We suggest that for low risk pregnancies, delaying oxytocin initiation might be considered. Quality of Evidence: Low – Grade C Strength of Recommendation: Weak – Grade 2 References 1. Bugg G, Siddiqui F, Thornton J. Oxytocin versus no treatment or delayed treatment for slow

progress in the first stage of spontaneous labour. Cochrane Database of Systematic Review. 2013; (6): CD007123: DOI: 10.1002/14651858.CD007123

Clinical Question #7: Does maternal body mass index (BMI) influence the oxytocin dose given for medical induction of labour? Summary of Findings: There is insufficient evidence to make a recommendation for oxytocin dosage based on maternal body mass index (BMI). Quality of Evidence: There is insufficient evidence to make a recommendation Strength of Recommendation: There is insufficient evidence to make a recommendation References 1. Society of Obstetricians and Gynecologists. Induction of Labour. SOGC; 2013 Sept.

Reviewed 2015 Mar. (Clinical Practice Guideline no. 296). 2. Frey H, Methodius G, Tuuli S, England K, Kimberly A, Roehl, A, et al. Factors associated with

higher oxytocin requirements in labor. J Matern Fetal Neonatal Med, 2015; 28(13): 1614–1619.

3. Chin J, Henry E, Holmgren C, Varner M, Ware Branch D. Maternal obesity and contraction strength in the first stage of labor. AM J Obstet Gynecol. 2012; 207:129.e1-6

4. New South Wales Government Policy Statement. Maternity - Oxytocin for the Induction of Labour at or Beyond Term. Sydney, Australia. 2011 Nov. PD2011_075.

5. Roloff K, Peng S, Sanchez-Ramos L, Valenzuela G. Cumulative oxytocin dose during induction of labor according to maternal body mass index. International J of Gynecol Obstet 2015; 131:54-58.

6. Hill M, Reed K, Cohen W. Oxytocin utilization for labour induction in obese and lean women. J. Perinat Med. 2015; 43(6): 703–706

7. Lassiter J, Holliday N, Lewis D, Mulekar M, Abshire J, Brocato B. Induction of labor with an unfavorable cervix: how does BMI affect success? J Matern Fetal Neonatal Med, 2016; 29(18): 3000–3002

Clinical Question #8: Once oxytocin is discontinued for induction of labour, what is a reasonable re-start dose? Summary of Findings: There is insufficient evidence to make a recommendation in determining a re-start dose for oxytocin following discontinuation Quality of Evidence: There is insufficient evidence to make a recommendation Strength of Recommendation: There is insufficient evidence to make a recommendation


References 1. Royal Berkshire National Trust Health Foundation. Maternity Guidelines Oxytocin regime for

augmentation or induction of labour guideline. 2014 July (Clinical guideline no.GL925) 2. American Congress of Obstetricians and Gynecologists (ACOG). Optimizing Protocols in

Obstetrics. Series 1. Albany (NY); 2011 Dec. 3. Yale University & Yale-New Haven Hospital. Clinical Practice Manual. Oxytocin for Labour.

Published 2009. 4. Budden A, Chen L, Henry A. High-dose versus low-dose oxytocin infusion regimens for

induction of labour at term. Cochrane Database of Systematic Review 2014 Aug. (10) CD009701.DOI: 10.1002/14651858

Clinical Question #9: What are the Maternal/Fetal risk/benefits to discontinuing versus continuing oxytocin during the active phase of labour? Summary of Findings: We recommend considering discontinuation of oxytocin after 5 centimeters dilation in term healthy women to decrease risks of hyperstimulation, post-partum hemorrhage, fetal heart rate abnormalities and NICU admission

Quality of Evidence: Low – Grade C Strength of Recommendation: Strong – Grade 1 References 1. Öztürk FH, Yılmaz S, Yalvac S, Kandemir O. Effect of oxytocin discontinuation during the

active phase of labor. J Matern Fetal Neonatal Med, 2015; 28(2): 196–198 2. Dimitrios-Efthymios V, Pergialiotis V, Papantoniou N, Trompoukis S, Vachlos G. Oxytocin

discontinuation after the active phase of labor is established. J Matern Fetal Neonatal Med. 2015; 28(12): 1421–1427

3. Bor P, Ledertoug S, Boie S, Knoblauch N, Stornes I. Continuation versus discontinuation of oxytocin infusion during the active phase of labour: a randomised controlled trial. BJOG. 2015


Clinical Knowledge Topic Working Group Member List We would like to acknowledge the contributions of the Provincial Clinical Knowledge Working Group members as follows. Your participation and time spent is appreciated.

Induction of Labour, Adult – Inpatient Clinical Knowledge Topic Working Group Membership Name Title Zone Knowledge Lead Dr. William Young Provincial Clinical Knowledge Lead– Maternal Health Provincial Topic Lead Dr. Wynne Leung Provincial Clinical Topic Lead Provincial Working Group Members Dr. Radha Chari Obstetrician Edmonton Dr. Stephen Wood Obstetrician Calgary Dr. Bruce Allan Obstetrician Calgary Dr. Young Phiri Obstetrician North Dr. Brian Muir Obstetrician North Dr. Duncan McCubbin Obstetrician South Heidi DeLange Clinical Nurse Educator Edmonton Rhonda Van Thournout Zone Coordinator Edmonton Hazel Mitschke Unit Manager Calgary Chelsea Miklos Midwife Calgary

Thank you to the following groups who participated in the review processes and final sign off.

• Taciana Pereira on behalf of Provincial Pharmacy • Carlota Basualdo and Marlis Atkins on behalf of Provincial Nutrition & Food Services • Dr. Bill Anderson on behalf of Provincial Diagnostic Imaging • Dr. James Wesenberg on behalf of Laboratory Services – Provincial Networks

We would also like to thank the following primary care physicians and clinicians who participated in the colleague review process. Your input has been invaluable to the process. Sundre Low Risk Obstetric Group, Dr. Vesta Warren, Dr. Erin Thompson, Dr. Adina McBain, Dr. Paul Walsh, Dr. Douwe Kits, Angela Curran, Megan McQuiston, Nora Landon


Additional Contributors We would like to acknowledge the contributions of non- working group members to the development of this Clinical Knowledge Topic. Your participation and time spent is appreciated.

Induction of Labour Additional Contributors and Resources Name Title Zone Allison Bichel Senior Provincial Director Maternal Newborn Child and Youth SCN Debbie Leitch Executive Director Maternal Newborn Child and Youth SCN Debbie McNeil PhD Scientific Director Maternal Newborn Child and Youth SCN Seija Kromm PhD Asst. Scientific Director Maternal Newborn Child and Youth SCN Dr. Douglas Wilson Obstetrician Calgary Gloria Keays MOH – Population Health Provincial Sandi Sebastian Director Central Dena Berci Unit Manager Calgary Yvonne Luu Unit Manager Calgary Carrie Collier Area Manager Calgary Candice Collier Unit Manager North Laureen McPeak Program Manager Edmonton Jolene Willoughby Clinical Nurse Educator North Amber Hauser Clinical Nurse Educator Calgary

For questions or feedback related to this knowledge topic please contact Clinical Knowledge Topics by emailing [email protected]

mailto:[email protected]


Appendix A – Society for Obstetricians & Gynecologists Recommendations

Table 1 SOGC Recommendations re Induction of Labour

Number Recommendation

1 The indication for induction must be documented, and discussion should include reason, method and risks for induction, including failure to achieve labour and possible increased risk of C/ssection.

2 If induction of labour is unsuccessful, the indication and method of induction should be re-evaluated

3 Inductions should not be performed solely for suspected fetal macrosomia

4 Inductions should not be performed solely because of patient or care provider preference.

5 Health care providers should assess the cervix (using the Bishop score) to determine the likelihood of success and to select the appropriate method of induction.

6 The Bishop score should be documented

7 Care providers need to consider that induction of women with an unfavourable cervix is associated with a higher failure rate and a higher Caesarean section rate in nulliparous and parous patients

8 Every woman should ideally have an ultrasound, preferably in the first trimester, to confirm gestational age

9 Institutions should have quality assurance programs and induction policies, including safety tools such as checklists, to ensure that inductions are performed only for acceptable indications

10 Women should be offered induction of labour between 41+0 and 42+0 weeks as this intervention may reduce perinatal mortality and meconium aspiration syndrome without increasing the Caesarean section rate.

11 Women who chose to delay induction > 41+0 weeks should undergo twice-weekly assessment for fetal well-being.

12 Intracervical Foley catheters are acceptable agents that are safe both in the setting of a vaginal birth after Caesarean section and in the outpatient setting.

13 Double lumen catheters may be considered a second-line alternative.

14 Prostaglandins E2 (cervical and vaginal) should not be used in the setting of vaginal birth after Caesarean section due to the increased risk of uterine rupture

15 Vaginal prostaglandins E2 may be considered with ruptured membranes at term and can be used in this setting

16 Misoprostol can be considered a safe and effective agent for labour induction with intact membranes and on an inpatient basis.

17 Misoprostol should not be used in the setting of vaginal birth after Caesarean section due to the increased risk of uterine rupture.

18 Oxytocin should be started no earlier than 4 hours after the last dose of misoprostol.

19 Amniotomy should be reserved for women with a favourable cervix. Particular care should be given in the case of unengaged presentation because there is a risk of cord prolapse

20 After amniotomy, oxytocin should be commenced early in order to establish labour.

21 In the setting of ruptured membranes at term, oxytocin should be considered before expectant management

22 Women positive for group B streptococcus should be started on oxytocin as early as possible after ruptured membranes in order to establish labour within 24 hours.

23 Both high- and low-dose oxytocin may be considered within a hospital protocol

24 Because of the various concentrations, oxytocin infusion rates should always be recorded in milliunits/min rather than mL/hr

25 Oxytocin induction maybe considered in the hospital setting of vaginal birth after Caesarean section.


Appendix B – oxytocin Conversion Chart

oxytocin Conversion Chart The following checklist can be used to assist with initiating oxytocin infusion and monitoring of the patient during an induction along with Smart Pump technology and drug libraries.

Table 1 oxytocin Conversion Chart 3

Based on 20 Units of Oxytocin in 1000 mL Rate of Infusion

(mL/Hour) Oxytocin Dose

(milliunit/minute) 3 1

6 2 9 3 12 4 15 5 18 6 21 7 24 8 27 9 30 10 33 11 36 12 39 13 42 14 45 15 48 16 51 17 54 18 57 19 60 20