Induction of Labour Audit Muhammad Uthman Khan FY2 in Obstetrics Airedale General Hospital April-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

Purpose Audit 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 Hospital Episode Statistics, Maternity data 2009-10 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

Maternal demographics Results Maternal demographics

Age

Ethnicity

Parity

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

PROM Labour ward busy Woman returning >24 hours later

Post-dates

Information provision and time of induction

Treatment and care to be offered No 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 6-hourly Laboured prior

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 management Reason for induction All women had Propess® None had Prostin™

Previous C-section management Outcome 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 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?