RCOG Guidelines for Induction of Labour June 2001

Woman-centred Care (C) Women must be able to make informed choices regarding their care or treatment via access to evidence based information. These choices should be recognised as an integral part of the decision-making process.

Place of Induction (C) Induction of labour with vaginal prostaglandin can be conducted on antenatal wards for women who are healthy For induction of labour in women with recognised risk factors (including suspected fetal growth compromise, previous caesarean section and high parity), the process should not occur on an antenatal ward

Fetal surveillance during Induction of Labour (C) Fetal wellbeing should be established prior to induction of labour. After vaginal prostaglandins check fetal wellbeing when contractions are detected or reported. For women who are healthy fetal wellbeing should comprise an initial assessment with continuous EFM. If normal then intermittent monitoring can be used. Continuous EFM is required with oxytocin

Using Prostaglandins The risk of hypercontractility with or without FHR changes is 1-5% Women should lie down for 30 min after PGs are inserted Oxytocin should not be started within 6 hours of PG insertion

Hypercontractility with PGs Remove any gel (C) Irrigation not beneficial (C) Prolonged maternal O2 administration may be harmful to fetus – Avoid There is no evidence that evaluates benefits or risks of short term maternal O2 Uterine tocolysis with a betamimetic can be useful (Grade A)

Hypercontractility with Oxytocin If the CTG is suspicious or abnormal then stop the infusion (B) If fetal compromise is suspected or confirmed then deliver ASAP taking account of severity of CTG changes and relevant maternal factors (B) – ideally within 30 min

Prolonged Pregnancy (A) Every pregnancy should have a scan at <20w to check dates Women with uncomplicated pregnancy should be offered IOL at 41+w Those who decline should have 2x weekly CTG and AFI estimations

IDDM in Pregnancy (C) These patients should be offered IOL prior to their EDD No recommendation concerning patients with gestational diabetes or those with impaired glucose tolerence

Prelabour Rupture of Membranes (A) When membranes rupture after 37w women should be offered either IOL or expectant management Expectant management should not exceed 96 hours

Social Induction of Labour Can occur when resources permit And the cervix is favourable Unable to provide advice concerning twins, suspected fetal macrosomia and history of precipitate delivery

Membrane Sweeping (A) Should be offered prior to formal induction of labour Is not associated with increased risk of fetal or maternal infection Is painful (patients should be warned) Will reduce the need for formal IOL for prolonged pregnancy if performed at >40w

Oxytocin or Prostaglandins (A) Prostaglandins better than oxytocin for nullips and multips with intact membranes regardless of state of the cervix If membranes have ruptured then PGs and oxytocin are equally as effective in both nullips and multips regardless of state of the cervix

Prostaglandin Regimens (C) Use 2 mg PGE2 gel for nullips with unfavourable cervix Use 1 mg PGE2 for all others Repeat in 6 hours No more than 3 applications in total

Oxytocin Infusion (C) Amniotomy is required Start at 1-2 mU/min Increase at 30 minute intervals Use the minimum dose compatible with effective contractions (often <12 mU/min) Licensed maximum is 20 mU/min Do not exceed 32 mU/min

Oxytocin Infusion (C) Protocols should be in mU/min – not volumes per time or by drip rate Must use a pump or syringe with a non- return valve