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 controlledrelease 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
of IOL:
• Reason:
An intervention to
stimulate uterine
contractions in pregnancy
prior to labour beginning
spontaneously
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 2009-10
2. 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
28%
30%
25%
25%
20%
20%
15%
15%
10%
10%
2%
5%
0%
17-20
21-25
26-30
31-35
36-40
41-45
Ethnicity
15%
British
Pakistani
85%
Parity
Parity
30
25
24
19
20
15
10
7
6
5
2
0
0
5
6
2
0
0
1
2
3
4
7
Previous C-Section
7%
Yes
No
93%
Induction information
Gestation at Induction (weeks)
45%
41
10%
40
17%
15%
39
38
7%
5%
37
36
2%
35
0%
10%
20%
30%
40%
50%
Reason for Inducing
PPROM
3%
Cholestasis
3%
Diabetes
5%
PIH/PET
5%
7%
Other
8%
Pre-IUGR
37%
Post-dates
18%
PROM
13%
IUGR
0%
10%
20%
30%
40%
‘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
Labour ward
busy
Woman
returning
>24 hours
later
PROM
45%
55%
Did
induction
occur
within 24
hours?
Yes
No
Post-dates
100%
9%
14%
Membrane
sweep
offered?
80%
Declined
60%
40%
20%
0%
77%
Unfavourable
cervix
Performed
Information provision and time
of induction
Treatment and care to be offered
No
documentation
48%
52%
Was written
information
given
regarding
this?
Yes
No
Time of induction
PROM
Admitted
from clinic
Labour
ward busy
47%
53%
Was the
woman
induced in
the
morning?
Yes
No
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
3%
Assessed?
Yes
No
97%
Vaginal PGE2 used
None (ARMable)
100%
10%
12%
80%
60%
40%
20%
0%
78%
Propess® +
Prostin™ (pessary
+ gel/tablet)
Propess®
(controlled-release
pessary)
Repeat CTG performed in all
(100%) women who developed
contractions
Intermittent auscultation following
normal CTG?
100%
50%
Laboured
prior or
CTG not
normal
20%
EFM
73%
7%
0%
N/A
No
Yes
Maternal observations
Recorded 4hourly?
5%
92%
3%
6hourly
0%
50%
100%
Yes
No
N/A
Laboured
prior
Propess®: duration in-situ
Time to labour:
0 to 6hrs
12%
27%
19%
15%
27%
6hr 1min to
12hrs
12hrs 1min to
18hrs
18hrs 1 min to
24hrs
Not in labour
after 24hrs
Modified Bishop score
reassessed in all (100%) women
who did not labour 24hrs
following Propess® insertion
Prostin™
100%
80%
1/5
1/5
60%
40%
20%
0%
3/5
Failed
2mg
1mg
Outcome of Induction
3%
NVD
13%
Instrumental
delivery
12%
C-Section
72%
Failed Induction
(C-Section)
Instrumental deliveries – reasons
for induction
5
5
4
3
2
1
1
1
0
Post-dates
PROM
Impending
IUGR
Indication for instrumental delivery
2
Pathological CTG
5
Prolonged 2nd stage
0
1
2
3
4
5
Caesarean sections – reasons for
induction
IUGR
1
Obstetric cholestasis
1
Impending IUGR
1
5
Post-dates
Maternal diabetes
1
PROM
1
0
1
2
3
4
5
Indication for caesarean section
Suboptimal CTG, FBS done
1
Failue to progress
1
3
Fetal bradycardia
2
Failed induction
1
Prolonged 1st stage, brow…
Pathological CTG prior to labour
1
Failed trial
1
0
0.5
1
1.5
2
2.5
3
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
3
3
All women
had
Propess®
2
1
None had
Prostin™
1
0
PROM
Post-dates
Previous C-section management
Outcome of
induction
NVD
1
C-section (failed
induction)
2
1
Instrumental
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 Csection rates (16%) in this audit compared to
national average (England: 16-19% and 2123% 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?