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Glasgow Obstetrical & Gynaecological Society
Prize for Medical Students in West of Scotland
2011
Name: Nada Mufti (Fifth year) and Mohammed Abdul Waduud (Intercalating
Year)
Contact Details
Mobile Number: 07515352229
Email: 0607199m@student.gla.ac.uk , 0707022w@student.gla.ac.uk
Matriculation Number: 0607199m
Name: Nada Mufti
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An Audit on the Induction of Labour (IOL) Obstetric Guidelines at Princess Royal Maternity (PRM),
Glasgow
Introduction and Background:
New guidelines for IOL where implemented on the 12th of January 2010, in PRM. This was done in order
to unify guidelines across maternity units in Greater Glasgow and Clyde.
The process of induction should be offered to women only when it is felt that vaginal delivery is the
preferred route1. This descision is not to be made lightly, and should be done by a consultant
obstetrician particularly in the case of high risk pregnancies. Uncomplicated pregnancies are routinely
offered induction of labour between 41+ 0 and 42+ 0 weeks1.
Prior to admission all women should be offered a membrane sweep1. Women, who agree to have a
membrane sweep, should be cautioned that they will experience increased discomfort along with the
possibility of some vaginal bleeding1.
After 42 + 0 weeks should the woman decline a formal induction it is important that she is offered
increased antenatal monitoring1. This should entail cardiotocography performed twice weekly and an
ultrasound estimating maximum amniotic pool depth1.
The main differences between previous and current induction of labour guidelines are highlighted
below:
1. Prostaglandins and syntocinon are used in preference to acute rupture of membranes in both
primigravidas and multigravidas with intact membranes regardless of the bishop’s score and
cervical favorability1.
2. Once one dose of 3 mg of prostin is inserted into the posterior fornix, a second dose should be
administered after 6-8 hours if labour is still not established1. The bishop’s score should be
recorded after each time. A maximum of 3 doses of prostin is allowed in all cases.
3. Times of admission into Antenatal wards have changed according to weather the mother is prim
or parous, and high risk or low risk (refer to Box. 1).
Matriculation Number: 0607199m
Name: Nada Mufti
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Box 1: What Defines a Woman as High Risk?
1) Previous caesarean section
2) Recent Antepartum Haemorrhage
3) High parity > 4
4) Any patient requiring continous CTG
5) AC > 10th centile
6) Severe pre-eclampsia
7) Twins
8) Severe asthma (Previous hospitalization or oral steroids)
9) Oligohydraminous (Deepest pool of liquor < 2 cm)
10) Anaesthetic high risk patients
11) Any patients identified as high risk by a consultant obstetrician
Adapted from: Mathers, A.M., GGC Obstetric Guidelines – Induction of Labour, pg.4
The differences listed above have been implemented with an aim to deliver more high-risk patients
during day-shift when more staff from key departments are on-call. This can be clearly illustrated
below (refer Fig. 1, Fig.2, and Fig. 3) in the flow chart’s extracted directly from the guidelines:
Matriculation Number: 0607199m
Name: Nada Mufti
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Fig.1: Induction of Labour of High and Low Risk Multigravidas
3 mg of Prostin given on the ward at 10 pm
*Reassess 6 am on antenatal ward
Transfer to Labour suite for ARM
and immediate Syntocinon when
possible.
OR
*Second dose of 3 mg
Prostin on the antenatal
ward
Reassess at 12 pm
Transfer to Labour suite
for ARM and immediate
Syntocinon when
possible.
OR
◊ Third dose of 3 mg
Prostin on the antenatal
ward. This is rarely
indicated but considered
after assessment by a
Middle Grade
Obstetrician.
*If It were a high risk multigravidas , a middle grade obstetrician should assess the patient at these
highlighted points
◊ A caesarean section could be considered at this point in the case of a high risk multigravida.
Adapted from: Mathers, A.M., GGC Obstetric Guidelines – Induction of Labour, pg.7
Matriculation Number: 0607199m
Name: Nada Mufti
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Fig.2: Induction of Labour of Low Risk Primigravidas
3 mg of Prostin given on the ward at 4 pm
Reassess on the antenatal ward at 10 pm and give the
second dose of prostin on the antenatal ward
Reassess on the antenatal ward 6 am by a Middle Grade Obstetrician
Transfer to Labour Suite for ARM and
syntocinon when possible.
OR
3rd dose prostin 3 mg tablet is given
in the antenatal ward if ARM is not
possible or following the
assessment of a Middle Grade
Obstetrician
Reassess at 12 pm
Adapted from: Mathers, A.M., GGC Obstetric Guidelines – Induction of Labour, pg.8
Matriculation Number: 0607199m
Name: Nada Mufti
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Fig.3: Induction of Labour of High Risk Primigravidas
3 mg Prostin tablet on the
antenatal ward at 10 pm
Reassess at 6 am
Transfer to Labour suite for ARM and
immediate Syntocinon when possible.
Second dose of 3 mg Prostin tablet
on the antenatal ward at 6 am.
OR
Reassess at 12 pm
Transfer to Labour suite for
ARM and immediate
Syntocinon when possible.
OR
Third dose of 3 mg Prostin
tablet rarely indicated but
consider after assessment
by a middle grade
obstetrician
Reassess at 6 pm for ARM if ARM is
not possible discuss with Consultant
Obstetrician regarding plan
Adapted from: Mathers, A.M., GGC Obstetric Guidelines – Induction of Labour, pg.9
Matriculation Number: 0607199m
Name: Nada Mufti
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Aims and Methodology:
Background reading was initially performed to compare both the previous and the current guidelines, a
summary of which is outline in the above section. Secondly, a pro-forma was devised with the assistance
of a trainee and a consultant obstetrician in the unit, bearing in mind the important parameters. And
lastly, a retrospective analysis was performed on 124 women (75 Primigravidas, 49 Multigravida)
admitted for Induction of labour over a four-month-period. Whilst collecting the data we had six aims in
mind:
1) Quantify the indications for Induction of Labour
2) Analyse the administration of prostin.
3) Compare spontaneous rupture of membranes versus acute rupture of membranes in women.
4) Analyse the waiting times of women waiting to be transferred to the labour ward, and, between
transfer to the labour ward and delivery.
5) Delivery outcomes of patients, and
6) Investigate wether more high risk patients were being delivered during day shift.
Results and discussion:
Past Obstetric History:
Initially the previous obstetric history of the audit population was analysed. It was found that the
highest route of previous delivery for these women was spontaneous vaginal delivery (43 women),
whilst the least where caesarean sections (2 women). There were 9 instrumental deliveries and this can
be seen illustrated below (refer to Fig. 4) :
Fig. 4
No. of patients
Previous Obstetric History of
Audit Population
60
43
40
20
3
6
2
1
Forceps
Ventouse
CS
Other
0
SVD
Mode of Delivery
Matriculation Number: 0607199m
Name: Nada Mufti
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Indications for Induction:
There were a wide variety of different reasons why women required induction of labour and this is
illustrated in the table below, separating the indications of prim and parous women (refer to fig.5). The
main indication, however, was postdates in prim and parous women. The others column represents
reasons which were uncommon such as maternal request as the woman’s partner was soon to be
posted abroad to work under armed forces, fibromyalgia, marfan’s syndrome, previous still birth, etc.
Fig 5. Indications for induction of labour
Number of doses of Prostin and Spontaneous Rupture of Membranes:
99 patients (79.8% of the audit population) were administered prostin. It consisted of 57 primigravidas
(76% of the prim women population) and 42 multigravidas (85.7% of the parous women population). 1
dose of prostin was given to 18 patients, 2 doses to 50 patients, 3 doses to 30 patients and 4 doses to
only 1 patient. The distribution of the doses of prostin between prim and parous are illustrated below
(refer to fig. 6).
Matriculation Number: 0607199m
Name: Nada Mufti
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Fig. 6 Percentage of Prim and Parous That Received Each Dose
As seen from the figure above it is clear that Primigravidas require more doses of prostin compared to
multigravidas which is as predicted.
Of the audit population it is also important to note that only 25 patients (20.2%) had a spontaneous
rupture of membrane. It consisted of 18 primigravidas (24% of prim women population), and 7
multigravidas (14.3% of parous population). This further emphasizes the need to caution women that
they may spontaneously rupture their membranes after having been administered prostin.
Waiting times:
Whilst compiling the data it was important to identify how long women were waiting to be transferred
to the labour ward after the descion has been made to transfer them. The results are outlined below on
the box plot (refer fig. 7) showing the waiting times of all women, prim, and parous women. The (*)
symbol represents outliers. It is important to highlight that the average waiting time was 245.4 minutes
for prim women, compared to the 179.6 minutes of parous women. This represents an important
finding from a patient safety view point. It should be investigated as to why prim women were taking
longer to be transferred and wether it may be essential to counsel future women of the suspected
Matriculation Number: 0607199m
Name: Nada Mufti
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waiting times. Counseling these women may influence their decision to be induced, and it would also
make their expectations more practical. It is of course essential to highlight that the labour ward is very
busy indeed and waiting times could not be eliminated. However, certain measures could be taken to
decrease the waiting times, for example, increasing the number of beds or increasing staff numbers.
Fig.7
Using another box plot (refer to fig. 8) it was illustrated how long those women then took to deliver
after being transferred. Predicatively prim women took longer to deliver (520.5 minutes on average),
compared to parous women (317.8 minutes on average).
Matriculation Number: 0607199m
Name: Nada Mufti
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Fig. 8
Time of delivery:
Out of the 124 women, 57 women (46%) were delivered during the morning shift. Out of these 37
women where prim (49.3% of all prim women) and 20 women were parous (40.8% of all parous
women).
Out of the 124 women, 39 women (31.5%) were classified as high risk using the outlines shown in box 1
above. Of these women 20 were prim (26.7% of all prim women) and 19 were parous (38.8% of all
parous women).
Only 18 out of the 39 high risk women were delivered during the morning shift (46.2%). Of the 18, 9
were prim (45% of all high risk prim women) and 9 were parous (47.4% of all high risk parous women).
These results illustrate that present protocols do not appear to deliver more high risk women during the
day shift. A suggestion would be re audit the data, or to revise the guidelines at a multidisciplinary team
meeting.
Matriculation Number: 0607199m
Name: Nada Mufti
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Delivery Outcomes:
71.4% of parous and 25.3% prims delivered via spontaneous vaginal delivery. 22.4% of parous and 50.7%
of prims had a caesarean section. The results are illustrated in the figure below (refer to fig.9). The
numbers of caesarean sections for prim women are much higher than expected. Reasons for this must
be explored further so that women could be counselled appropriately. One must keep in mind the
emotional stress that these Primigravidas were exposed to. They went through an unsuccessful
induction of labour, followed by an emergency caesarean section in addition to that. Furthermore,
having a caesarean section may have implications on their descions to deliver vaginally in subsequent
pregnancies.
Fig. 9
Other interesting findings:
In July 2010, new guidelines were issued by the National Institute for Clinical Excellence (NICE),
highlighting that doctors and nurses should encourage women to achieve a healthy weight pre, during
and post pregnancy. This were done after results from the UK Obstetric Surveillance Systems study
(UKOSS) published that ‘obesity during pregnancy poses one of the greatest risks to the health of the
mother and her unborn child’ 2.
Matriculation Number: 0607199m
Name: Nada Mufti
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Thus it became important to investigate complications that have arisen perinatally in this audit
population due to an abnormal pre-pregnancy BMI. Of the 124 women, only 116 had a recorded prepregnancy BMI. Of these 116 women, there were 51 women with normal BMI, 23 women whom were
overweight, 25 women whom were obese and, 17 morbidly obese women. In total 65 women had an
abnormal BMI, and the percentages in each group are illustrated below (refer to fig 10).
Fig 10
Distribution of BMI Amongst Pregnant
Mothers
Massively Obese
( BMI>35)
14%
Obese (BMI 3034.9)
25%
Normal (BMI 1824.9)
42%
Overweight (
BMI 25-29.9)
19%
The pregnancy complications in each group were then explored, namely hypertension in pregnancy,
diabetes, fetal abnormalities detected on ultrasound and pre-existing maternal morbidities. Also
analysed, were the pregnancy outcomes of each including the rates of caesarean sections, instrumental
deliveries, admission into ITU (hospitalization), and the anaesthetic requirements during labour. The
results are portrayed below (refer to fig 11):
Matriculation Number: 0607199m
Name: Nada Mufti
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Fig. 11
60
50
40
30
20
Percentage In Normal BMI (18-24.9)
10
0
Percentage In Overweight, Obese
and Morbidly obese women ( BMI >
24.9)
As can be seen above it is evident that collectively women of overweight, obese, and morbidly obese
BMI suffer greater complications during pregnancy as a result. Attention must be drawn to the increased
need for epidurals and spinal blocks in mothers with an abnormal BMI compared to those of a normal
BMI. Also increased is the number of caesarean sections and instrumental deliveries in the abnormal
BMI population compared to the normal BMI mothers.
The results portrayed are comparable to other studies, for example, by Vahratian et al., which discussed
‘the need for more frequent administration of oxytocinon to stimulate labour contraction’ 3. Cedergren
et al also report a ‘significant increase in instrumental deliveries for obese or morbidly obese women’ 4.
Knight et al. furthermore recorded that more obese women underwent caesarean sections at delivery5.
The data by Knight et al. can be illustrated below (refer to fig 12) to show the increased health risks
incurred by obese mothers in comparison to mothers of normal weight 5. Looking at the figure below
the similarity to the results portrayed in this audit is clearly highlighted.
Matriculation Number: 0607199m
Name: Nada Mufti
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Fig 12
60
50
40
30
20
Obese Women (%)
10
Normal Weight Women (%)
0
Adapted from: Knight, Marian, Kurinczuk, Jennifer et al. Extreme Obesity In The United Kingdom, 2010.
The American College of Obstetricians and Gynaecologists 15:5
Conclusions:
In summary it appears that present protocols do not achieve aims of delivering more high-risk women
during the day-shift. Furthermore, the number of caesarean sections in prims is higher than expected
and reasons for this need to be explored further so that women can be advised and counselled
appropriately. Moreover, 58% of the populations have demonstrated increased perinatal complications
due to an increased pre-pregnancy BMI. This underlines the need of implementing uniform guidelines to
support and educate future mothers both psychologically and physically alerting them to the potential
risks that the extra weight may bring to themselves and their babies.
Word Count: 1,936 (including tables and figures)
References:
1. Mathers, A.M., GGC Obstetric Guidelines – Induction of Labour,2010, pp. 1 -9
2. July 2010, National Institute for Clinical Excellence: Weight Management and Pregnancy
Guidance News.
Matriculation Number: 0607199m
Name: Nada Mufti
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3. Vahratian A, Zhang J, Troendle JF, Savitz DA, Siega-Riz AM. Maternal prepregnancy overweight
and obesity and the pattern of labor progression in term nulliparous women. Obstet Gynecol
2004; 104(5): 943-951.
4. Cedergren MI. Maternal morbid obesity and the risk of adverse pregnancy outcome. Obstet
Gynecol 2004; 103(2): 219-224.
5. Knight, Marian, Kurinczuk, Jennifer et al. Extreme Obesity In The United Kingdom, 2010. The
American College of Obstetricians and Gynaecologists 15:5
Matriculation Number: 0607199m
Name: Nada Mufti