Induction of Labour: Prelabour ROM at Term PPT 2024

INDUCTION OF LABOUR (PROLONGED PREGNANCY, PRELABOUR RUPTURE OF MEMBRANES AT TERM ,) NU3115 Sept 2024  INDUCTION OF LABOUR  Can be viewed as any procedure or intervention that...

INDUCTION OF LABOUR (PROLONGED PREGNANCY, PRELABOUR RUPTURE OF MEMBRANES AT TERM ,) NU3115 Sept 2024  INDUCTION OF LABOUR  Can be viewed as any procedure or intervention that starts off labour rather than  Definition allowing it to commence spontaneously  The artificial initiation of labour before spontaneous onset occur (Brodrick 2024) 2  IOL IN IRELAND - INCIDENCE Varies considerably between units 3 https://www.saolta.ie/sites/default/files/publications/Women%E2%80%99s%20%26%20Children%E2%80%99s%20Manage d%20Clinical%20%26%20Academic%20Network%20Annual%20Clinical%20Report%202022-compressed.pdf Saolta Annual Report 2023 4  INDICATIONS Maternal indications Fetal indications - Prolonged or post-term pregnancy Suspected fetal compromise - Medical problems – diabetes, - IUGR hypertension, Cholestasis - Reduced fetal movement - Poor obstetric history (prev. stillbirth) - Macrosomia - Prelabour rupture of membrane >24hrs (NICE 2008, amended 2021) - Rhesus iso-immunization - Maternal Request: Consider Severe congenital requests for induction of labour only abnormalities after discussing the benefits and risks with the woman, taking into account Fetal death the woman’s circumstances and preferences. [NICE 2008, amended (NICE 2021, Brodrick 2024) 2021] Advanced maternal age (Brodrick 2024) 5  PREVENTION OF PROLONGED PREGNANCY  Explain to women that labour usually starts naturally by 42+0 weeks. At the 38-week antenatal visit, reconfirm a woman’s preferences for birth. Take into account her individual circumstances and discuss options for birth, including:  expectant management or  induction of labour or  planned caesarean birth  In uncomplicated singleton pregnancies, offer induction of labour at 41+0 weeks, to take place then or as soon as possible afterwards. Women’s preferences, local circumstances and identified risk factors determines the exact timing (NICE 2008 updated 2021). 6 PREVENTION OF PROLONGED PREGNANCY  Consider IOL from 39+0 weeks in women with otherwise uncomplicated singleton pregnancies at a higher risk of complications (for example, BMI 30 kg/m2 or above, age 35 years or above, with a black, Asian or minority ethnic family background, or after assisted conception). Take into account: the risk of complications, the woman’s preferences  the woman’s previous obstetric history  Support the woman’s decision, including her choice of place of birth, if she chooses not to have induction of labour.  Discuss the woman's care options from this point on with her. (NICE 2008, amended 2021)  Offer increased fetal monitoring to women who choose not to have their labour induced.  Advise women that monitoring only gives a snapshot of the current situation, and cannot predict reliably any deterioration after monitoring ends 7 PREVENTION OF PROLONGED PREGNANCY  Adverse effects on the baby (including stillbirth), and when these events might happen, cannot be predicted reliably or prevented even with monitoring - monitoring might consist of twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth. (2008, amended 2021)  Explain to women that the risks associated with a pregnancy continuing beyond 41+0 weeks increase over time, and include: increased likelihood of caesarean birth increased likelihood of the baby needing admission to a neonatal intensive care unit increased likelihood of stillbirth and neonatal death a possible increased likelihood of assisted vaginal birth (using forceps or ventouse) (NICE 2021) 8 PROLONGED PREGNANCY (POST TERM) - Often used interchangeably with the term postmaturity - Prolonged pregnancy- one that exceeds 42 completed weeks or 294 days from the first day of LMP, it relates to duration of pregnancy not a maternal condition -Postmaturity describes the baby born after 42 weeks 9 INDUCTION OF LABOUR Insufficient evidence for IOL for the following reasons To be offered with caution in the situations - Previous CS or uterine scar -Multiple pregnancy - High parity -Macrosomia - In the absence of diabetes and other indications, - Polyhydramnios IOL should not be recommended - Uncertain due date (NICE, 2008) -History of precipitate labour: IOL should not be routinely offered to women with a history of precipitate labour (Elliot 2009) 10 CONTRAINDICATIONS Placenta praevia or vasa praevia Oblique or Transverse lie Malpresentation - breech Cord presentation or cord prolapse Severe fetal compromise (Brodrick 2024) 11 ASSESSMENT BEFORE INDUCTION  Abdominally assess the level and stability of the fetal head in the lower part of the uterus at or near the pelvic brim assess and record the Bishop score  Confirm a normal fetal heart rate pattern and absence of uterine contractions using ant Ensure facilities are available for cardiotocography wherever induction of labour is started [NICE 2008, amended 2021] 12  MODIFIED BISHOP’S SCORE A method of assessing SCORE 0 1 2 3 whether the cx is Dilatation favourable for induction, to Closed 1-2 3-4 5+ decide which method is (cm) Length of suitable 3 2 1 0 cervix (cm) For women with a Bishop score Station to of 6 or less, offer induction of -3 -2 -1 +1+2 labour with dinoprostone as spines vaginal tablet, vaginal gel or Consistency controlled-release vaginal Firm medium Soft NA delivery system or with low dose of cervix (25 microgram) oral misoprostol Position of Posterio Anteri tablets [NICE 2021] Mid NA cervix r or 13 MONITORING When uterine contractions begin after administering dinoprostone or misoprostol, assess fetal wellbeing and uterine contractions with intrapartum CTG interpretation and: if the CTG is confirmed as normal, review the individual circumstances and, if considered low risk, use intermittent auscultation unless there are clear indications for further cardiotocography. if the fetal heart rate is abnormal or there are excessive uterine contractions do not administer any more doses and remove any vaginal pessaries or delivery systems if possible. Reassess the Bishop score at appropriate intervals to monitor progress, depending on the method of induction being used, and the clinical condition of the woman [NICE 2008, amended 2021] 14  METHODS OF INDUCTION  Membrane Sweeping  membrane sweeping might make it more likely that labour will start naturally (reduce the need for IOL)  Offer women a VE for membrane sweeping before formal IOL (NICE 2008)  At antenatal visits from 39+0 weeks, offer women a vaginal examination for membrane sweeping  Consider additional membrane sweeping if labour does not start spontaneously. Obtain consent from the woman before  discomfort and vaginal bleeding are possible carrying out membrane sweeping. (NICE from the procedure (NICE 2008, amended 2021) 2021) 15 ALTERNATIVE METHODS OF IOL Discuss with women that the available evidence does not support the following methods for induction of labour:  herbal supplements  acupuncture  homeopathy  castor oil  hot baths  enemas  sexual intercourse. (NICE 2008 / 2021) 16 METHODS OF IOL – MEDICAL METHODS Prostagladins – PGE2 -  Locally acting chemical compounds Indication: Unfavourable cervix (Bishop score ≤ 6) - available in gel or pessary form - Helps to ripen the cervix - Most commonly administered by vaginal route in the posterior fornix - Contributes to uterine contraction - Labour results in 30 – 50%  monitor fetal heart and contractions 17 USING PROPESS String hangs down – similar to Propess - Slow release of prostaglandin over 24 hours tampon similar purpose – soften the  Bed rest for 30 min Cx Assessment of maternal well being  Informed consent  Assessment of fetal well- being prior to administration (20 min EFM)  Insert the pessary to cervical canal, positioning it behind the posterior vaginal fornix to keep it insitu 18 WHEN TO REMOVE PROPESS 1. When regular, painful contractions have been established 2. Spontaneous rupture of the membranes or amniotomy. 3. Any suggestion of uterine hyperstimulation or hypertonic uterine contractions. 4. Evidence of fetal distress. 5. Evidence of maternal systemic adverse dinoprostone effects such as nausea, vomiting, hypotension or tachycardia. 6. At least 30 minutes prior to starting an intravenous infusion of oxytocin. 7. After 24 hrs irrespective of whether cervical ripening has been achieved. 19 Guideline for Prostaglandin - UHG 20 PROSTAGLANDINS – SIDE EFFECT - nausea, vomiting - diarrhoea, Risks – PGE2 may lead to: - uterine hyperstimulation, placental abruption, fetal hypoxia - uterine rupture rare – beteween 0.3% and 7% (Rimmer 2014 in Myle TextBook for Midwives) 21 CARE OF A WOMAN FOLLOWING PGE 2 No Contractions Regular Painful Contractions Four hourly observations, as follows: Perform abdominal examination Perform abdominal examination Assess uterine activity and fetal movements Auscultate FHR with Pinard /Sonicaid (1 full minute) CTG Assess uterine activity and fetal Assess vaginal loss movements Perform vaginal examination Assess vaginal loss Documentation 22 AMNIOTOMY – ARTIFICIAL RUPTURE OF MEMBRANE (SURGICAL METHOD) ARM perfomed when Risks cervix is favourable or to accelarate/augment labour - Infection (chorioamnionitis) Prior to the procedure, - Early decelaration abdominal palpation is - Cord prolapse crucial - Bleeding - VE – to assess cx, confirm presentation and station, exclude cord prolapse and vasa praevia -A well fitting presenting part is essential 23 CARE OF A WOMAN FOLLOWING ARM  Outrule cord prolapse  Assess FHR immediately following procedure for one full minute and again in 15 mins for 1 full minute.  Document liquor colour and consistency  Encourage mobilisation to promote onset of uterine contractions  Consider Oxytocin in Mulitparous women after 2 hrs of ARM if no contraction.  Oxytocin can be commenced immediately after ARM in nulliparous women unless the BISHOPs score is 7 or more 24 OXYTOCIN  Synthetic form – powerful uterotonic agent  Use of oxytocin alone for IOL is not recommended or the use of Usually in form of oxytocin and ARM as ‘primary syntocinon method’ of IOL, unless PGE2 is contraindicated (NICE 2008)  Given IV – diluted with Normal Saline  After cervical ripening and ruptured membranes  Dose titrated using volumetric pump 25 RISKS ASSOCIATED WITH OXYTOCIN - Uterine hyper stimulation or hypertonus Management of - Fetal hypoxia and asphyxia Oxytocin in labour– To be covered in another - Fluid retention due to its anti-diuretic effect lecture – Active - Uterine rupture management of labour - Amniotic fluid embolism - PPH (Prolonged use may cause uterine atony) (Simmer 2014 in Myles Textbook) - Increase need to for epidural analgesia - Restricted mobility (NICE 2008, 2021) 26 27 AUGMENTATION OF LABOUR  Accelaration of Labour  Methods  Amniotomy  Syntocinon 28 PRELABOUR RUPTURE OF MEMBRANE AT TERM  Accurate history  Note time, amount, colour and odour of liquor / vaginal loss.  Note any pain, discomfort or contractions or history of same, fetal movements.  Monitor and record all vital as per IMEWS. Physical examination  General well being  Abdominal examination to establish gestation, lie, position, presentation, and 29 PRELABOUR RUPTURE OF MEMBRANE AT TERM Auscultate fetal heart with pinnards/doppler, fetal movements and note any uterine tenderness  Note vaginal loss – provide a sterile sanitary pad.  Four hourly observations (or sooner if clinically indicated) as per IMEWS.  Advised the woman to report any changes in general wellbeing including flu type symptoms, abdominal pain/tenderness or changes in the pattern of fetal movements.  Speculum not necessary if liquor is visible 30 PRELABOUR RUPTURE OF MEMBRANE AT TERM  Fetal Assessment  Abdominal examination to  Offer women with prelabour estimate growth, position and rupture of membranes at term presentation and to exclude (at or after 37+0 weeks) a uterine tenderness. choice of:  CTG is performed if the woman induction of labour as soon as meets the criteria for CTG possible or monitoring.  expectant management for up  Ultrasound scan is performed to 24 hours, offer IOL after 24 assess liquor i.e. if required to hours (NICE 2008 updated diagnose rupture of membranes 2021) and assess fetal wellbeing.  31 PRELABOUR RUPTURE OF MEMBRANE AT TERM  Support the woman’s decision if she chooses not to have induction of labour after 24 hours. Discuss  See UHG Protocol the woman's care options from this point on with her. [NICE 2021]  If a woman has prelabour rupture of membranes at term (at or over 37+0 5 weeks) and has had a positive group B streptococcus test at any time in their current pregnancy, offer immediate induction of labour or caesarean birth (NICE 2021) 32 IOL AFTER PREVIOUS LSCS  Advise women who have intrauterine fetal death, and who have had a previous lower segment caesarean birth, that the uterine scar increases the risk of uterine rupture if labour is induced and that this should be taken into account when deciding on their birth option. [NICE 2021]  If a woman with an intrauterine fetal death and a previous lower segment caesarean birth chooses an induced labour, follow the recommendations on monitoring of uterine contractions and provide one-to-one midwifery care of the woman during labour and birth. [NICE 2021]  Be aware that both dinoprostone (Prostaglandin) and misoprostol are contraindicated in women with a uterine scar. [NICE 2021] 33 IOL IOL for maternal request IOL for IUD (IUFD) – Consider maternal requests  More than 85% of women with an for IOL only after discussing IUFD labour spontaneously within the benefits and risks with the three weeks of diagnosis woman, taking into account the woman's circumstances and  Support the woman's preferences preferences (NICE 2008, regarding timing of IOL. amended 2021, Brodrick  Delaying IOL for a few days should 2017) be supported, if desired, provided: IOL may be offered at 40  Membranes are intact weeks (NICE 2008, updated 2021)  No evidence of infection (NICE, updated 2008) 34 IOL IN SPECIFIC CIRCUMSTANCES  Previous CS – contraindicated if classical incision  History of precipitate labour: Do not routinely offer IOL to avoid a birth unattended by healthcare professionals. (NICE 2008)  Fetal macrosomia in the absence of diabetes with no other indication  Consider maternal requests for IOL only after discussing the benefits and risks with the woman, taking into account the woman's circumstances and preferences -(NICE 2008, amended 2021, Brodrick 2024) 35 OUTPATIENT INDUCTION  Consider outpatient induction of labour with vaginal dinoprostone preparations or mechanical methods in women without existing medical conditions or obstetric complications. (NICE 2008, amended 2021]) Carry out a full clinical assessment of the woman and fetus) and ensure safety and support procedures are in place. [NICE 2008, amended 2021]  For induction being undertaken on an outpatient basis, agree a review plan with the woman before she returns home. [NICE 2008, amended 2021] Ask women to contact their obstetrician/midwife: - when contraction begins - if there are no contractions (in an agreed timeframe, depending on the method used) or - if her membranes rupture or if she develops bleeding or - if she has any other concerns, such as reduced fetal movements, excessive pain or uterine contractions, side-effects or loss of the pessary [NICE 2008, amended 2021] 36 ROLE OF THE MIDWIFE Planning - Good communication skills - Information and informed consent - Provide support for women Labour - Monitoring maternal and fetal well being - Assessment of pain - Assessment of progress - Accurate record keeping 37 NICE GUIDELINE - SUMMARY The NICE guideline, an update of the 2008 version, recommends that women with uncomplicated singleton pregnancies should be offered induction at 41 weeks and the induction should take place as soon as possible (NICE 2021) - If women choose not to have induced labour their decision should be supported and their care options discussed with them (NICE, 2021). -Recent research which compared induction times and outcomes showed higher infant mortality after 42 weeks if the woman had not been induced. 38  SUMMARY NICE 2021(IOL OVERVIEW) 39 IOL FOR POST-TERM By 40/40 – 58% will give birth By 41/40 - 74% will give birth By 42/40 – 82% 18% will remain pregnant after 42/40 without IOL Incidence of stillbirth increases with gestation 40  REFERENCES Alfirevic, Z., Kelly, A.J. and Dowswell, T. (2009) Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD003246. DOI: 10.1002/14651858.CD003246.pub2. Brodrick A. (2024) Induction of labour and Post-tern pregnancy IN Mayes Text book for Midwives, 17th EdnPP 1244-1256 Gülmezoglu, A., Crowther,C. and Middleton, P. (2006) Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews.; Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2. Gülmezoglu, A., Crowther,C. and Middleton, P. et al (2012) Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews.; Issue 6. Art. No.: CD004945. Mitchell J.M, Nolan C, El Shaikh M, Cullinane, S, Borlase D. National Clinical Practice Guideline: Induction of Labour. National Women and Infants Health Programme and The Institute of Obstetriciansand Gynaecologists. October 2023 NICE (2021) Induction of labour overview https://pathways.nice.org.uk/pathways/induction-of-labour.  National Collaborating Centre for Women's and Children's Health (NICE) (2012) Quality statement 12: Fetal wellbeing – membrane sweeping for prolonged pregnancy http://www.nice.org.uk/guidance/qs22/chapter/quality-statement-12-fetal-wellbeing-membrane-sweeping- for-prolonged-pregnancy Rimmer A. (2014) Prolonged pregnancy and disorders of uterine action In Myles Textbook for Midwives pp. 417-433. Selo-Ojeme ,D., Pisal, P., Lawal ,O., Rogers, C., Shah, A. and Sinha, S. (2009) A randomised controlled trial of amniotomy and immediate oxytocin infusion versus amniotomy and delayed oxytocin infusion for induction of labour at term. Archives of Gynecology and Obstetrics. 279(6):813-20. 41