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 PGE 2 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

• Definition of IOL: • Reason: Background 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 induced 1 Induced labour may be less efficient and more painful than spontaneous labour 2 Associated with higher rates of assisted delivery (17-19%) compared to 12% with spontaneous labour 1 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 30% 25% 20% 15% 10% 5% 0% 10% 20% 28% 25% 15% 2% 17-20 21-25 26-30 31-35 36-40 41-45

15% Ethnicity British Pakistani 85%

Parity

Parity

30 25 20 15 10 5 0

24

0

19

1

7

2

6

3

2

4

0

5

0

6

2

7

Previous C-Section 7% Yes No 93%

Induction information

Gestation at Induction (weeks) 45% 41 40 39 38 37 36 35 0% 2% 7% 5% 10% 17% 15% 10% 20% 30% 40% 50%

PPROM Cholestasis Diabetes PIH/PET Other Pre-IUGR Post-dates PROM IUGR 0% Reason for Inducing 3% 3% 5% 5% 7% 8% 10% 13% 18% 20% 30% 37% 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 55% PROM 45% Did induction occur within 24 hours?

Yes No

100% 80% 60% 40% 20% 0% 9% 14% 77% Post-dates Membrane sweep offered?

Declined 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

PROM Admitted from clinic Labour ward busy 47% Time of induction 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%

100% 80% 60% 40% 20% 0% Vaginal PGE 2 used 10% 12% 78% None (ARMable) 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% 73% EFM N/A No Yes 7% 0%

0% 5% Maternal observations 6 hourly 92% 50% 3% Recorded 4 hourly?

Yes No N/A 100% Laboured prior

Propess®: duration in-situ 19% 12% 15% Time to labour: 0 to 6hrs 27% 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

100% 80% 60% 40% 20% 0% Prostin™ 1/5 1/5 3/5 Failed 2mg 1mg

12% Outcome of Induction 3% 13% NVD Instrumental delivery C-Section 72% Failed Induction (C-Section)

5 4 1 0 3 2 Instrumental deliveries – reasons for induction 5 1 1 Post-dates PROM Impending IUGR

Indication for instrumental delivery Pathological CTG 2 Prolonged 2nd stage 0 1 2 3 4 5 5

Caesarean sections – reasons for induction IUGR Obstetric cholestasis Impending IUGR Post-dates Maternal diabetes PROM 0 1 1 1 1 1 1 2 3 4 5 5

Indication for caesarean section Suboptimal CTG, FBS done Failue to progress Fetal bradycardia Failed induction Prolonged 1st stage, brow… Pathological CTG prior to labour Failed trial 0 0,5 1 1 1 1 1 2 1 1,5 2 2,5 3 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 2 All women had Propess ® 1 1 None had Prostin™ 0 PROM Post-dates

Previous C-section management Outcome of induction NVD 1 2 C-section (failed induction) 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 C section rates (16%) in this audit compared to national average (England: 16-19% and 21 23% 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?