Induction of Labour Audit

1
Induction of Labour Audit

• Muhammad Uthman Khan
• FY2 in Obstetrics
• Airedale General Hospital
• April-August 2011

2
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)

3
Aim

• To gain an appreciation of the efficacy of
  single-dose Propess (vaginal PGE2
  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

4
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

5
Background

• Definition An intervention to of
  IOL stimulate uterine contractions in
  pregnancy prior to labour beginning
  spontaneously
• Reason Deemed that early delivery is safer
  for the mother and/or foetus than allowing the
  pregnancy to continue its natural course

6
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

7
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

8
Results

• Maternal demographics

9
Age
10
Ethnicity
11
Parity
12
Previous C-Section
13
Induction information
14
Gestation at Induction (weeks)
15
Reason for Inducing
16
Other reasons

• Foetal tachycardia, reduced movements
• Hughes syndrome (antiphospholipid syndrome)
• Severe symphysis pubis dysfunction
• Suspicious CTG after presenting in query labour

17
Induction in specific circumstances
18
PROM
Labour ward busy Woman returning gt24 hours later
19
Post-dates
20
Information provision and time of induction
21
Treatment and care to be offered
No documentation
22
Time of induction
PROM Admitted from clinic Labour ward busy
23
Maternofoetal assessment monitoring prior to
and during induction, before the establishment of
labour
24
Prior to induction

• EFM to assess foetal wellbeing, performed in all
  (100) cases

25
Modified Bishop Score
Information in notes but not formally calculated
26
Vaginal PGE2 used
27
Repeat CTG performed in all (100) women who
developed contractions
28
Intermittent auscultation following normal CTG?
Laboured prior or CTG not normal
EFM
29
Maternal observations
6-hourly
Laboured prior
30
Propess duration in-situ
Time to labour
31
Modified Bishop score reassessed in all (100)
women who did not labour 24hrs following Propess
insertion
32
Prostin
33
Outcome of Induction
34
Instrumental deliveries reasons for induction
35
Indication for instrumental delivery
36
Caesarean sections reasons for induction
37
Indication for caesarean section
38
Maternal complications

• A total of 3 women (6 of those receiving
  Propess) suffered from uterine hyperstimulation
• 2/3 given Terbutaline

39
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

40
Previous C-section management
Reason for induction
All women had Propess None had Prostin
41
Previous C-section management
Outcome of induction
42
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

43
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

44
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

45
Thank you for listening

• Any Questions?