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
Hospital Episode Statistics, Maternity data
NICE clinical guideline 70, Induction of labour, July 2008

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. Maternal demographics
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 >24 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
Hospital Episode Statistics, Maternity data

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?