Failed Induction Of Labour In Nulliparous Patients Audit

 

Mr Max Robinson, O&G Senior SpR

Mr Jaroslaw Beta, O&G Consultant

Medway Maritime Hospital

 

Background

- Induction of labour (IOL) is a common obstetric intervention

- Being performed in over 20% of maternities in the UK.

- It is indicated when interrupting the pregnancy is thought to be safer for the mother or the baby

   - Than allowing gestation to continue.

- When discussing IOL the balance between potential benefits + complications of IOL should be considered.

- In many circumstances the decision is not clear cut

   - Early delivery may be associated with benefit for the mother but risks for the baby, or vice versa.

- For example, IOL for moderate pre-eclampsia at 36 weeks of gestation may avoid maternal complications

   - But is associated with the increased risks of prematurity.

 

Aims & Objectives

Aim

- Assist NHS providers to determine whether the service is in compliance with:

     - The local maternity services guideline - Induction of Labour (IOL)

     - Revision No. 6

     - Approved date: 25/07/2021, Review Date: 25/07/2023

 

Objectives

- Audit failed induction of labour in nulliparous patients

- To assess if their management is compliant with the local maternity guideline on

   induction of labour

- At the Medway Maritime Hospital

 

Induction Of Labour Indications

- Prolonged pregnancy

- Maternal diabetes (including gestational diabetes)

- Twin pregnancy

- Prelabour rupture of membranes

- Fetal growth restriction and suspected in utero fetal compromise

- Hypertensive disorders in pregnancy and other maternal medical conditions

- Maternal request

- History of precipitate labour

- History of reduced fetal movements at term

- Suspected fetal macrosomia

 

Induction Of Labour Contraindications

- Induction of labour is contraindicated where vaginal delivery is contraindicated.

- Absolute contraindications to induction of labour include:

     - Placenta praevia/vasa praevia

     - Transverse lie

     - Prolapsed umbilical cord

     - Active genital herpes (first episode in third trimester - not recurrent herpes)

     - Previous classical uterine incision

     - Maternal or fetal anatomical abnormality that contraindicates vaginal delivery.

- Relative contraindications to vaginal delivery (and, therefore, induction of labour) include:

     - Triplet or higher order multiple pregnancy

     - Breech presentation

     - Two or more previous low transverse caesarean sections.

 

Method

- Retrospective audit from 01/09/2021 to 30/01/2022

- 147x patients were identified during this period with a management plan for IOL

   - Reduced to 8x patients after applying the Inclusion + Exclusion criteria as per this audit

- Data collected from patient case note reviews + Euroking searches

- 6x Standards created using IOL Trust guideline

 

Inclusion Criteria

- Primigravida

- Failed Induction Of Labour due to unable to perform Artificial Rupture of Membranes

- Induction of Labour for:

   - Post Dates at 40+7/40 Weeks Gestation / Reduced Fetal Movements

   - Large for Gestational Age / Essential Hypertension / Preeclampsia 

   - Symphysis Pubis Dysfunction / Prolonged Rupture Of Membranes 

   - Abnormal Dopplers / Maternal Request / Intrauterine Growth Restriction

   - Gestational Diabetes Mellitus / Obstetric Cholestasis

 

Exclusion Criteria

- Failed IOL due to Failure To Progress In Labour (60x Patients Excluded, 40.8% Reduction)

- Failed IOL due to Pathological CTG (36x Patients Excluded, 24.5% Reduction)

- Multiparous (21x Patients Excluded, 14.3% Reduction)

- Maternal Request For Not Wanting To Continue With IOL (12x Patients Excluded, 8.2%

   Reduction)

- Failed IOL due to Failed Instrumental Delivery Requiring LSCS (3x Patients Excluded, 2%

  Reduction)

- Failed IOL due to Chorioamnionitis (2x Patients Excluded, 1.4% Reduction)

- Maternal Request For Exhaustion (1x Patient Excluded, 0.7% Reduction)

- Maternal Request As Unable To Tolerate Vaginal Examination Due To Sexual Abuse History             

   (1x Patient Excluded, 0.7% Reduction)

- Removal Of Propess Causing Hyperstimulation + Not Reintroducing Propess Due To  

   Potential Hyperstimulation Recurrence (1x Patient Excluded, 0.7% Reduction)

- Ballotable Fetal Head + ARM-Able, But Controlled ARM Not Done

   (1x Patient Excluded, 0.7% Reduction)

- Failure To Progress In 1st Stage Of Labour On Syntocinon + Preterm SROM

   (1x Patient Excluded, 0.7% Reduction)

 

                     Total Patients Excluded From Original Sample Identified = 139x

 

What Went Well?

Standard 1 was almost achieved:

- Only for 1x patient it was not clearly documented

- If a membrane sweep was offered + attempted

 

Standard 3 was achieved:

- In that all involved patients

- Were appropriately given a 2nd dose of Propess for Bishop’s Score < 6

 

Standard 5 was almost achieved:

- It was not clearly documented

- If a consultant was involved in the management of a failed IOL

 

What Could Be Improved?

Standard 2 was far from being achieved

- IOL leaflet was only documented to have been given to two patients

 

Standard 4 was also far from being achieved

- Only 1x patient was examined by an O&G SpR / Consultant

 

Standard 6 was not even considered for any of the IOL patients

 

Conclusions

Overall only one standard

  (Standard 5 - Giving 2nd dose of Propess for Bishop’s Score < 6) was 100% achieved

    - Therefore there is a lot of room for improvement

 

- 12x patients declined to continue with IOL after 1x Propess

   - Preventing potential opportunity for a vaginal delivery

      - If a 2nd Propess / Trial of Syntocinon was given

 

- Surprisingly most patients (94.6%) that were classed as failed IOL as per the original patient audit

   list

   - Was not actually due to the fact that an ARM was not achievable

   - But due to various other reasons as per the exclusion criteria

 

Recommendations

- Send an email to all healthcare professionals working within the O&G department including this

   presentation

 - To increase awareness + improve adoption of good documentation to ensure for all IOL’s:

    - Membrane sweep are offered + given

    - IOL leaflets are provided

    - Vaginal examinations for 2nd dose of Propess are to be performed by O&G SpR’s / Consultants

    - Consultants should be involved if IOL fails i.e. after 1x Propess used + not ARM-able

    - Trial of Syntocinon is a valid alternative option to a 2nd Propess / after a 2nd Propess + still not

       ARM-able

 

- Add a check list box to the IOL Proforma to ensure IOL leaflets are given to all patients

 

- Reaudit in 6-12 months to assess for changes from these recommendations

 

References

Induction Of Labour - Medway Maritime Hospital Local Maternity Guideline

- Revision No. 6

- Date Approved: 25/07/2021

- Review Date: 25/07/2023

 

Inducing Labour - NICE Guideline [NG207]

- Published: 04/11/2021