Induction of Labour (IOL) with Prostaglandin gel

There are risks associated with any obstetric intervention. There must be a balance between benefits of intervention and women’s wishes. This list of considerations for IOL is not exhaustive. Women centred care should be relevant to each case along with risk factors. The decision to induce labour should include a discussion around induction method, balloon being preferred over prostaglandin unless the mother specifically prefers prostin (please see Balloon Induction SOP). Low risk women on the ‘midwifery led care pathway’ will have an appointment booked for IOL at

 term +10-12 following a discussion with their community midwife.

Specific considerations;

• Age >40 years old
• Post-dates
• Hypertension
• PET
• Reduced Fetal Movement
• Term pre-labour rupture of membranes
• Pre-term rupture of membranes
• Cholestasis of pregnancy
• Macrosomia
• Diabetes

Contra indications

• Previous Caesarean section
• Other major uterine surgery
• Suspected or evidence of fetal distress
• Placenta praevia/vasa praevia
• Lack of consent
• Allergy/anaphylaxis
• Malposition (unless breech and woman fully counselled of risks) This is exceptional

When the decision has been made to induce labour this should be made in consultation with the woman, the woman’s details should be booked into the induction diary kept on Ward 16. Please state name, CHI, reason for IOL, gestation and which method of induction. Women should be signposted to patient information leaflets. This decision should be documented on BadgerNet along with the consent of the woman.

Women are admitted to Ward 16 on the evening of induction for balloon induction or in the morning if prostin is planned. The midwife should review the mother to ensure that there has been no change in the original indication. Consent should be confirmed prior to commencing the procedure. Particular care is required when induction is undertaken for fetal reasons, particularly suspected IUGR, and a CTG should be carried out with the first contractions to ensure fetal wellbeing.

Prostaglandin  Induction

• 30 min CTG. If reactive, assess cervix and record Bishop score.
• Confirm cephalic presentation by ultrasound scan and document within BadgerNet.

If CTG reactive, assess cervix and record Bishop score.

• If cervical score ≤ 6 give Prostin E2 Gel 2 mg PV for primigravida, or 1mg for multigravida.
• Continue CTG for 1 hour. A further CTG must be carried out with the onset of uterine activity. It is good practice to auscultate the Fetal Heart and document the woman’s perception of fetal movement and uterine activity on a one - two hourly basis, when the mother is awake.
• If cervical score >6 at initial assessment, withhold mechanical induction and discuss with on-call Registrar regarding artificial rupture of membranes (ARM). Simple analgesia in the form of Paracetamol, hot pack, tens machine and a bath can be offered during induction. If additional analgesia is required perform a Vaginal examination (VE) to assess and consider transfer to Labour Ward for amniotomy if appropriate.
• If labour is not established within 6 hours re-assess for further prostin. This should not be given if there is significant uterine activity. It is good practice to assess uterine activity by palpating the abdomen over a period of 10 minutes.
• If labour not established by evening leave overnight. Subsequent VE’s should be by medical staff. Maximum recommended dose of prostin is 2+2+1mg, and 1+1+1mg for multiparous women.
• When a woman establishes in labour following a prostin-induced induction there should be a low threshold for continuous fetal heart monitoring if there is any evidence or concerns of hyperstimulation. Concerns regarding hyperstimulation or non-reassuring CTG should be escalated to the labour ward co-ordinator and Obstetric Registrar. If after a period of continuous monitoring the CTG is normal it can be discontinued and intermittent auscultation commenced. Those on oxytocin require continuous CTG monitoring.

• Document conversations around decision to induce labour
• Document CTG- review and peer review
• Document all vaginal examinations
• Document plans of care
• Provide SBAR/handover if woman requires transfer

• Nausea
• Vomiting
• Diarrhoea
• Vaginal discomfort/irritation
• Rapid cervical dilatation
• Fetal distress

Unsuccessful induction of labour will be managed with on an individualised women centred basis and a plan for continuing care made by the Obstetric Registrar and/or Consultant in partnership with the woman and her partner.