induction of labour for post-dates · •policy of labour induction at 41+0 vs. policy of expectant...
TRANSCRIPT
![Page 1: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/1.jpg)
Post-dates induction of labour
Michelle Wise MD MSc FRCSC FRANZCOG
Senior Lecturer, Department of O&G, FMHS
Obstetrician & Gynaecologist, National Women’s
13 June 2017
![Page 2: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/2.jpg)
Objectives
• Present the evidence for reducing post-term pregnancy
• Propose a way forward
![Page 3: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/3.jpg)
LEVELS OF EVIDENCE
![Page 4: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/4.jpg)
![Page 5: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/5.jpg)
Diabetes
Fetal growth restriction
Preeclampsia
Oligohydramnios
Decreased FM
Macrosomia
Age > 35 ↑ risk
of CS
Twins
Post-term
Indications for IOL
![Page 6: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/6.jpg)
![Page 7: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/7.jpg)
![Page 8: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/8.jpg)
THE EVIDENCE FOR ↓ POST-TERM
![Page 9: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/9.jpg)
Post-term
• ≥ 42 weeks
• Associated with oligohydramnios, meconium, “fetal distress”
• Post-maturity syndrome
PinsDaddy
![Page 10: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/10.jpg)
Reduce post-term pregnancy
1. Accurate dating of pregnancy
< 14 weeks scan +/- 5 days
2. Membrane sweeping at term
3. Policy of labour induction at 41 wks
![Page 11: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/11.jpg)
Reduce post-term pregnancy
1. Accurate dating of pregnancy
< 14 weeks scan +/- 5 days
2. Membrane sweeping at term
3. Policy of labour induction at 41 wks
![Page 12: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/12.jpg)
Reduce post-term pregnancy
1. Accurate dating of pregnancy
< 14 weeks scan +/- 5 days
2. Membrane sweeping at term
3. Policy of labour induction at 41 wks
![Page 13: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/13.jpg)
Pregnant women at 41+0
Policy of expectant management
Policy of labour induction
10 outcome: perinatal death
20 outcomes: CS, MAS, admit NICU
![Page 14: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/14.jpg)
Results
• 22 RCTs of 9,383 women
• Policy of labour induction at 41+0 vs. policy of expectant management
• Fewer perinatal deaths (RR 0.31)
• Fewer caesareans (RR 0.82)
• Fewer babies developed meconium aspiration syndrome (RR 0.50)
Cochrane review 2012
![Page 15: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/15.jpg)
PMMRC 2015
• Perinatal related mortality risk from 41+0 weeks = 3.2 per 1000 ongoing pregnancies
• Policy of IOL at 41+0 (RR 0.31) could ↓ risk to
1.0 per 1000
![Page 16: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/16.jpg)
CURRENT PRACTICE
![Page 17: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/17.jpg)
Evidence-based practice
• Offer IOL when appropriate, and avoid IOL when not appropriate (NICE guideline)
Risk to mum
and/or babe
Benefit to mum
and/or babe
![Page 18: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/18.jpg)
Strong IOL governance
• Multidisciplinary, engage all stakeholders
![Page 19: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/19.jpg)
Strong IOL governance
• Clinical prioritisation of IOLs
![Page 20: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/20.jpg)
Indications for IOL at NWH 2015
IOLs at term
diabetes
PROM
post-dates
sga
HTN
latent phase
fetal
Other
![Page 21: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/21.jpg)
Strong IOL governance
• Reduce variation in practice
– by individuals
– by DHB
![Page 22: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/22.jpg)
National Maternity Indicators 2015
![Page 23: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/23.jpg)
Auckland consensus guidelines 2014
• To guide clinicians to offer IOL when appropriate (i.e. where evidence shows that benefit to mother and/or baby outweighs the risk) and to avoid IOL when not appropriate
• http://nationalwomenshealth.adhb.govt.nz/ health-professionals/induction-of-labour
Risk to mum
and/or babe
Benefit to mum and/or babe
![Page 24: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/24.jpg)
Auckland consensus guidelines 2014
• IOL should be arranged around 41+5, but this can be individualised where resources allow
• Could offer fetal assessment at 41+0 (e.g. ultrasound scan, CTG) and if there are any concerns about fetal well-being, then IOL should be offered.
![Page 25: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/25.jpg)
ELECTIVE Induction of Labour (IOL) Booking Request Form
For all urgent/acute IOL required within 24-48 hours, please call the L&BS SMO on call
Referring Doctor to complete and fax to DAU: int. 25905 and ext. 09-307-8904
Requested date for IOL ....../………/……
Requested time for IOL ☐ 07:30 ☐ 09:30 ☐ 10:30 ☐ 12:00 ☐ 16:30 ☐ other: ______
☐ anytime
Today’s date ....../………/……
EDD ……/………/……
Gestational age on requested date ……………weeks ………….days
Parity …………….
LMC Name: ☐ Self Employed Midwife
☐ Hospital Midwife
☐ Private obstetrician Mobile:
Specialist responsible for IOL decision:
Guideline based indication for IOL Other factors (tick all that apply)
☐ Rupture of membranes, pre-labour ☐ Maternal age 35 -39 years
☐ Multiple pregnancy ☐ Obesity: Booking BMI ______
☐ Pre-eclampsia ☐ IVF pregnancy
☐ Diabetes
Detail: __________________________
☐ Slowing of growth
☐ Antepartum haemorrhage (APH)
☐ Small for gestational age (SGA)
Detail: __________________________
☐ Maternal request
☐ Maternal medical condition
☐ Maternal age ≥ 40 years ☐ Fetal condition ___________________
☐ Post-dates
☐ Hypertension, no preeclampsia ☒ Other __________________________
_________________________________
Location
☐ WAU ☐ L&BS ☐ HDU
Method
☐ PGs ☐ Balloon ☐ ARM ☐ Synto ☐ Team to decide
☐ ADHB IOL pamphlet provided ☐ Stretch and sweep offered to woman
To start IOL: ☐ LMC ☐ Hospital MW Care in labour: ☐ LMC ☐ Hospital MW
Interpreter needed? ☐Y ☐ N Language:
Staff Use only:
Confirmed IOL Date: ....../………/……
Confirmed IOL Time: ……:……
MUST ATTACH PATIENT LABEL HERE SURNAME: ___________________________ NHI: ______________ FIRST NAMES: ________________________ DOB: _____________
Please ensure you attach the correct visit patient label
![Page 26: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/26.jpg)
![Page 27: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/27.jpg)
Strong IOL governance – next steps
• IOLs requested outside of consensus guidelines → peer review
• Audit
– % IOLs as per IOL guidelines
– Unintended consequences
![Page 28: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/28.jpg)
PROPOSE WAY FORWARD
![Page 29: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/29.jpg)
National 2018Auckland consensus guidelines 2014
YES
• Arrange IOL
• No scan, no CTG, no extra visit
NO
• Fetal surveillance
• Risk assessment
Offer IOL at 41+0
![Page 30: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/30.jpg)
National 2018Auckland consensus guidelines 2014
For women who decline IOL at 41+0
• Fetal surveillance
– counsel re limitations of research
– daily FMs (prompt assessment if ↓)
– CTG
– deepest fluid pocket
• Risk assessment
– exclude fetal growth restriction and hypertension
![Page 31: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/31.jpg)
National 2018
Auckland consensus guidelines 2014
• Email me if you want to participate
![Page 32: Induction of labour for post-dates · •Policy of labour induction at 41+0 vs. policy of expectant management •Fewer perinatal deaths (RR 0.31) •Fewer caesareans (RR 0.82) •Fewer](https://reader034.vdocuments.site/reader034/viewer/2022050304/5f6cf9ae9bb53c38845b538a/html5/thumbnails/32.jpg)
Outpatient foley balloon vs.
Inpatient PG gel RCT for low-risk women having IOL
CENTRE