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Audit on Induction of labour

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Induction of Labour Audit:

Induction of Labour Audit Mya Kyar Phyu Trust Grade (OG) Sana Maroof FY1 (OG)

Aim:

Aim To look at the indications, process and outcome of induction of labour at Stafford General Hospital To determine whether this meets the CNST Maternity Standards 2011 and NICE Guidance (clinical guideline 70 – Induction of labour, July 2013)

Aim:

Aim To gain an appreciation of the efficacy of single-dose and multiple-dose Prostin® (vaginal PGE 2 gel), the most commonly used agent at Stafford, 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

Purpose:

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

Background:

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

Background:

Background Around 1/5 deliveries in the UK induced In Stafford Hospital, 23.42% of deliveries are induced labour (during the whole year 2013) Induced labour may be less efficient and more painful than spontaneous labour 1 Associated with higher rates of assisted delivery (17-19%) compared to 12% with spontaneous labour 1 NICE clinical guideline 70, Induction of labour, July 2013

Methodology:

Methodology Sample of 33 patients from those induced at Stafford General Hospital from November-December, 2013 Used hospital maternity records to gather data and analysed using SPSS version 16.0 Defined as those administered vaginal prostaglandin and/or those in whom amniotomy was performed when the woman was not in labour

Results:

Results Maternal demographics

Age:

Age

Ethnicity:

Ethnicity

Parity:

Parity

Previous Caesarean section:

Previous Caesarean section

Induction information :

Induction information

Gestation at induction (weeks):

Gestation at induction (weeks)

Indication for IOL:

Indication for IOL

‘Other’ reasons:

‘Other’ reasons Symphysis pubis dysfunction Guillan-Barre syndrome with pain in buttock Obstetric cholestasis with impaired liver function test Not documented

Induction in specific circumstances:

Induction in specific circumstances

Postdates:

Postdates

Number of sweeping in post date:

Number of sweeping in post date

Information provision and time of induction:

Information provision and time of induction

Documentation about treatment offered:

Documentation about treatment offered

Decision making :

Decision making

Interval between admission and examination:

Interval between admission and examination

Interval between admission and IOL:

Interval between admission and IOL

Maternofoetal assessment & monitoring prior to and during induction, before the establishment of labour :

Maternofoetal assessment & monitoring prior to and during induction, before the establishment of labour

Prior to induction:

Prior to induction EFM to assess foetal wellbeing, performed in all (100%) cases Modified Bishop score done in all cases as vaginal examination although it is not calculated in notes

Modified BSS:

Modified BSS

Use of prostin:

Use of prostin

Necessity for ARM:

Necessity for ARM

Necessity for syntocinon:

Necessity for syntocinon

Repeat CTG performed in all (100%) women who developed contractions:

Repeat CTG performed in all (100%) women who developed contractions

Maternal observations documented 4 hourly:

Maternal observations documented 4 hourly

Interval between admission and delivery:

Interval between admission and delivery

Interval between IOL and delivery:

Interval between IOL and delivery

Modified Bishop score reassessed in all (100%) women who did not labour 24hrs following Prostin insertion:

Modified Bishop score reassessed in all (100%) women who did not labour 24hrs following Prostin insertion

PowerPoint Presentation:

No hyperstimulation in IOL cases No need for tocolytic drugs

Result analysis:

Result analysis

Outcome of IOL:

Outcome of IOL

Instrumental deliveries- indication for induction:

Instrumental deliveries- indication for induction

Indications for instrumental deliveries:

Indications for instrumental deliveries

Caesarean section – indications for IOL:

Caesarean section – indications for IOL

Indications for Caesarean section:

Indications for Caesarean section

Maternal Complications:

Maternal Complications

Fetal outcome according to APGAR:

Fetal outcome according to APGAR

SCBU Admission:

SCBU Admission Only 2 cases admitted to SCBU LGA (4720 g with APGAR <7, 7-8 at 1 and 5 minutes Preterm (2320 g with gestation 34 weeks 3 days)

Correlation between gestational age and outcome of IOL:

Correlation between gestational age and outcome of IOL NVD Ventouse Forceps Em CS Total 32-<37 weeks 2 0 0 1 3 37-<41 weeks 15 1 1 2 19 >=41 weeks 4 3 1 3 11 Total 21 4 2 6 33

Correlation between gestational age and outcome of IOL:

Correlation between gestational age and outcome of IOL

Correlation between sweeping and MOD:

Correlation between sweeping and MOD No of sweeping NVD Ventouse Forceps Em CS Total 0 7 2 2 5 16 1 14 1 0 1 16 2 0 1 0 0 1 Total 21 4 2 5 33

Correlation between sweeping and MOD:

Correlation between sweeping and MOD

Correlation between birth weight and MOD:

Correlation between birth weight and MOD B.Wt NVD Ventouse Forceps Em CS Total 1500-<2500 2 0 0 1 3 2500-4000 17 4 2 5 28 >=4000 2 0 0 0 2 Total 21 4 2 6 33 ≥ 4000  4703 g and 4270 g

Correlation between birth weight and MOD:

Correlation between birth weight and MOD

Previous Caesarean section :

Previous Caesarean section 2 cases – Guillan Barre’s syndrome with pain in buttock Obstetric cholestasis with impaired LFT MOD Both - NVD

Correlation between number of prostin and MOD:

Correlation between number of prostin and MOD Number of prostin NVD Ventouse Forceps Em CS Total 0 9 3 0 0 12 1 4 1 0 3 8 2 4 0 1 1 6 3 4 0 1 2 7 21 4 2 6 33

Correlation between number of prostin and MOD:

Correlation between number of prostin and MOD

Correlation between BSS and MOD:

Correlation between BSS and MOD BSS ≤ 5 BSS ≥ 6

Comparison with background Hospital Maternity ward data:

Comparison with background Hospital Maternity ward data

Admission Vs delivery (2013):

Admission Vs delivery (2013)

IOL (2013):

IOL (2013)

MOD (all patients Vs IOL ):

MOD (all patients Vs IOL )

Findings:

Findings One time sweeping is very effective before induction and it can result in NVD in 87.5% of the cases whereas no sweeping (no VE) ends up with 43.8% of NVD Lower C-section rates (18.2%) and same instrumental delivery rates ( Ventouse 12.1% and forceps 6.1%) in this audit compared to national average (England: 21-23% and 16-19% respectively) MOD in IOL are quite similar to all patients in delivery suite, Stafford Hospital

Findings (contd):

Findings (contd) Majority (57.6%) of cases were examined within 1 hour of admission IOL started in 1-<2 hour in most cases (48.5%) Delivery occurred after 48 hours in majority (24.2%)

Main Recommendations:

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 Sweeping should be done before induction To re-audit in the near future after implementation of the new Induction of Labour proforma to determine effects

Areas for development:

Areas for development Recording of actual bishop scores to allow analysis of correlation amongst successful and failed inductions Documentation about treatment offered and consent about IOL should be obtained in every case To record timing of P/PROM from induction to delivery

PowerPoint Presentation:

Thank you

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