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Clinical question
- How are the complications of induction of labour prevented and managed?
The following complications of induction of labour were reviewed: uterine hyperstimulation, failed induction, umbilical cord prolapse and uterine rupture.
8.1. Uterine hyperstimulation
Uterine hyperstimulation can appear as tachysystole or hypertonus, which may lead to FHR changes. Across all the different preparations used for induction reviewed in this guideline, there is level 1+ evidence that the incidence of uterine hyperstimulation with or without FHR changes ranged from 1% to 5%.
Overview of available evidence
One study assessed the effects of tocolytics in the management of uterine hyperstimulation caused by induction with PGE2. No evidence was identified relating to management of uterine hyperstimulation caused by induction with intravenous oxytocin.
No evidence was identified evaluating the use of intravenous magnesium sulfate, or swabbing or irrigating the vagina after uterine hyperstimulation in an attempt to wash out vaginal PGE2. No evidence was identified on the management of prolapse of cord, cord compression, vasa praevia or the use of oxygen therapy.
PGE2-induced uterine hyperstimulation
A retrospective study of case notes (n = 3099) investigated women who underwent induction with low-dose PGE2 (vaginal tablet, gel and intracervical gel). Uterine hyperstimulation (defined as contraction frequency being more than five in 10 minutes or contractions exceeding 2 minutes in duration) occurred in 181 cases (5.8%), of which 57 (31.5%) were associated with FHR abnormalities. Administration of tocolytic treatment with β2-adrenergic drugs (hexoprenaline at 0.3 micrograms/minute or a single dose of terbutaline 250 micrograms intravenously or subcutaneously) was successful in normalising uterine contractions and reversing any FHR abnormality in 178 cases (98.3%). Improvement usually began within 5 minutes regardless of hyperstimulation patterns. Three cases required caesarean section and there were no postpartum complications.185 [EL = 3]
Guidance is provided by the NICE clinical guideline on intrapartum care relating the management of suspicious or pathological EFM traces once active labour is established.17
Evidence statements
Evidence suggested that uterine hyperstimulation after low-dose PGE2 therapy is uncommon and usually rapidly reversible with β2-adrenergic therapy without apparent maternal and fetal complications. [EL = 3]
Interpretation of evidence
For uterine hyperstimulation, tocolytics can be effective for PGE2-induced uterine hyperstimulation. Methods of tocolysis should follow the local standard protocol.
8.2. Failed induction
The criteria for failed induction are not generally agreed. It is estimated that a failed induction in the presence of an unfavourable cervix is found in 15% of cases.188
Failed induction of labour must be differentiated from failure of labour progress due to cephalopelvic disproportion or malposition. In this guideline, failed induction is defined as failure to establish labour after one cycle of treatment, consisting of the insertion of two vaginal PGE2 tablets (3 mg) or gel (1–2 mg) at 6-hourly intervals, or one PGE2 controlled released pessary (10 mg) over 24 hours (see Section 5.1.1).
Overview of available evidence
No evidence was identified relating to management of failed induction.
Reference is made to the NICE clinical guideline on intrapartum care as supplementary evidence.17
Interpretation of evidence
When induction fails, the GDG considered it important, as in all clinical practice, to review the situation for subsequent management options on a case-by-case basis. A further attempt to induce labour can be considered, and the timing should depend on the woman’s wishes and her clinical situation.
The GDG agrees with and supports the recommendations made in the NICE intrapartum care guideline relating to the management of suspicious or pathological EFM traces, once labour is established.17
8.3. Cord prolapse
Prolapsed cord is always a potential risk at the time of membrane rupture, especially when the membranes are ruptured artificially.
Overview of available evidence
No evidence was identified relating to management of prolapsed cord
8.4. Uterine rupture
Uterine rupture at the time of induction of labour is an unusual event (see Section 4.4 on induction of labour in women with a previous caesarean section).
Overview of available evidence
No evidence was identified relating to the management of uterine rupture.
Publication Details
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Publisher
RCOG Press, London
NLM Citation
National Collaborating Centre for Women's and Children's Health (UK). Induction of Labour. London: RCOG Press; 2008 Jul. (NICE Clinical Guidelines, No. 70.) 8, Complications of induction of labour.