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National Collaborating Centre for Women's and Children's Health (UK). Induction of Labour. London: RCOG Press; 2008 Jul. (NICE Clinical Guidelines, No. 70.)

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Induction of Labour.

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8Complications of induction of labour

Clinical question

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.

Recommendation on uterine hyperstimulation

Tocolysis should be considered if uterine hyperstimulation occurs during induction of labour.

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

Recommendations on failed induction

If induction fails, healthcare professionals should discuss this with the woman and provide support. The woman’s condition and the pregnancy in general should be fully reassessed, and fetal wellbeing should be assessed using electronic fetal monitoring.

If induction fails, decisions about further management should be made in accordance with the woman’s wishes, and should take into account the clinical circumstances.

If induction fails, the subsequent management options include:

  • a further attempt to induce labour (the timing should depend on the clinical situation and the woman’s wishes)
  • caesarean section (refer to ‘Caesarean section’ (NICE clinical guideline 13)).

For women who choose caesarean section after a failed induction, recommendations in ‘Caesarean section’ (NICE clinical guideline 13) should be followed.

Research recommendations on failed induction

Research is needed to establish frequency and interval of vaginal PGE2 to achieve successful induction of labour.

Research is needed to examine different management policies for failed vaginal PGE2 induction (additional PGE2, amniotomy, oxytocin, elective caesarean section or delay of induction if appropriate).

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

Recommendations on cord prolapse

To reduce the likelihood of cord prolapse, which may occur at the time of amniotomy, the following precautions should be taken:

  • Before induction, engagement of the presenting part should be assessed.
  • Obstetricians and midwives should palpate for umbilical cord presentation during the preliminary vaginal examination and avoid dislodging the baby’s head.
  • Amniotomy should be avoided if the baby’s head is high.

Healthcare professionals should always check that there are no signs of a low-lying placental site before membrane sweeping and before induction of labour.

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.

Recommendation on uterine rupture

If uterine rupture is suspected during induced labour, the baby should be delivered by emergency caesarean section (refer to ‘Caesarean section’ (NICE clinical guideline 13)).

Copyright © 2008, National Collaborating Centre for Women's and Children's Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Bookshelf ID: NBK53624

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