Anda di halaman 1dari 9

Auckland District NATIONAL WOMENS MATERNITY Clinical Practice

Health Board (Section 3) Manual


INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 1 of 9
Overview

Document Type Guideline
Function(s) Clinical Service Delivery
Health Service Group (HSG) Womens Health
Department(s) affected Maternity
Patients affected All maternity patients having IOL
Staff members affected All clinicians in maternity (including access holder
LMCs)
Key words Induction, labour, IOL,
Author role only Clinical Director of Obstetrics
Owner (see ownership structure) Clinical Director of Obstetrics
Edited by Clinical Policy Advisor
Date first published August 2007
Date this version published April 2012
Date of next scheduled review April 2015
Unique Identifier NMP200/SSM/063

Content This document covers the following topics relating to the induction
of labour in pregnancy post dates.

Topic See Page
Overview ..................................................................................... 1
Associated Documents ................................................................ 3
References ................................................................................... 4
Policy Statements ........................................................................ 5
Prolonged Pregnancy Pathway .................................................... 8


Purpose To define the criteria for induction of labour for post dates pregnancy
at National Women's.

Continued on next page
Clinical Practice NATIONAL WOMENS MATERNITY Auckland District
Manual (Section 3) Health Board
INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 2 of 9
Overview, Continued

Scope This policy applies to all medical and midwifery practitioners, both
ADHB and non-ADHB practitioners, who provide services at
National Women's for pregnant women.

Background
Information
Gestation related Perinatal mortality increases beyond 38 weeks with
a marked increase after 42 weeks of gestation.

Current evidence favours arranging Induction of Labour after 41
weeks due to a reduction in perinatal mortality (of approximately 1
perinatal death per 500 inductions) and no associated increase in the
caesarean section rate for such women. However, increased fetal
surveillance beyond 41 weeks may also be an acceptable approach
following appropriate risk selection and discussion with the woman.

For women aged 35 or more, the perinatal mortality at 40 weeks
gestation is equivalent to that of younger women at 42 weeks but this
is a continuum as age increases. (Reference 3 & 4)

Auckland District NATIONAL WOMENS MATERNITY Clinical Practice
Health Board (Section 3) Manual
INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 3 of 9
Associated Documents

Associated
Documents
The table below indicates other documents associated with this
policy.

Type Document Titles
Board Policy Informed Consent
National
Womens
Policies
Access - Consultation with a National
Women's Obstetric Specialist
Access - Obstetric Handover & Hand Back
Clinical Care Responsibility
Access - Post Handover Independent
Midwifery Care Options
Access - Transfers to Maternity Services
Induction of Labour - Roles & Responsibilities
Induction of Labour - RBP
Day Assessment Unit - Indications & Referrals
Other THA Guidelines for referral to an obstetric
specialist
RANZCOG Guidelines for interpretation of
CTGs
NICE (2001) Induction of labour guideline,
National Institute of Excellence, London.

Clinical Practice NATIONAL WOMENS MATERNITY Auckland District
Manual (Section 3) Health Board
INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 4 of 9
References

Type Document Titles
References The New England Journal of Medicine, Vol
326, No 24, PP 1587-1592, June 1992:
Induction of Labour as compared with serial
antenatal monitoring in post-term pregnancy.
Crowley P, Cochrane Library, 2000 Issue 2;
Interventions for preventing or improving the
outcome of delivery at or beyond term.
British Journal of Obstetrics and Gynaecology,
April 1994, Vol 101, PP 301-306; Effects of
maternal age, parity, and smoking on the risk
of stillbirth.
The New England Journal of Medicine, Vol
333, No 15, October 1995; Increased maternal
age and the risk of fetal death.
Nohr, E.A., Bech, B.H., Davies, M.J.,
Frydenberg, M., Henriksen, T.B., & Olsen, J.
(2005) Prepregnancy obesity and fetal death,
American College of Obstetricians &
Gynecologists, Vol.106, (No.2, Aug), p250 -
258.

Auckland District NATIONAL WOMENS MATERNITY Clinical Practice
Health Board (Section 3) Manual
INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 5 of 9
Policy Statements

Policy Statements Gestation should be calculated from the womans last menstrual
period. If ultrasound dating differs from the menstrual dating then
the margin of error of the scan should be considered. If the
discrepancy between the menstrual dating and scan dating is more
than the margin of error for the scan and the menstrual dating is sure,
then the menstrual dating should be confirmed as correct.

The margin of error of the scan is calculated by taking 8% of the
gestation in days.

Examples of margin of error :
6 wk +/- 3 days
7 wk +/- 4 days
8 wk +/- 4.5 days
10 wk +/- 5.5 days
16 wk +/- 9 days
20 wk +/- 11 days

Management of pregnancies continuing beyond 41 weeks requires
consultation with a specialist either at ANC at Greenlane Clinical
Centre or a private obstetrician consultation.

Routine antenatal care (i.e. Weekly visits) is not a safe option after
41 weeks gestation.

Discussion with the woman regarding her options for ongoing care
must occur at around 41 weeks (EDD 40 weeks plus 5 days to EDD
40 weeks plus 9 days).

Induction of Labour should be arranged promptly in the following
circumstances:
Maternal hypertensive disease
Maternal diabetes
A small-for-gestational-age baby
Any other concern regarding maternal or fetal condition
If reduced movements or reduced liquor are present.

Continued on next page
Clinical Practice NATIONAL WOMENS MATERNITY Auckland District
Manual (Section 3) Health Board
INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 6 of 9
Policy Statements, Continued

Policy Statements,
continued
Induction of labour for post dates pregnancy, when there is no
medical indication other than prolonged pregnancy: should occur
after 41+3 weeks (EDD plus 10 days) and up to 42 weeks (EDD plus
14 days).

Where expectant management after 41 weeks is the approach to be
taken, utilisation of the Day Assessment Unit should be offered and
appropriate investigations booked with the womans consent.

The importance of monitoring fetal movements and reporting any
reduction in movements should be emphasised.

A formal ultrasound scan should be arranged at 41 weeks. This
should include measurement of the babys growth parameters and the
liquor volume. Induction of Labour should be arranged promptly if
there is any evidence of fetal growth restriction, reduced liquor or
reduced fetal activity.

Fetal assessment by ultrasound for measurement of the liquor be
performed twice a week and CTG two to three times a week utilising
the Day Assessment Unit facilities though the evidence of the
efficacy of these fetal monitoring methods in preventing intrauterine
death is unclear .

Induction of labour should occur the same day if the CTG is non-
reassuring or the depth of the deepest pocket of liquor is 2.0 cm or
if there are reduced fetal movements
For women over 35, fetal monitoring as described in section 6,
above, should begin at 40 weeks gestation and induction of labour be
planned by 41 weeks.

Continued on next page
Auckland District NATIONAL WOMENS MATERNITY Clinical Practice
Health Board (Section 3) Manual
INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 7 of 9
Policy Statements, Continued

Policy Statements,
continued
For women with BMI >30 a plan for delivery should be made at 40
weeks with consideration of induction at 41 weeks and perhaps
earlier if the women is also older than 35.

In instances where the EDD is uncertain because of late booking or
late ultrasound, fetal monitoring as in point 6 above should begin
from the best estimate of the EDD and generally an expectant
approach is favoured.

Note The policy statements above are based on the best evidence currently
available and should be used to inform women. All actions noted
above are contingent upon the woman:
Receiving appropriate information about the evidence as it
applies to her clinical situation (and this policy should be
supported by a patient information leaflet), and
Giving her informed consent to any procedures being undertaken.
Deviations in management from this policy, including refusal of
treatment by the patient need to be clearly documented in the
clinical record, along with recording of the advice given by her
caregiver.

Clinical Practice NATIONAL WOMENS MATERNITY Auckland District
Manual (Section 3) Health Board
INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 8 of 9
Prolonged Pregnancy Pathway

Clinical Care
Pathway for
Prolonged
Pregnancies
All women experiencing a prolonged pregnancy will be reviewed
either in Antenatal clinic or Private consultation rooms depending on
womans choice and LMC. These women will not be seen for an
IOL date assessment in WAU or DAU.

Referral Criteria Criteria for referring for review to Antenatal clinic (ANC) at
Greenlane Clinical Centre:
Referral letter must be faxed (09 630 9781) to ANC and a
summary of pregnancy with any known risk factors identified
either faxed or brought with the woman. (A woman will not be
seen if the summary of pregnancy and reason for referral are not
received).
Ultrasound report of Liquor volume, fetal growth and BPP
performed within 2 days of scheduled appointment, must be
brought by the woman to her appointment. This is to be
arranged, where possible, with community Ultrasound providers
not our in house ultrasound department (this service is very
oversubscribed). Growth should be plotted on a customized
chart.

Continued on next page
Auckland District NATIONAL WOMENS MATERNITY Clinical Practice
Health Board (Section 3) Manual
INDUCTION OF LABOUR
POST DATES PREGNANCY
Section: National Womens Maternity Issued by: Clinical Director O&G
File: Induction Labour Post Dates Apr12.doc Authorised by: Clinical Director O&G
Classification: NMP200/SSM/063 Date Issued: Reviewed April 2012
Induction of Labour Post Dates Pregnancy Page: 9 of 9
Prolonged Pregnancy Pathway, Continued

Antenatal Clinic
Appointment
Purpose of Antenatal clinic appointment:
For the woman to be reviewed by Registrar or Consultant and,
where appropriate, an IOL date to be booked through the Charge
Midwife of WAU/DAU. The Charge Midwife can be contacted
from 0730 1600 on 021400983 to book an IOL. An IOL can
only be booked up to 7 days in advance. NB: If the suggested
IOL date is more than 7 days ahead the same rules apply to
booking; the Dr needs to inform the LMC midwife to ensure they
book the IOL for the woman. The LMC midwife must phone on
the appropriate day to book the IOL with the Charge MW of
WAU/DAU (e.g. if wishing to book an IOL on Wednesday the
following week and it is only Monday of the previous week, the
midwife will need to contact the Charge Midwife on
Wednesday).
Where necessary, increased surveillance is to be offered to the
woman and carried out in Day Assessment Unit found on L9
support building, ACH. Please complete and fax (3078904 or
x25905) a management plan referral form (CR8791) for DAU
and contact on 3074949 x25907 to arrange an appointment (very
important to arrange an appointment as this is not a drop in
clinic) and provide the woman with an information leaflet with
her appointment recorded on.

Note: When referring to DAU this woman must already have an IOL
appointment scheduled.