Oxford Handbook of Midwifery (84 page)

The score should be recorded in the woman’s notes each time an assessment is made, i.e. at the time of administration of prostaglandin

gel and amniotomy.

If the Bishop score is:

Variations on this scoring include one recommended in the NICE guidlines.
⁴

Sweeping the membranes

When a woman’s care during pregnancy has been midwifery-led, induction of labour should be discussed by the midwife towards term. The commu- nity midwife may arrange with the delivery ward for the induction to be planned for a mutually convenient time.

Prior to induction of labour in hospital, offer the woman a vaginal examination to assess the state of the cervix and to perform a sweeping of the membranes. This has been shown to increase the possibility of labour occurring naturally with in the following 48h.
⁴

The NICE antenatal guidelines
⁵
recommend that this should form part of the antenatal consultation at 41 weeks’ gestation. If the membrane sweep is discussed at a previous appointment, the woman has the opportunity to arrange support for the visit if she wishes.

This procedure may be performed in the woman’s home or at an antenatal clinic visit. It may be a preferable first step to stimulate labour and sometimes may pre-empt formal induction.

Table 18.2
Modified Bishop (Calder) score

CHAPTER 18
High-risk labour

366

• The pregnancy should be uncomplicated.
  
• The gestational age should be term, 41 weeks.
  
• The membranes must be intact.
  
• Warn the woman that she may experience some discomfort as a result of the procedure and that she may have a mucoid/bloodstained ‘show’ and should wear a light sanitary pad.
  

  •
  Reassure her that membrane sweeping is not associated with increased maternal or neonatal infection.
  

• Perform a vaginal examination and locate the cervix. A finger is inserted through the internal os, stretching the cervix slightly, and the membranes are palpated. Use a sweeping circular movement of the finger to separate the fetal membranes from the decidua/lower uterine segment.
  
• There is potential for a natural rapid increase in prostaglandin production in late pregnancy. Sweeping of the membranes is a mechanical stimulant to tissue prostaglandin release in the cervix and lower segment. This, in turn, can initiate the onset of labour.
  

  Prostaglandins for induction of labour
  

• Obtains consent from the woman, perform a vaginal examination and assess the cervix using the Bishop score.
  
• If the cervix is not favourable (Bishop score <5), use vaginal prostaglandin dinoprostone (PGE2) gel to soften/ripen the cervix, as follows:
  
  • Nulliparous women: 2mg prostaglandin gel.
    
  • Multiparous women: 1mg prostaglandin gel.
    
• The gel should be placed in the posterior fornix of the vagina.
  
• Record the Bishop score, amount of prostaglandin gel, and time of procedure in the notes.
  
• Encourage the woman to rest on the bed for an hour following the procedure, during which time the fetal heart is monitored continuously. If the recording is reassuring, the woman should mobilize and eat/drink as normal.
  
• Warn the woman that she may experience mild discomfort/ soreness in the vagina as a result of prostaglandin, or painful uterine contractions caused by the prostaglandin prior to the onset of the
  

  regular contractions of labour. Oral or intramuscular analgesics may be prescribed.
  

• Repeat the vaginal examination to assess progress in 6–12h. Nulliparous women admitted for post-dates induction may rest overnight and be reviewed the following morning.
  
• If the cervix is still firm in consistency and in a posterior position (Bishop score <5), a second dose of prostaglandin gel should be given and the fetal heart monitored as previously.
  
• The total dose of prostaglandin gel given should not exceed 4mg for nulliparous and 3mg for multiparous women.
  
• Vaginal (PGE2) tablet preparations are also available and the recommended dose is 3mg PGE2 6h. The maximum dose is 6mg for all women.
  
• Propess
  ^®
  vaginal insert 10mg (PGE2) may be preferred by women to help soften the cervix as it is a slow release preparation and delivers
  

  INDUCTION OF LABOUR
  

  367
  

  about 0.4mg/h of active agent in 24h. Propess
  ^®
  should be inserted into the posterior fornix of the vagina using a water-soluble lubricant. It has a tape to aid removal after 24h. Follow local protocols for use.
  

  Risks of induction with prostaglandin
  

• Women with severe asthma
  
• Non-reassuring fetal heart pattern
  
• IUGR
  
• Previous precipitate labour
  
• Previous caesarean section, myomectomy, hysterotomy.
  ²
  

Artificial rupture of the membranes

• The senior registrar authorizes/performs the procedure in the high- risk client
  
• The woman understands the procedure and consents
  
• The fetal head is engaged or 3/5 palpable abdominally
  
• 6h have elapsed since the last insertion of prostaglandin gel
  
• The CTG is reassuring.
  

  Management