SDMS ID: P2010/0489-001 2.

14/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Mid Trimester Induction of Labour Mid Trimester Induction of Labour WACSClinProc2.14/06 Mid trimester induction of labour Midwifery and Medical Staff, Queen Victoria Maternity Unit Misoprostol, oxytocin, extra-amniotic PGF2, balloon catheter P2010/0501-001Perinatal Bereavement

Purpose: This clinical guideline is designed to comply with the Tasmanian State Legislation for pregnancy terminations during the second trimester. Background: Methods of mid trimester induction of labour include Misoprostol (Cytotec), Cervagem (Gameprost), IV Oxytocin or transcervical Foley catheter PGF2 instillation. Misoprostol is not licensed for use an abortifacient in Australian: therefore, although the efficacy and safety of misoprostol in second trimester pregnancy interruption is supported by the published medical literature, all women must be informed of its therapeutic licence status prior to its prescription. Mid trimester induction of labour may be conducted in ward 4O. Misoprostol Induction Dosage: 400 mcg misoprostol is inserted in to the posterior fornix every 6 hours until delivery or to a maximum period of 48 hours. Treatment should not continued beyond 48 hours without consultant medical review. Maternal Side Effects Nausea Vomiting Diarrhoea Abdominal pain Fever Procedure Prior to procedure ensure Medical Termination of Pregnancy Consent and hospital consent (including manual removal of placenta) has been completed where required. Consider IV access Blood for FBC, group and hold and antibodies. Misoprostol is to be ordered on the medication chart and maybe administered by the medical officer, midwife or the woman using water based lubricant. Women should remain in bed for 45 minutes following insertion of the tablets. Maternal observations should be recorded prior to the insertion of the first tablets and 4 hourly thereafter, unless condition warrants more frequent observation.
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Free fluids and full diet until onset of contractions, then clear fluids only. Consider IV fluids for hydration. Analgesia should be provided as required. IV Syntocinon 10 units IMI should be given after the birth of the baby (as per general orders). If the placenta is not delivered within 30 minutes of the birth of the baby then registrar or consultant should be notified. If bleeding becomes excessive then management should be as per the Management of Postpartum Haemorrhage Clinical Guideline WACSClinPro2.9. Intravenous Oxytocin If the membranes have ruptured and delivery is not imminent oxytocin may be required. The oxytocin infusion regime is 50units of oxytocin in 500ml Hartmanns solution and infused at a fixed rate of 50ml/hour through an intravenous pump. Extra-amniotic Prostaglandin Ensure there is no contraindication to the use of PGF2 A solution of 5mg PGF2 (1ml ampoule) is added to 19ml of normal saline (250mcg PGF2 /ml) A FG 18g Foley catheter is inserted through the cervix into the lower uterine cavity. The balloon is inflated with 40cc of water and traction applied by taping the catheter to the womans thigh. PGF2 should be administered via a 21g Butterfly cannula inserted and taped into the spigotted end of the Foley catheter. An initial dose of 5mls of the PGF2 solution is injected via the butterfly needle into the Foley catheter. Subsequent doses of 10ml every 2 hours are administered via the catheter into the extra-amniotic space. Traction should be applied to the catheter before each dose to ensure the balloon has not been extruded from the cervix. A vaginal examination should be performed if there is any doubt as the catheter may be located in the upper vagina. Cervagem (Gameprost) Vaginal Pessaries Not kept in the hospital pharmacy - needs to be ordered and dispatched from Melbourne which would usually take 2 working days. One pessary is inserted every 3 hours until labour or a maximum of 5 pessaries. Postnatal Considerations Anti D for Rh negative women Social worker referral should be offered during and after admission. Advise women to seek medical review if they feel worried about pain, bleeding or high temperature. Education on lactation suppression and consider Carbergoline if gestation greater than 18 weeks. Contraception advice Physio referral and handout GP notification and follow up appointment Follow up gynae clinic appointment in 12 weeks for pathology results (earlier postnatal appointment may be required for bereavement support) Genetic counselling if appropriate

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Attachments Attachment 1 Attachment 2 Attachment 3

Clinical Notes Consent References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 3 August 2009

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APPENDIX 1 Clinical Notes The median time from commencement until delivery is 18 hours (12 hours in the case of fetal death). Intravaginal misoprostol will effect delivery within 24 hours in 75-80% of women. Retained placenta occurs in 40% of cases. Women should be informed that removal of placenta in the operating room may be required. If the placenta is not spontaneously delivered within 60 minutes of the fetus (or earlier should excessive bleeding occur) operative delivery is indicated. Risk of haemorrhage is 4 in 1000 at more than 20 weeks and 0.88 in 1000 at less than 13 weeks. Risk of uterine rupture is under 1 in 1000. Carbergoline 1mg as a single oral dose is routinely administered for lactation suppression in gestations greater than 18 weeks. Information regarding suppression of lactation should be given.

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APPENDIX 2 CONSENT Termination of Pregnancy Referral Form This form must be signed by the woman, medical officer, obstetrician gynaecologist and the CEO. In the event of urgent procedures this does not need to be completed prior to the commencement but can be completed as soon as practical. A standard consent form should also be completed. Consent to Procedure/Treatment/Operation A standard consent form should be signed by the woman and medical officer for the termination of pregnancy and possible surgical procedures if necessary. Where the woman is unable to complete a consent form an Authorisation to Treat must be completed. Authorisation to Treat This consent form can be used in situations were a surgical or medical procedure is necessary on an urgent basis to: save a patients life prevent serious damage to the patients health prevent or alleviate significant pain or distress. This form can be filled in and signed by the Director of Clinical Services or his/her delegate. The Medical registrar is the after hours delegate.

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APPENDIX 3 REFERENCES King Edward Memorial Hospital Clinical Guidelines 2001 Mid trimester termination of pregnancy. Online: http://www.kemh.health.wa.gov.au/development/manuals/sectionb/index.htm#5 Kiran U, Amin P and Penketh RJ Self-administration of misoprostol for termination of pregnancy: safety and efficacy. 2004 Journal of Obstetrics & Gynaecology 24(2): 155-6. Medema s, Wilschut HIJ, Van Gemund N, Scherjon SA. Medical methods for midtrimester termination of pregnancy. (Protocol) Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD005216. DOI: 10.1002/14651858.CD005216. Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database of Systematic Reviews 2006. Issue 3. Art. No.: CD002253. DOI: 10.1002/14651858.CD002253.pub3. Royal Australian and New Zealand College of Obstetricians and Gynaecologists College Statement The use of misoprostol is obstetrics and gynaecology 2005 Online: http://www.ranzcog.edu.au/publications/collegestatements.shtml#CObs Royal College of Obstetricians and Gynaecologist The care of women requesting induced abortion. 2004 Online: http://www.rcog.org.uk/index.asp?PageID=662

Mid Trimester Induction of Labour May-11

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