SDMS ID: P2010/0483-001 2.

8/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Prostaglandin E2 (PE2 gel) Cervical Ripening Prostaglandin E2 (PE2 gel) Cervical Ripening WACSClinProc2.8/06 Induction of labour using Prostaglandin E2 (PE2 gel) Midwifery and Medical Staff, Queen Victoria Maternity Unit PE2 gel P2010/0321-001 Induction of Labour for Post Maturity P2010/0486-001 Intrapartum Fetal Monitoring P2010/0528-001 Uterine Hyperstimulation Purpose: Vaginal prostaglandin E2 (PE2 gel) has been shown to be efficacious in ripening the cervix prior to the induction of labour. The likelihood of delivery within 24 hours is increased although there appears to be no significant change in the Caesarean section rate. There is however evidence for increased rates of uterine hyperstimulation with fetal heart rate change. Indication for Prostaglandin PE2 gel is used where induction of labour is indicated and the Bishops score is <6. It should not be used in the place of ARM and Syntocinon where the cervix is favourable. The Bishops score must be documented in the womens progress notes. Bishops Score SCORE Dilation Length of Cervix Station Consistency Position

0 0 3 -3 Firm Posterior

1 1-2 2 -2 Medium Mid

2 3-4 1 -1 Soft Anterior TOTAL

3 5+ 0 0

Contraindications Known hypersensitivity to Prostaglandin E2 or the component gel Grand multiparity (5 or more previous births) Known or suspected cephalopelvic disproportion Hyperactive or hypertonic uterine contractions Unexplained vaginal bleeding in pregnancy Where vaginal birth is contraindicated placenta praevia, active genital herpes, malpresentation. PE2 gel should be used with caution in women with asthma, epilepsy, glaucoma or raised intraocular pressure. PE2 gel maybe used in the following circumstance with consultant approval: History of previous uterine surgery

Abnormal fetal heart trace Ruptured membranes

Dosage The recommended dose is: Primiparous women 2mg PE2 gel Multiparous women 1 to 2mg PE2 gel In the absence of significant uterine activity the dose maybe repeated in six hours. The decision to administer a second or third dose of PE2 gel must be made by the obstetric registrar or consultant. The maximum dose of PE2 gel vaginal gel must not exceed 3mg over a six hour period. Administration Woman for cervical ripening should be admitted to 4B between 3 and 4 pm (or at a time convenient to the labour ward and clinician inserting the gel). The first dose of PE2 gel will be administered at 4pm and the second dose given at 10pm. The woman will then be reviewed the following morning with a view to ARM and Syntocinon infusion. Prostaglandin should be removed from the fridge 30 minutes prior to administration. A CTG must be performed prior to the administration. The CTG must be reassuring prior to the administration of the PE2 gel. A consultant obstetrician may administer PE2 gel in the presence of a non-reassuring CTG after appropriate discussion and counselling with the woman. The PE2 gel maybe administered by midwifery staff when Bishops scoring has been documented and the PE2 gel has been ordered on the medication chart by the medical officer. The gel should be inserted high into the posterior fornix of the vagina, avoiding administration into the cervical canal. It should be given using a water based lubricant only. The woman should remain recumbent for one hour following administration of PE2 gel. Because of the risk of hyperstimulation when used in conjunction with oxytocin, there should be a delay of an absolute minimum of six hours after the PE2 gel has been administered and the commencement of intravenous oxytocin. Clinical Observations A CTG must be performed for one hour following the administration of PE2 gel. Maternal observations should be recorded prior to the insertion of PE2 gel, one hour after the insertion of PE2 gel and thereafter, every four hours. Continuous fetal heart rate monitoring should be repeated 30 minutes prior to the insertion of another dose. A reassuring CTG should be obtained once contractions are established and continuous CTG should be commenced when risk factors for fetal compromise have been detected antenatally or are detected at the onset of labour or develop during labour (P2010/0486001 Intrapartum Fetal Monitoring) Indications for Removal of PE2 gel Uterine hyperstimulation or hypertonic uterine contractions Fetal distress Should this occur: Reposition women left lateral Consider Terbutaline 0.25mg subcutaneously Swab the vagina with a dry swab to remove residual prostaglandin gel. Notify midwife in charge and obstetric registrar/consultant.

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Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit. 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: 30 June 2010

REFERNCES Kelly AJ, Kavanagh J, Thomas J. Vaginal prostaglandin (PE2 GEL and PGF2a) for induction of labour at term. Cochrane Database of Systematic Reviews 2003, Issue 4. art. No.: CD003101. DOI: 10.1002/14651858.CD003101. Royal Australian and New Zealand College of Obstetricians and Gynaecologist 2009 College Statement Use of prostaglandins for cervical ripening prior to induction of labour. Online: http://www.ranzcog.edu.au/publications/collegestatements.shtml Mims Online Prescribing Information 2008 Prostin E2 Vaginal Gel viewed 14 September 2009 < http://proxy8.use.hcn.com.au/ifmx-nsapi/mimsdata/?MIval=2MIMS_abbr_pi&product_code=811&product_name=Prostin+E%3csub %3e2%3c%2fsub%3e+Vaginal+Gel>. National Institute for Clinical Excellence Clinical Guideline D 2008 Induction of labour. Online http://www.nice.org.uk/guidance/index.jsp?action=byID&o=12012