Insertion of vaginal prostaglandin E2
Approximately 1 in 5 labours are induced in the UK. Induction of labour can be a very frightening time for women and partner. The midwife is well placed to ensure that women receive evidence-based information to help them reach an informed choice about their care.
Currently, in the UK the most common method of induction utilises synthetic forms of prostaglandin, Prostin®. These come in the form of gels, tablets or 24-hour release formulations. For greatest efficacy these should be administered at regular intervals to maintain a therapeutic range of the drug within the system. Gels and tablets are commonly prescribed for administration at 6-hourly intervals with a maximum of three doses in 24 hours. There are many factors that can impact on the midwife’s ability to adhere to this regimen. Capacity and staffing often delay or impede on the induction process. The single-dose Propess® delivers 0.3 mg per hour over the 24-hour period.
As with all medications it is vital that the midwife is aware of common side effects, indications and contraindications for administration of prostaglandin preparations (Boxes 55.1 and 55.2). The midwife must also ensure that the drug has been prescribed, checked and dispensed correctly.
- Ensure that the mother is fully aware of the process and gives informed consent.
- Encourage mother to empty bladder.
- Ensure privacy and comfort is maintained throughout the procedure.
- Wash hands.
- Undertake full antenatal examination, including abdominal palpation and auscultation of fetal heart with Pinnards stethoscope/hand-held sonicaid.
- Monitor fetal wellbeing via cardiotocograph (CTG) for 30 minutes.
- Do not undertake the procedure if any abnormalities identified with CTG or antenatal examination/ palpation.
- Gather all equipment (Figure 55.1) and the prescribed prostaglandin (Figures 55.2 and 55.3).
- Wash hands and put on apron.
- Maintaining asepsis, put on sterile gloves and undertake a vaginal examination.
- Ascertain Bishop’s score (see Chapter 54). If 0–6 administer the prescribed prostaglandin.
- For Prostin tablet –secure tablet between index and middle fingers of examining hand. Insert lubricated fingers gently into the vagina in a downwards and backwards direction along posterior vaginal wall.
- Deposit the tablet high into the posterior vaginal fornix.
- For Prostin Gel – this comes in a syringe applicator. Locate posterior fornix as above, guide syringe applicator along examining fingers, squirt the gel into the posterior vaginal fornix.
- For Propess this needs to be placed crosswise, high in the posterior vaginal fornix (Figure 55.4). In order to achieve this, place the Propess between index and middle finger, enter vagina, once posterior fornix located manoeuvre the Propess into a transverse position, remove fingers, being careful not to pull retrieval tape and thus inadvertently removing Propess.
- Ensure woman is left clean and comfortable post procedure.
- Monitor fetal heart via CTG for 30 minutes postinsertion of prostglandin.
- Document fully all actions and observations.
- Ensure documented management plan in place that the woman is in agreement with.
- Monitor maternal and fetal condition in line with national/ local guidelines.
- Inform the woman of signs and symptoms to report to midwife, e.g. regular contractions, vaginal bleeding, ruptured membranes or Propess fallen out.
- Ensure that she has call bell in easy reach and anything else she may need.
- Remove Propess if indicated, i.e. ruptured membranes, regular painful contractions, vaginal bleeding.
- Ensure accurate, contemporaneous documentation is maintained.