Approximately 25% of pregnant women in the UK have their labour induced (Kelly et al, 2013). At a national level, it is recommended that women be offered a membrane sweep to avoid the need for post-dates induction of labour (IOL) (National Institute for Health and Care Excellence (NICE), 2008). Locally, it is advocated that all women are offered a membrane sweep at both 40 weeks and 41 weeks, and that IOL is booked between 10–12 days post-dates.
IOL has been described by women as more painful than spontaneous onset of labour, and may have a negative impact on a woman's birth experience (Shetty et al, 2005). Traditionally, IOL has taken place in hospital. However, national guidance now upholds the principle of maternity services offering IOL in an outpatient setting, as long as safety and support procedures are in place (NICE, 2008). Having the choice to go home while waiting for labour onset is appealing both to women and most care providers. An outpatient service suggests improved maternal satisfaction (Kelly et al, 2013; Dhavliker et al, 2016) and a potential reduction in hospital length of stay, with associated reduced cost to the NHS.
This paper outlines how a ‘home’ IOL service for post-dates women at low risk of complication was developed, and how it evolved. Key audit findings from before, during and after the service development are reported, and proposed future actions are described.
Summary of the literature
During IOL, offering women the choice to go home while awaiting the onset of labour aims to improve maternal satisfaction (Kelly et al, 2013). This choice is mainly restricted to women deemed to be at low risk of medical or obstetric complications, because frequent continuous fetal or maternal monitoring is not required (Kelly et al, 2013). Slow-release prostaglandins are an obvious choice for IOL at home, and there is no evidence that any other agent is more effective or safer (Rauf and Alfirevic, 2014).
Studies evaluating outpatient IOL services are small in number, with effectiveness and safety remaining in question (Kelly et al, 2013). Nevertheless, a number of observational studies suggest that for low-risk women, outpatient IOL is both feasible and acceptable, providing that successes, failures and any adverse outcomes are reported (Rauf and Alfirevic, 2014). Despite the fact that adverse events are rare and neo natal admissions for diverse reasons have not been found to be associated with slow-release prostaglandins, some units only offer outpatient IOL for women in whom cervical ripening and IOL is likely to last 24 hours or more (Rauf and Alfirevic, 2014), while others appear more flexible.
A Cochrane review highlighted differences between outpatient vs inpatient IOL using slow-release prostaglandins, regarding: numbers of women requiring additional induction agents; failure of IOL; IOL to birth interval; outcome for babies; and overall length of hospital stay (Kelly et al, 2013). However, the importance of achieving maternal satisfaction and a positive childbirth exper ience is imperative (Taylor-Clarke et al, 2012). Women at home during IOL have reported high levels of satisfaction (Turnbull et al, 2013; Dhavliker et al, 2016), without increased anxiety (Turnbull et al, 2013), des pite the suggestion that some women will worry at home because of uncertainties and potential risks (Rauf and Alfirevic, 2014). It is recognised that IOL at home is associated with: home comforts; presence of family members; quiet surroundings if preferred; no immediate need for child care for existing children (Oster et al, 2011); a sense of control; privacy; freedom of move ment; and less focus on anticipation and labour onset (Rauf and Alfirevic, 2014). In contrast, hospitals tend to have restricted space and flexibility, as well as unfamiliar faces (O'Brien et al, 2013).
Anecdotally, many women describe disappointment when IOL is indicated. This home IOL service was therefore developed in an attempt to offer women an additional choice about where labour onset can be awaited. The aim of the baseline audit (hospital group) was to fully understand the factors surrounding IOL for low-risk post-dates women, and inform the development of a care pathway for the new home group. Once the home IOL option was available, the second audit aimed to highlight any advantages or disadvantages with the new service so as to inform future improvement.
Practice context
Birmingham is a multicultural city and the Trust supports some 8200 births per annum. There is a large obstetric unit (OU) and an alongside midwife-led unit (MLU) where up to 1500 women give birth each year. The MLU has accepted women undergoing post-dates IOL for many years, providing labour is established following one Propess and women are otherwise suitable for the MLU.
While developing the option for low-risk women to receive Propess and return home, it was recognised from the outset that the development was driven very much as a woman-centred initiative, rather than a change likely to impact on the IOL service as a whole. Positive views were received from the Maternity Services Liaison Committee and women who had experienced IOL when the proposed improvements were explained. The aim of the home IOL option was to offer an addi tional choice for women and create positive birth experiences. Ensuring that women then continued to access the MLU once in labour was another important factor. It was anticipated that if women went home, it would reduce the hospital length of stay for them and ‘free up’ bed space for other women.
Development of the home induction of labour framework
This paper describes how the new service evolved, highlighting key audit findings, women's views and how the home induction of labour (HIL) framework was developed.
The new Propess and home service (home group) took approximately 12 months from conception to implementation. Table 1 outlines the HIL framework, which highlights consider ations for others embarking on a similar initiative.
| Tenure as a practising midwife |
| Visit a Trust already providing the service (e.g. Edinburgh) |
| Develop an evidence-based options appraisal to discuss with senior team |
| Develop suitability criteria and care pathway for the home option |
| Develop a patient group directive (PGD) for midwives to administer Propess for going home |
| Identify an obstetrician keen to support the initiative and endorse the care pathway |
| Consider the option of ultrasound scan (USS) prior to Propess. We undertake USS to confirm cephalic presentation and exclude oligohydramnios (minimum 2 cm liquor). However, USS can cause delays |
| Negotiate a dedicated one-stop place for women to receive an initial assessment with USS, Propess and go home — ideally in a clinic or outpatient area e.g. day assessment unit |
| Prepare written information for women outlining the choices available along with pros and cons of going home with Propess |
| Ensure there is a system in place to monitor care safety |
| Do not underestimate the time required to promote the service with community midwives and others to ensure women are informed about the choice to go home |
| Midwives providing the home option need support in clinical practice to ensure that queries are resolved quickly and women receive appropriate choices |
| Prepare to audit the process and highlight any difficulties so plans to resolve them can be made |
| Seek women's views |
Visiting Edinburgh to discuss the home service that has been implemented there, and identifying an obstetrician locally to alleviate medical staff anxieties, were invaluable steps in the process. Although we were keen to provide care in collaboration with the day assessment unit (DAU) to avoid potential delays, for various reasons we were required to set up as a ward-based service. The project did not incur any direct costs, but took time to develop the suitability criteria (Table 2) and care pathway.
| Suitable for midwifery-led care and 40 weeks + 10–12 days’ gestation |
| English-speaking |
| Parity ≤ 3 |
| No previous uterine surgery |
| Live within 30 minutes' travelling time from hospital |
| Normal ultrasound liquor volume > 2 cm and cephalic presentation confirmed |
| Normal observations on admission: abdominal palpation (cephalic 3/5 or less above pelvic brim); intact forewaters; normal cardiotocography; Bishop score of 7 or less |
| Woman happy to go home with the Propess |
A care pathway was designed to ensure evidence-based care was promoted, with the aim of it being timely and documented. Having received Propess, women usually return home after hyper-stimulation is excluded, with advice about when to return along with signs to observe. Women who have gone home are also encouraged to phone triage approximately 12 hours later to ‘check in’ regarding their wellbeing.
As part of this service development, three separate audits were undertaken for women booked and suitable for post-dates midwife-led IOL (Table 3). The objective of these audits was to put a spotlight on care with the aim of improving it. Data were collected prospectively, with some retrospective data collected for clarification. The main audit findings were then reported.
| Audit group | Audit indication | Number |
|---|---|---|
| Hospital | Prior to home service for baseline information | 50 women |
| Home | To note any differences between the home and hospital groups | 40 women |
| Hospital but appeared suitable for home | To find out why women booked for midwife-led post-dates induction of labour were not going home | 68 women |
Key audit findings
All women booked for both home and hospital post-dates IOL were found to be appropriately booked between 40 + 10–12 days (NICE, 2008).
Going home with Propess
The audit found positive benefits for women returning home (Table 4). Unsurprisingly, and in line with the advice given, the main reason women returned to hospital after home IOL was because of regular contractions (n = 13, 33%), with four women (10%) in established labour. Other reasons included: spontaneous ruptured membranes; Propess had fallen out (similar number to the hospital group); or for more than one of these reasons.
| The majority of women n = 15 (58%) remained at home for between 6–14 hours—similar to results reported by Kelly et al (2013). All returned to hospital from home safely |
| This audit appeared to show that women in the home group (n = 5, 45%), with a greater proportion of nulliparous women, subsequently transferred out of the midwife-led unit to the obstetric unit less often than the hospital group (n = 8, 62%). While this could be a coincidence, it warrants mentioning and will be monitored in future |
| Most women on the day of induction of labour were seen efficiently on the ward by 13:00 (n = 27, 68%), compared with the hospital group (n = 7, 14%). This was a striking difference, likely attributable to the anticipation that women would be seen and depart without using a bed for more than a couple of hours |
| Having experienced the home option, women reported their experiences positively |
Women who went home with Propess were asked whether they had appreciated the oppor tunity to return home. Some of the comments received include:
‘I had only been back home for a few hours when I started to get intense tightenings, but it was nice to be in the comfort of my own home with my partner.’
‘I don't think that you should extend the time of living 30 minutes from the hospital as I would have struggled with the distance whilst contracting.’
‘In my case, the pessary wasn't effective so it was great to be at home for the first 24 hours.’
Teething problems with the new home service
While the home option was being established, an interim audit was undertaken to find out why more women were not opting for home IOL, as had been expected. The main reasons found for not going home included:
Immediate actions taken included: explaining the audit findings to community midwives to reiterate the aim of a second membrane sweep to avoid the need for IOL in the first place; the importance of informing all potentially suitable women; and booking the ultrasound scan in advance.
Following Propess, half of the home group, (n = 20, 50%) required a 24-hour review, compared with only 9/40 women (23%) in the hospital group. This finding may be attributable to an unknown reason, but is likely because of the higher percentage of nulliparous women in the home group (n = 31, 78%) compared with the hospital group (n = 32, 64%). In addition, the hospital group received, on average, two additional vaginal examinations with inevitable cervical stimulation compared with the home group. At the 24-hour review, 11 women in the home group (28%) required the Propess to remain in for up to 32 hours, while nine women (23%) had Propess removed because artificial rupture of membranes was possible.
Access to the midwife-led unit and mode of birth
Similar numbers of women established in labour and transferred to the MLU from both the hospital and home groups (Table 5).
| Home | Hospital | |||
|---|---|---|---|---|
| n = 40 | % | n = 50 | % | |
| Established in labour following Propess | 20 | 50 | 19/40* | 48 |
| Transferred to MLU in established labour | 11 | 27.5 | 13 | 26 |
| – of whom later required transfer to the OU | 5 | 45 | 8 | 61.5 |
MLU midwife-led unit; OU obstetric unit
The main reasons why women did not access the MLU included:
Both groups reported some abnormal cardiotoc-ography (CTG) recordings and blood-stained or meconium-stained liquor.
Some women later transferred from the MLU to the OU. The main reasons were similar in both groups and included:
The modes of birth were similar in both groups (Table 6). The main indications for caesarean section were delay in labour and/or for a pathological CTG with meconium-stained liquor.
| Mode of birth | Home group | Hospital group | Amalgamated home and hospital | |||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Normal birth | 17* | 42.5 | 18 | 45 | 35 | 43.75 |
| Instrumental | 10 | 25 | 12 | 30 | 22 | 27.5 |
| Emergency caesarean section | 13 | 32.5 | 10 | 25 | 23 | 29.75 |
| Notes | (10 excluded as they did not receive Propess) | (10 excluded) | ||||
| Total | 40 | 100 | 50 | 100 | 90 | 100 |
Findings for the baby
Although one infant in the hospital group had an Apgar score of 6 recorded at 5 minutes, all other infants' Apgar scores were recorded as 7 or more at 5 minutes. Subsequently, three infants required neonatal unit admission from the home group. The reasons were not considered attributable to the women having been at home. All women had been appropriately transferred to the OU in labour for:
General induction of labour observations
Membrane sweeping
Although the majority of women received one membrane sweep prior to their IOL date (NICE, 2008), fewer than 40% from both groups received the recommended two sweeps. Interestingly, around 50% of all multi parous women who had previously been induced required IOL again.
Propess
Both audits found that for more than 30% of women, cervical dilatation was considered ‘too favourable’ for Propess, but artificial rupture of membranes was possible. Other reasons why women were considered unsuitable for Propess included:
Half of all women who received Propess (both home and hospital) established in labour following just Propess either within 24 hours or while awaiting artificial rupture of membranes.
Discussion
A total of 90 low-risk women who received post-dates IOL were included in both audits (home and hospital groups), with more nulliparous women in the home group. One possible explanation for the higher numbers of nulliparous women is that midwives may have been more confident in offering home for these women, as they could be considered less likely to progress quickly in labour. While some comparisons between the home and hospital groups have been described, it is necessary to interpret the findings with caution, because the numbers are small and were not subject to randomisation.
Going home with Propess
The audit found promising benefits for women returning home. Importantly, all women appropriately followed the advice offered regarding when to return to hospital, and their infants were all born safely, despite the safety of home IOL remaining in question (Kelly et al, 2013).
Access to the midwife-led unit and mode of birth
The audits showed that women in the hospital group were marginally more likely to request an epidural (before accessing the MLU) than women who went home. Midwives, therefore, are faced with the need to balance both maternal satisfaction and timely access to an MLU when suitable and where possible. MLUs are recognised for a reduction in the requirement for epidural compared with an OU; other benefits include normal birth being more likely and caesarean section less so (Brocklehurst et al, 2011).
As described in other studies (Turnbull et al, 2013; Dhavliker et al, 2016), women in this audit enjoyed the option of going home. Importantly, ward midwives also highlighted advantages for other women who were unable to go home, because it meant that beds became available for them sooner.
While the main reasons for subsequent transfer to the OU were similar to those known for spontaneous onset of labour, the home group appeared to require fewer transfers than the hospital group. Although this might be a coincidental finding, it is worthy of note for future monitoring.
Similar modes of birth were found for both the home and hospital groups, echoing the findings of Kelly et al (2013). The audits showed that women undergoing post-dates IOL, despite being at low risk of complications at the outset of the IOL, were more likely to require an emergency caesarean section in labour (mean = 29%). This is compared with women in spontaneous labour accessing an MLU where the need for caesarean section is low (Birmingham Women's Foundation NHS Trust, 2004–2016; Brocklehurst et al, 2011). This point is worth noting when planning this service development.
Teething problems with new home service
The option for women to receive care on a DAU would be preferable for others developing this type of service. The opportunity for women to receive care in one location will avoid a disjointed experience and hospital admission. Although we have maintained the ultrasound scan option—not least to ensure that all women going home with Propess have a confirmed cephalic presentation—there are notable disadvantages with this intervention, including organising its timeliness. While anomalies were not found on clinical palpation, ultrasound scan detected mild polyhydramnios (> 8 cm liquor) or oligo hydramnios (< 2 cm) in a few women. Although these findings appeared not to have a negative impact on the outcome for the infant, again, the con-sequence of this information required women to receive care on the OU with continuous electronic fetal monitoring and no opportunity to access the MLU. Anecdotally, other organisations have opted not to use ultrasound scans for women going home with Propess. With time, increased confidence and more available evidence about the pros and cons of ultrasound scans, we may follow suit.
General induction of labour observations
Membrane sweeping
Membrane sweeping is recommended to reduce the need for formal IOL (NICE, 2008). Despite Trust guidance and raising staff awareness with training sessions advocating at least one membrane sweep for all post-dates women by 40 + 10–12, it was disappointing to find that fewer than 40% of these women received two sweeps. Women may have required a lower rate subsequent intervention had a second sweep been undertaken (Boulvain et al, 2007). Because 50% of multiparous women required post-dates IOL previously, noting this finding will assist in prioritising membrane sweeps for these women in future, thus providing a benchmark for improvement.
Propess
Only half of all women established in labour following Propess without further assistance (home n = 20, 50%; hospital n = 19, 48%). This is another interesting observation, highlighting uncertainty in labour progress for women booked for IOL. Although the time lapse from Propess to birth interval was captured as described by Kelly et al (2013), because of subsequent delays with some women awaiting transfer to the OU, our data could not be analysed meaningfully.
Although the Bishop score might be considered a sub jective assessment, locally a Bishop score of 7 or less is used for Propess and home. However, the audit findings suggested that there was apparent hesitance offering home IOL for women with a Bishop score of 6. Initially, this may be because of midwives' confidence with offering home for women deemed so favourable. However, this could potentially have a significant and negative impact on women subsequently. The aim of Propess is for women to establish in labour without additional interventions (artificial rupture of membranes and syntocinon). This point highlights the need for midwives' clinical decisions to be supported in practice. Negative effects for women who do not receive Propess in this instance include: not having the option to go home; transfer to the OU with associated delays for syntocinon infusion; continuous electronic fetal heart rate monitoring; reduced opportunity to move around; and, importantly, no option to access the MLU.
Recent changes in Trust guidance on IOL reverted to Prostin E2 (rather than Propess) for all multiparous women in hospital if the cervical dilatation is 3 cm or less. This change is having a positive impact on the number of women subsequently establishing in labour. To date, this change has not been agreed for the home group. However, Wilkinson et al (2015) found that Prostin E2 was associated with uterine hyper-stimulation and CTG anomalies, and only half of the women randomised remained at home overnight. With this in mind, it is to be questioned whether women who are not in established labour could receive Propess if the cervix is 3 cm or less and return home (if otherwise suitable). Our impression of working closely with this group of women and striving to offer a home option and balance safety now requires negotiation and flexibility with cervical dilatation and Propess administration.
Conclusion
This paper describes how a Propess and home service was developed and the home IOL framework evolved, to offer a choice for low-risk women undergoing post-dates IOL. The home IOL framework aims to benefit others keen to embark on the same initiative. Audit findings from before, during and after the Propess and home service was available highlight some useful benefits for women, who reported liking the option to return home and did so without any adverse outcomes. It is recommended that implementing a similar service requires careful monitoring of findings.
This work also highlights a number of observations. Firstly, midwives require clinical support with decisions to ensure home is offered where possible while confidence develops. Secondly, despite being otherwise low risk, women requiring IOL are unsurprisingly less predictable than those in spontaneous labour, often resulting in the requirement for sub se quent interventions, with caesarean section more likely. This highlights the need for women to be offered a simple midwifery inter vention of two mem brane sweeps where possible, in an attempt to reduce the need for IOL in the first place. Lastly, the audit findings demonstrated that the MLU re mained a safe option for women, despite many requiring subsequent transfer to the OU. Our ongoing plan will be to negotiate the option for women with a more favourable cervical dilatation to receive Propess and return home, while care fully monitoring the woman's journey and outcomes.