Booking of Induction of Labour (public) v3

This IOL booking form is for public funded women and for non-urgent indications. If IOL is required within the next 24 hours, please ring the Birth Suite Team Leader on 6580
UR#*
Date of birth*

DayMonthYear
Woman's email
Woman's mobile
Form completed by*
Designation*
Age
Midwife or ANC GP or sRMO
Date IOL booking form completed

DayMonthYear
EDB (as per confirmed date in Antenatal Record)*

DayMonthYear
Date

	Gravida	Parity	Previous CS
.

Current gestation
Maternal risk factor*

YesNo
Please list maternal risk factors:*
Is the woman under the care of any other specialties?*

NoCardiologyObs MedNeurologyRespiratoryOther
Has that specialty team been notified of the proposed induction?*

YesNo
Fetal risk factor*

YesNo
Please list fetal risk factors:*
Is there a Maternity Care Plan with additional information?*

YesNoUnsure
If unsure please look in the O&G dept on the intranet under 'Maternity Care Plan Database' and change the response to the previous Q accordingly.
Psychosocial risk factor*

YesNo
Please provide details regarding these risk factors*
Head palpable abdominally*

0/5, 1/5, 2/5 or 3/5 palpable4/5 or 5/ palpable
Is there a Patient Journey Plan with additional information?

YesNo
Modified Bishop Score
Dilatation
Length
Station
Consist
Position
Modified Bishop's (Calder) Score
Which doctor have you discussed this IOL booking with?
She has had a previous CS
Days from request until start of booking window
Days from request until end of booking window
This IOL booking form is for public funded women and for non-urgent indications. If IOL is required within the next 24 hours, please ring the Birth Suite Team Leader on 6580
Days from EDB until start of booking window
Days from EDB until end of booking window
End window minus start
Start of IOL booking window*

DayMonthYear
Date
ERROR - end-date for window needs to be after start-date
End of IOL booking window*

DayMonthYear
Date
ERROR - booking window needs to be less than 5 days wide
Indication for IOL*
Method of IOL*
Where is the IOL to commence*
Error: ARM/Synto can only be performed in Birthsuite. Please change your selection.
You have entered the IOL must happen only on this date*
Please justify why IOL booking date is inflexible
With which senior doctor have you discussed this IOL indication?*
If previous CS, IOL must be discussed with Consultant or Reg prior to booking
Maternal age is NOT 38 years or older*
Please justify
Post-term IOL booking request starts before 40+7*
Please justify or adjust window
IOL booking request ends beyond 40+14*
Please justify or adjust window
Post-term IOL booking request is not commencing at 40+7*
Please justify or adjust window
GDM (metformin) IOL is usually after 39+0*
Please justify or adjust window
T1/T2 DM IOL is usually before 38+0*
Please justify or adjust window
What is the plan for peripartum BGL management?*
IOL for twins is usually before 38+0*
Please justify or adjust window
Calculation
GDM (insulin) IOL is usually before 38+0*
Please justify or adjust window
Gestation USS for macrosomia performed*
EFW on USS for macrosomia*
USS EFW is required for this indication. Clinical suspicion of macrosomia is not an acceptable indication for IOL
Your entries do not match threshold for intervention*
Please justify indication of macrosomia
This indication requires further details*
GDM diet is NOT a usual indication for IOL*
Please justify
Balloon catheter selected but 4/5 or 5/5 palpable*
Please justify
ARM/synto selected but woman is nulliparous*
Please justify
ARM/synto selected but the bishop score is unfavourable*
Please justify
PGE/Balloon selected but the bishop score is favourable*
Please justify
You have selected PGE2 in setting of previous CS*
Please justify
Number of previous CS
Parity
IOL is undertaken in Birth Suite when there is a need for ongoing / extra-ordinary maternal or fetal monitoring
Please justify
I confirm that I have discussed with the woman*

Admin only section
This section must only be completed by the Birthsuite AO managing the IOL bookings.
Priority
Birth Suite IOL review
Should be Empty: