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Cervical Ripening and Induction/Augmentation of Labor

Daren Sachet, RNC/MPA

List the indications and contraindications for cervical ripening and induction of labor. Discuss the different methods used for cervical ripening, labor induction and augmentation. Discuss the nurses role in the safe administration of cervical ripening and induction agents.

What is cervical ripening?
Preparation of an unfavorable cervix for labor induction

What is induction?
Stimulation of uterine contractions before the spontaneous onset of labor

What is augmentation?
Correcting ineffective uterine contractions or hypocontractility

Incidence in the United States

Since 1989, there has been a 137% increase in induction and a 75% increase in augmentation rates.
NCHS, 2009

Risk of Cesarean Birth for Nulliparous Women: 17.2% spontaneous labor 30.4% induced labor 77.7% increase for induction
Reisner et al., 2009

Use of pharmacologic agents increases risk for tachysystole, indeterminate or abnormal FHR patterns and failure to progress

Cascade of Interventions Related to Induction of Labor

IV Bedrest Continuous EFM Amniotomy Significant Pain Epidural Prolonged Labor

Economic Costs
Spontaneous Labor/vaginal birth $4000 Induction of labor/vaginal birth $5000 Cesarean Birth/scheduled $7000 Cesarean Birth/failed induction $7500
Simpson, KR., 2009

Indeterminate/Abnormal FHR (Category II and Category III FHR)

Nearly twice the risk, possibly related to: Tachysystole Early Amniotomy Labor Dystocia Longer Labor Less Fetal Tolerance
Glantz, 2005, Simpson, KR., 2009

Risks to the Infant

Respiratory Distress Syndrome TTN Hypoglycemia Sepsis Admission to higher level of nursery care > LOS
Tita, 2009

Indications for Cervical Ripening and Induction of Labor

Medical Premature rupture of membranes, post term pregnancy, preeclampsia, diabetes, fetal compromise. Induction without a medical indication is discouraged but according to ACOG, labor may be induced for logistic or psychosocial indications. It is not recommended to induce these patients until 39 completed weeks and should only be undertaken after fully informing the woman of potential risks involved. Joint Commission Perinatal Care Quality Measure Decrease the rate of women with elective delivery at 37-39 weeks.

Contraindications-Induction of Labor
Generally, the contraindications for labor induction are the same as those for spontaneous labor and vaginal birth Vasa previa or complete placenta previa Transverse fetal lie Umbilical cord prolapse Previous transfundal uterine incision Active genital herpes infection Pelvic structural deformities Invasive cervical cancer

Situations Requiring Special Attention

One or more previous low-transverse cesarean births Breech presentation Maternal heart disease Multifetal pregnancy Polyhydramnios Presenting part above the pelvic inlet Severe hypertension Abnormal FHR patterns requiring emergent birth A trial of labor after a previous cesarean birth or history of prior uterine scar
ACOG 2009, 2002

Indications for Augmentation of Labor

Dystocia Uterine Hypocontractility

Uterine hypocontractility should be augmented only after both the maternal pelvis and fetal presentation have been assessed.
ACOG 2009

Pre-induction/Ripening Criteria
Availability of trained nursing and provider staff Cervical ripening agents should be administered at or near the labor and birth suite where uterine activity and FHR can be monitored continually Assessment of gestational age, cervical status, pelvic adequacy, fetal size and presentation A physician capable of performing a cesarean birth should be readily available.
ACOG 2009

Criteria continued
Considerations to any risks to mother or fetus Patient counseling regarding indications, agents/methods, and possibility of repeat induction or cesarean birth The medical record should document that a discussion was held between the pregnant woman and her health care provider
ACOG 2009

Bishop Score Has been shown to be an important determinant of the success or failure of induction
Score Dilate cm Efface% Station Consistency Pos Cx





















Cervical Status
For women at term, a Bishop score of 6 or more may be useful in predicting onset of spontaneous labor within 7 days
Rozenberg, Goffinet & Hessabi, 2000

Cervical Ripening Agents

These agents may soften the cervix and change the Bishop score Mechanical/Non pharmacologic Methods Pharmacologic Methods

Mechanical Dilators

Laminaria Tents Synthetic Osmotic Dilators Foley Catheter Double Balloon Cervical Ripening Catheter Extraamniotic saline infusion- balloon catheter

Pharmacologic Methods
Not recommended for use in women with history prior c-birth or uterine scar

Prostaglandin E1: Misoprostol (Cytotec) Oral or vaginal use

Wide variations exist in time of onset of uterine contractions Peak action is approximately 1-2 hours but can be up to 4-6 hours May re-dose only if parameters met

Complications with Misoprostol (Cytotech)

Tachysystole Indeterminate/Abnormal FHR pattern Precipitous Labors Uterine Rupture Need careful maternal/fetal assessments Need consent/protocols
ACOG, 2009

Prostaglandin E2-Dinoprostone



Cervical Ripening Agents

Minimum safe interval from prostaglandin to oxytocin administration not established Manufacturers guidelines recommend
Misoprostol- at least 4 hours after last dose Prepidil- 6-12 hours after last dose Cervidil-30-60 minutes after removal of vaginal insert

Not contraindicated with PROM

Induction and Augmentation of Labor

Mechanical methods of Induction of Labor Stripping the Membranes Amniotomy

Most commonly used induction agent in the United States and worldwide
Kelly & Tan, 2001


Synthetic oxytocin is chemically and physiologically identical to endogenous oxytocin Half life between 10-12 minutes
Dawood, 1995a; Arias, 2000

3 4 half-lives to reach steady state Full effects of oxytocin cannot be determined until steady-state concentration has been achieved. Physiologic steady state 40 min, basis for dosing interval.

Endogenous Oxytocin
First Stage Labor Maternal circulating concentration 2-4 mU/min Fetal Contribution 3 mU/min Combined effects = 5-7 mU/min Second Stage Labor Surge of oxytocin at Fergusons reflex
Simpson, KR, 2009

Response to Oxytocin
Prolonged exposure Oxytocin receptor sites compared with spontaneous labor More oxytocin for dysfunctional labor will cause further desensitization. A rest period of 1-2 hours is recommended
Phaneuf et al., 2000

Continued oxytocin after active labor is established will not shorten labor. Active labor is self-sustaining.

Oxytocin Dosing
Considerable controversy exists about dosage and rate increase intervals-there is no consensus in the literature You take the high road
and Ill take the low road

Oxytocin Dosing
Only increase oxytocin rate if: FHR is normal Labor has not progressed 0.5 -1 cm/hr Contractions are no closer than every 2-3 minutes Excessive uterine activity over the course of 1 hour in first stage of labor is associated with an umbilical artery pH 7.11 at birth Decrease or discontinue oxytocin in active labor
Simpson, KR, 2009

Physiologic Dosage
Start with doses of 0.5-1 mU/min Increase in 1-2 mU/min increments every 3040minutes until contractions are every 2-3 minutes apart and labor is progressing ACOG, 2009
SOGC, 2001

Current literature suggests that 90% of pregnant women at term will have labor successfully induced with 6mU/min or less of oxytocin
Dawood, 1995a, 1995b; Seitchik, Amico et al., 1984

Oxytocin Administration
No maximal dose of oxytocin has been firmly established Doses above 40mU/min are rarely used, except in cases of intrauterine fetal demise (IUFD). Infusion rates >=20mU/min can decrease free water clearance by the kidney resulting in water intoxication.
Smith and Merrill, 2006

High Dose Oxytocin

According to ACOG (2009), protocols that involve high-dose oxytocin are acceptable; however, high-dose oxytocin is associated with more uterine tachysystole

Oxytocin and Medication Safety

August 2007 oxytocin added to the Institute for Safe Medication Practices to the High Alert Medication list. Joint Commission Standard MM.7.10

The organization develops processes for managing high-risk or high-alert medications The organization must develop additional processes for selecting, procuring, storing, ordering, transcribing, preparing, dispensing, administering and monitoring these high-risk or high-alert medications.

Nursing responsibilities
Titrate oxytocin infusion drip to achieve three contractions in 10 minutes with a duration of 60-90 seconds Closely monitor fetal response, uterine activity and resting tone Monitor maternal vital signs and fluid balance

Potential Complications-Oxytocin
>5 contractions in 10 minutes, averaged over a 30-minute window. Tachysystole should always be qualified as to the presence or absence of associated FHR decelerations.

Abruptio placentae Uterine rupture Hyponatremia (water intoxicaiton)

I & O when on oxytocin

Nursing Interventions for Tachysystole with Normal FHR pattern

Lateral positioning of mother Increase IV fluid (LR) If uterine activity not returned to normal after 10 minutes, oxytocin by half If tachysystole persists, D/C oxytocin until tachysystole resolves Consider terbutaline 0.25 mg SQ, with order
ACOG, 2010, AWHONN, 2008

Nursing Interventions for Tachysystole with Indeterminate or Abnormal FHR pattern

Discontinue or reduce oxytocin Lateral positioning of Mother IV fluid bolus (LR) If hypotensive, (as with epidural) contact anesthesia provider, prepare to administer epinephrine, with order Oxygen, 10 LPM, non-rebreather mask Consider terbutaline 0.25 SQ, with order If unresolved, inform provider immediately, possibly prepare for C/S.
(ACOG 2010)

Resuming Oxytocin
Once uterine activity and FHR pattern are normal: If oxytocin was discontinued >20-30 minutes, resume at no > the rate that caused tachysystole. Gradually increase rate if needed based on protocol and maternal/fetal status If oxytocin was discontinued >30-40 minutes resume at initial dose ordered

Women attempting VBAC

Should women with a previous cesarean birth undergo induction or augmentation of labor?
Spontaneous labor more likely to result in successful VBAC Some studies show women with oxytocin administration undergoing TOLAC may be at increased risk of uterine rupture than spontaneous labor. Other studies have not. Use of prostaglandins are associated with a higher rate of uterine rupture and are NOT RECOMMENDED
ACOG, 2010

VBAC Success Rates

Induced labor- 67% success rate Augmented labor-74% success rate

Spontaneous labor-81% success rate

Smith & Merrill, 2006

VBAC Induction
Physician and surgical team must be immediately available throughout active labor Recommend 1:1 nursing care with an experienced RN Continuous EFM Must have ability to perform emergency C/birth

Nursing Implications with VBAC Induction/Augmentation

Access to operating room readily available Monitor as for high risk Signs and symptoms of uterine rupture/dehiscence of prior scar
Patient c/o increasing pain and tenderness even with epidural Presentation may take place over period of time or suddenly like something has given away

Vomiting, syncope, vaginal bleeding, tachycardia, fetal bradycardia or absent fetal heart rate

Maternal stabilization and immediate cesarean birth Key to diagnosis is suspicion of uterine rupture
Simpson, K.R & Creehan, P., 2001

Conflict? No way!

Evidence suggests that cervical ripening can increase the chances of successful induction Misoprostol (cytotec) is becoming more widely used for cervical ripening and labor induction No elective inductions before 39 completed weeks of gestation Protocols should be based on ACOG/AHWONN standards and guidelines Multiple factors contribute to the steady increase in the rate of induction in the United States Consider implementation of an Induction of Labor Patient Safety Bundle.

1. 2. 3. 4. 5. 6. 7. 8. 9. American College of Obstetricians and Gynecologists. (August, 2009). Induction of Labor, Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, Number107. Washington DC: Author. American College of Obstetricians and Gynecologists. (November, 2010). Management of Intrapartum Fetal Heart Rate Tracings, Number116. Washington DC: Author. American College of Obstetricians and Gynecologists. (August 2010).Vaginal Birth After Previous Cesarean Delivery, Practice Bulletin, Clinical Management Guidelines for ObstetricianGynecologists, Number115, Washington DC: Author. Simpson, K.R., (2008). Cervical Ripening and Induction and Augmentation of Labor. 3rd edition. Association of Womens Health, Obstetric and Neonatal Nurses. Washington DC. American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2007). Guidelines for Perinatal Care (6th Ed.). Elk Grove, IL, Washington DC: Authors. National Center for Health Statistics (NCHS) year 2000 - 2009 data Tita, A.,et al. (2009). Timing of elective preterm and neonatal outcomes. (Electronic Version). NEJM. 360:2, 111-120 Joint Commission. (2010). Specifications Manual for Joint Commission Quality Core Measures Phaneuf S., et al, Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocinaugmented labour. Journal of Reproduction & Fertility 2000;120(1):91-97. Glantz, J (April 2005). Elective Induction vs. spontaneous labor Associations and Outcomes. Ele Med. 50(4):235-240. International Classification of Diseases, Code ICD-9-CM Description Shortened Description Table Number 11.07: Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (Ver. 2011A)