Cervical Ripening and Induction/Augmentation of Labor

Daren Sachet, RNC/MPA

Objectives
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.

Definitions
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

.4% induced labor 77.2% spontaneous labor 30. indeterminate or abnormal FHR patterns and failure to progress . 2009 Use of pharmacologic agents increases risk for tachysystole.7% increase for induction Reisner et al.Risk-Benefit Risk of Cesarean Birth for Nulliparous Women: 17.

Cascade of Interventions Related to Induction of Labor •IV •Bedrest •Continuous EFM •Amniotomy •Significant Pain •Epidural •Prolonged Labor .

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

2009 . 2005. possibly related to: Tachysystole Early Amniotomy Labor Dystocia Longer Labor Less Fetal Tolerance Glantz.. Simpson. KR.Indeterminate/Abnormal FHR (Category II and Category III FHR) Nearly twice the risk.

Risks to the Infant Respiratory Distress Syndrome TTN Hypoglycemia Sepsis Admission to higher level of nursery care > LOS Tita. 2009 .

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. fetal compromise. diabetes. Induction without a medical indication is discouraged but according to ACOG. . post term pregnancy. Joint Commission Perinatal Care Quality Measure Decrease the rate of women with elective delivery at 37-39 weeks.Indications for Cervical Ripening and Induction of Labor Medical Premature rupture of membranes. preeclampsia.

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 .

2002 .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.

ACOG 2009 .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 . fetal size and presentation A physician capable of performing a cesarean birth should be readily available. cervical status. pelvic adequacy.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.

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 . agents/methods.Criteria continued Considerations to any risks to mother or fetus Patient counseling regarding indications.

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 0 Closed 0-30 -3 Firm Post 1 1-2 40-50 -2 Med mid 2 3-4 60-70 -1/0 Soft Ant 3 5-6 80 +1/+2 ___ ___ .

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

Cervical Ripening Agents    These agents may soften the cervix and change the Bishop score Mechanical/Non pharmacologic Methods Pharmacologic Methods .

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

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 Prepidil Cervidil .

6-12 hours after last dose Cervidil-30-60 minutes after removal of vaginal insert Not contraindicated with PROM .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.

Induction and Augmentation of Labor Mechanical methods of Induction of Labor Stripping the Membranes Amniotomy .

Arias.Most commonly used induction agent in the United States and worldwide Kelly & Tan. 2000 3 – 4 half-lives to reach steady state Full effects of oxytocin cannot be determined until steady-state concentration has been achieved. . 1995a. basis for dosing interval. Physiologic steady state 40 min. 2001 Oxytocin Synthetic oxytocin is chemically and physiologically identical to endogenous oxytocin Half life between 10-12 minutes Dawood.

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 Ferguson’s reflex Simpson. 2009 . KR.

A rest period of 1-2 hours is recommended Phaneuf et al. Active labor is self-sustaining. .. 2000 Continued oxytocin after active labor is established will not shorten labor.Response to Oxytocin Prolonged exposure →  Oxytocin receptor sites compared with spontaneous labor More oxytocin for dysfunctional labor will cause further desensitization.

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

KR.Oxytocin Dosing Only increase oxytocin rate if: FHR is normal Labor has not progressed 0. 2009 .11 at birth Decrease or discontinue oxytocin in active labor Simpson.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.

Amico et al.Physiologic Dosage Start with doses of 0. 1995b. 1995a. 2001 Current literature suggests that 90% of pregnant women at term will have labor successfully induced with 6mU/min or less of oxytocin Dawood. 1984 .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. Seitchik. 2009 SOGC..

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

high-dose oxytocin is associated with more uterine tachysystole .High Dose Oxytocin According to ACOG (2009). protocols that involve “high-dose” oxytocin are acceptable. however.

Joint Commission Standard MM. transcribing. procuring.10 The organization develops processes for managing high-risk or high-alert medications The organization must develop additional processes for selecting.Oxytocin and Medication Safety August 2007 oxytocin added to the Institute for Safe Medication Practices to the High Alert Medication list. preparing. administering and monitoring these high-risk or high-alert medications. storing. . dispensing.7. ordering.

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

Potential Complications-Oxytocin Tachysystole  >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 .

25 mg SQ. 2010.  oxytocin by half If tachysystole persists. with order ACOG. 2008 . AWHONN. D/C oxytocin until tachysystole resolves Consider terbutaline 0.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.

non-rebreather mask Consider terbutaline 0. with order Oxygen. inform provider immediately.25 SQ. possibly prepare for C/S. (as with epidural) contact anesthesia provider. with order If unresolved. 10 LPM.Nursing Interventions for Tachysystole with Indeterminate or Abnormal FHR pattern Discontinue or reduce oxytocin Lateral positioning of Mother IV fluid bolus (LR) If hypotensive. prepare to administer epinephrine. (ACOG 2010) .

Resuming Oxytocin Once uterine activity and FHR pattern are normal: If oxytocin was discontinued >20-30 minutes. resume at no > ½ 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 .

Use of prostaglandins are associated with a higher rate of uterine rupture and are NOT RECOMMENDED ACOG.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. 2010 . Other studies have not.

67% success rate Augmented labor-74% success rate Spontaneous labor-81% success rate Smith & Merrill. 2006 .VBAC Success Rates Induced labor.

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. vaginal bleeding. syncope. fetal bradycardia or absent fetal heart rate . tachycardia.

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

Conflict? No way! .

Summary 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. .

org/releases/TJC2010A/MIF0166. Washington DC.References 1. 11. American College of Obstetricians and Gynecologists. (August 2010).2009 data Tita. (2010)..120(1):91-97. Code ICD-9-CM Description Shortened Description Table Number 11. Washington DC: Author.. J (April 2005). Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocinaugmented labour. Practice Bulletin. Journal of Reproduction & Fertility 2000. 2011A) 10. Washington DC: Authors. Specifications Manual for Joint Commission Quality Core Measures http://jointcommission. 4. (2007). 360:2. A. (2008). (August. 2. Management of Intrapartum Fetal Heart Rate Tracings. (November. spontaneous labor Associations and Outcomes. Induction of Labor. Timing of elective preterm and neonatal outcomes. American Academy of Pediatrics & American College of Obstetricians and Gynecologists. Clinical Management Guidelines for ObstetricianGynecologists. Number116. IL. 2009). Washington DC: Author. American College of Obstetricians and Gynecologists. Elective Induction vs.html Phaneuf S. American College of Obstetricians and Gynecologists. . 6. 3. 5. Glantz. National Center for Health Statistics (NCHS) year 2000 . Elk Grove. (2009). NEJM. Guidelines for Perinatal Care (6th Ed. 3rd edition. 50(4):235-240. Obstetric and Neonatal Nurses. Cervical Ripening and Induction and Augmentation of Labor. Clinical Management Guidelines for Obstetrician-Gynecologists.07: Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (Ver. 9. 8.et al.).R. Number107.Vaginal Birth After Previous Cesarean Delivery. K. Simpson. International Classification of Diseases. Practice Bulletin. 7. Number115. Washington DC: Author. 111-120 Joint Commission. et al. (Electronic Version). Association of Women’s Health.. Ele Med. 2010).

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