Cervical Ripening Induction and Augmentation of Labor Pam
+ Cervical Ripening Induction and Augmentation of Labor Pam Jordan, Ph. D, RNC October 2012
+ Cervical Ripening n The process of effecting physical softening and distensibility of the cervix in preparation for labor and birth [American College of Obstetricians and Gynecologists. (1999 a). Induction of labor (Practice Bulletin No. 10). Washington, DC: Author]
+ Induction of Labor n The stimulation of uterine contractions before the spontaneous onset of labor for the purpose of accomplishing vaginal birth [American College of Obstetricians and Gynecologists. (1999 a). Induction of labor (Practice Bulletin No. 10). Washington, DC: Author]
+ Augmentation of Labor n The stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus. [American College of Obstetricians and Gynecologists. (2003). Dystocia and the augmentation of labor (Practice Bulletin No. 49). Washington, DC: Author]
Why mess with a normal process? Indications for cervical ripening/induction of labor + n Legitimate reasons for cervical ripening/induction of labor are those situations in which the intrauterine environment is no longer best for the fetus or continued pregnancy puts the mother at significant risk n Sometimes there are logistical reasons, such as history of very rapid labor or distance from the hospital
Why mess with a normal process? Indications for cervical ripening/induction of labor (continued) + n Unfortunately, there are still woman undergoing induction of labor for ‘maternal misery’ or convenience of the OB care provider n 1/2 to 2/3 of labor inductions are for nonmedical reasons n Induction of labor is a leading cause of iatrogenic prematurity n In 2009, 23% of births were induced labors [http: //www. cdc. gov/nchs/births. htm]
Why mess with a normal process? Indications for cervical ripening/induction of labor (continued) + n Placental abruption [premature separation of the placenta from the uterine wall] n Chorioamnionitis n Fetal [intraamniotic infection] demise n Gestational hypertension n Pre-eclampsia/eclampsia n Premature rupture of membranes
Why mess with a normal process? Indications for cervical ripening/induction of labor (continued) + n Postterm pregnancy n Maternal medical conditions [such as diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension] n Fetal compromise [such as severe fetal growth restriction or isoimmunization]
+ Cervical Ripening n. There are two different methods of cervical ripening n Mechanical n Pharmacological
+ Cervical Ripening: Mechanical Methods n Have been used for hundreds of years n Used when induction is indicated but there is little to no cervical effacement n Includes the insertion into the cervix of materials that absorb fluid from the cervical tissues and swell up, causing mechanical dilation of the cervix and the local release of prostaglandins n n n Laminaria Lamicel Dilapan
+ Cervical Ripening: Mechanical Methods (continued) n Balloon catheters [14 to 26 gauge Foley catheter with balloon inflated above the internal cervical os with 30 -50 cc of sterile water OR Cook catheter with two balloons both inflated with sterile water (with one inflated above the internal cervical os and the other inflated outside the external cervical os)] n The Cook catheter creates a ‘cervical sandwich’
+ Cervical Ripening: Mechanical Methods Cook Catheter
+ Cervical Ripening: Mechanical Methods (continued) n Balloon catheters cause direct pressure and overstretching of the lower uterine segment and cervix as well as local prostaglandin release n Women may be discharged after insertion and a period of initial monitoring of uterine activity and fetal heart rate n Results are usually seen within 8 to 12 hours of insertion n The balloon catheter usually falls out when the cervix is dilated to about 4 cm
+ Cervical Ripening: Mechanical Methods (continued) n Nursing care includes Client education n Client support during placement of the material/device n Documentation of the type and size of the catheter and the volume(s) injected into the balloons n Initial monitoring of maternal and fetal response after placement of the material/device n Maternal vital signs n Maternal comfort level/coping status n Assessment of uterine contractions n Assessment of fetal heart rate n
+ Cervical Ripening: Pharmacological Methods n Various hormonal preparations are available for cervical ripening n They may also lead to the onset of labor if the cervix is favorable
Why mess with a normal process? Indications for cervical ripening/induction of labor (continued) + n Postterm pregnancy n Maternal medical conditions [such as diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension] n Fetal compromise [such as severe fetal growth restriction or isoimmunization]
+ Induction of Labor n The stimulation of uterine contractions before the spontaneous onset of labor for the purpose of accomplishing vaginal birth [American College of Obstetricians and Gynecologists. (1999 a). Induction of labor (Practice Bulletin No. 10). Washington, DC: Author]
+ Induction of Labor: Mechanical Methods Stripping the membranes = digital separation of the chorioamnionic membrane from the wall of the cervix and lower uterine segment during a vaginal exam n Best results when vertex is well applied to the cervix in a term pregnancy n Seems most beneficial in first pregnancies
+ Induction of Labor: Mechanical Methods Amniotomy = artificially rupturing the amniotic membranes n Does not result in a significant decrease in the length of labor n Removes n Results the ‘padding’ of the baby’s head in more variable FHR decelerations and an increased risk of cesarean birth for ‘nonreassuring’ FHR status
+ Induction of Labor: Mechanical Methods Amniotomy = artificially rupturing the amniotic membranes n Risk of umbilical cord prolapse n Commits to labor/birth because of the increased risk of infection once the membranes are ruptured
+ Induction of Labor: Pharmacological Methods n The stimulation of uterine contractions before the spontaneous onset of labor for the purpose of accomplishing vaginal birth [American College of Obstetricians and Gynecologists. (1999 a). Induction of labor (Practice Bulletin No. 10). Washington, DC: Author]
Why mess with a normal process? + n Labor induction is not an isolated intervention—It results in a cascade of other interventions and activities that have the potential to negatively affect the normal processes of labor and birth Insertion of an intravenous line n Bedrest n Continuous electronic fetal monitoring n Amniotomy n Increased discomfort n Epidural analgesia/anesthesia n Increased likelihood of cesarean n Increased risk of postpartum hemorrhage n Prolonged stay on the labor unit n
+ Induction of Labor Bishop Scoring indicates the likelihood of success of labor induction. The higher the score, the more likely labor will occur.
+ Induction of Labor: Pharmacological Methods Oxytocin n Most commonly used induction agent in the US and world n Often n Half used after a cervical ripening agent life of 10 -12 minutes n Uterine response usually occurs within 35 mins of initiating IV administration
+ Induction of Labor: Pharmacological Methods Oxytocin n. Dosing is in miliunits per minute n. Causes uterine contractions that increase in frequency and intensity n. Controversy continues over the ‘best’ increment of dosing and frequency of increasing dosing
+ Induction of Labor: Pharmacological Methods Oxytocin n. Risk of uterine tachysystole n. Increases risk of postpartum hemorrhage due to saturation of oxytocin receptors in the uterus n. Potentially highly dangerous drug
+ Augmentation of labor n The stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus. [American College of Obstetricians and Gynecologists. (2003). Dystocia and the augmentation of labor (Practice Bulletin No. 49). Washington, DC: Author]
+ Why mess with a normal process? Indications for augmentation of labor n Dysfunctional labor [prolonged or arrested progress in cervical dilation during active labor or fetal descent during second stage] n Uterine hypocontractility [uterine contractions that are too infrequent or too weak to be effective]
+ Augmentation of labor n Similar to induction of labor because an oxytocin infusion is used to stimulate contractions n The difference between induction and augmentation is that with augmentation, labor has already begun and is being stimulated, while induction is used to start labor
Contraindications to Augmentation of Labor + n Placenta or vasa previa n Umbilical cord presentation n Prior classical uterine incision [increased incidence of uterine rupture] n Active genital herpes infection n Pelvic structure deformities n Invasive cervical cancer
+ Nursing Care During Induction or Augmentation of Labor n Client education and ongoing support n Initial and ongoing monitoring of maternal and fetal response to oxytocin n Maternal vital signs n Maternal comfort level/coping status n Assessment of uterine contractions n Assessment of fetal heart rate n Preparation and administration of oxytocin n Interventions labor to promote comfort and progress in
+ Resource n The primary resource for this Power. Point set was… Simpson, K. R. (2009). Cervical ripening and induction and augmentation of labor. (3 rd ed. , updated). Washington, DC: Association of Women’s Health, Obstetric, and Neonatal Nurses. This is an example of the outstanding resources provided by nursing specialty organizations.
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