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Induction of labor

Sally Ault RN, MN

March 2016

OBJECTIVES

•Describe indications for inducing labor

• Identify various methods for inducing labor

•Discuss appropriate nursing management for the patient undergoing induction of labor

What is Induction of Labor?

Induction of Labor (IOL)

Artificial stimulation of uterine contractions before the spontaneous onset of labor in effort to achieve vaginal delivery

ACOG 2013

Incidence 23.4%

•one in four pregnant women

•doubled since 1990

(ACOG 2009; Bakker 2013; Simpson 2013)

Elective induction of labor is discouraged because it is often performed for the convenience of women / provider and spontaneous labor is associated with fewer complications

Elective inductionPsychosocial Issues:Partner leaving town, prolonged military engagement

Family in townAnxiety/DepressionAdoptionMaternal DiscomfortMaternal Exhaustion

Logistical Reasons:History of Rapid labor, remote from hospital

(ACOG 2012; 2013; Simpson 2013)

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Why is it important to wait for spontaneous labor?

• Final weeks of gestation are important

•Risks are associated with induction

Indications for induction•Abruptio placentae•Chorioamnionitis•Fetal Demise•Gestational/Chronic Hypertension•Preeclampsia, eclampsia•PROM•Post-term pregnancy•Maternal Medical Condition (Diabetes, renal disease)•Fetal Compromise (IUGR, Oligohydramnios)

(ACOG 2009)

Recommendations for Timing of Delivery (ACOG

2013)

•Condition

•General Timing

• Suggested Specific Timing

Contraindications

Vasa Previa or complete Placenta Previa

Transverse fetal lie

Umbilical Cord Prolapse

Previous classical cesarean birth

Active genital herpes infection

Previous myomectomy entering the endometrial cavity

Prior to starting the Induction

Gestational Age Assessment

Patient Counseled

Availability of appropriate nursing staff

Assessment of cervix, pelvic adequacy, fetal size, presentation

Ability to monitor FHR/Contractions

Physician capable of performing a cesarean delivery readily available

Confirmation of TermUltrasound measurement at less than 20 weeks of gestation supports gestational age of 39 weeks or greater

Fetal heart tones have been documented as present for 30 weeks by Doppler ultrasonography

It has been 36 weeks since a positive serum or urine HcG pregnancy test result

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Assessment of the Cervix

Favorable or Unfavorable ?

IOL is more successful if the cervix is Favorable

Favorable Cervix = Bishop Score of 7 or Greater

Induction with favorable cervix is same risk for cesarean as spontaneous, if unfavorable cervix, risk for cesarean is 45% higher

(ACOG 2013)

Bishop ScoreCharacteristic 0 1 2 3

Dilation Closed 1-2 3-4 5 or greater

Effacement 0-30% 40-50% 60-70% 80-100%

Position Posterior Mid Anterior ----

Consistency Firm Medium Soft ----

Station -3 -2 -1,0 +1,+2

Total

Cervical Exam: Posterior, medium, -3, 60%, 2cm’s

Characteristic 0 1 2 3

Dilation Closed 1-2 3-4 5 or greater

Effacement 0-30% 40-50% 60-70% 80-100%

Position Posterior Mid Anterior ----

Consistency Firm Medium Soft ----

Station -3 -2 -1,0 +1,+2

Total 4

Methods for Cervical RipeningPharmacological

ProstaglandinsDinaprostone PgE2 (Gel, cervidil)Misoprostol PgE1

MechanicalHygroscopic Dilators (laminaria)Balloon CathetersMembrane Sweeping/StripingAmniotomy

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Prostaglandins

• effective cervical ripeners

• increase myometrial contractility

•not recommended for previous cesarean delivery or uterine scar

Management of Tachysystole During Cervical Ripening

Tachysystole with or without change in FHR

• Maternal repositioning

• IV Fluid bolus (500ml)

• Supplemental Oxygen

• Communication with provider/Charge Nurse

• Removal of cervidil insert (reversal in 15 mins)

• Consider 0.25 mg Terbutaline Subcutaneously

Cervidil Laminaria sticks

Balloon CatheterAmniotomy

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Induction Algorithm Washington State Induction of Labor with Oxytocin

Oxytocin

Most commonly used induction agent

Half life of 10 – 15 minutesSteady state in (40 minutes)

When rate of administration is equal to rate of elimination

Endogenous Oxytocin

Hypothalamus Pituitary Circulation

Breast StimulationSensory stimulation of lower genital tractCervical stretching and pressureSurge during second stage of labor with stretching of pelvic floor receptors the Ferguson reflex (+1 station)

Exogenous Oxytocin

•Artificially manufactured

•Works same in the body

• Increases strength/ frequency contractions

•Higher doses once stable phase has been reached result in low-intensity, coupling, tripling or tachysystole

• “Pit through” is a myth

• Treat desensitization with decrease or 30- 60 minutes off and 500 ml bolus of Lactated Ringer

Goal

Give the minimal amount of Oxytocin required to achieve effective contraction pattern with labor progress

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Nursing Role

•Monitor FHR and Uterine Contractions

•Vital Signs

•Communication with Charge RN and Provider

• Follow Hospital Protocol

Tachysystole

Tachysystole is most concerning side effect of oxytocin

decreases perfusion/fetal oxygenation

Fetal Injury from Tachysystole is completely preventable

(Simpson, 2013; Helwick/Mahony 2012)

Oxytocin-Induced Tachysystole (Normal FHR)

Maternal repositionIV fluid bolus 500 ml LRIf not resolved in 10 – 15 mins, decrease by ½If not resolved after decrease in 10-15 mins

discontinueIf discontinued for 30 mins or more, re-start at

initial dose ordered

(Simpson, 2013)

Tachysystole

Oxytocin-Induced Tachysystole (Category II / III FHR)

Discontinue oxytocinMaternal reposition (left/right lateral)

IV fluid bolus 500 ml LR

Consider oxygen at 10 L via non-rebreather Consider Terbutaline 0.25 mg SQ

Resume oxytocin after resolution at ½ previous rate if less than 20 -30 mins

If oxytocin off longer than 30 mins, resume at initial dose ordered

(Simpson, 2013)

Tachysystole

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Miso Induction 1 Hour After Miso

2 Hours After Miso 5 Minutes Later

1 Hour LaterMiso Induction4 Hours After Miso

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Cook Catheter AROM & Oxytocin

IUPC 6 Hours Later…still 6 cm’s

References• Alfirevic, Zarko, Kelly, Anthony J, Dowswell, Therese. Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane

Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003246. DOI: 10.1002/14651858.CD003246.pub2.

• Alfirevic, Zarko, Weeks, Andrew. Oral misoprostol for induction of labour. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD001338. DOI: 10.1002/14651858.CD001338.pub2.

• American College of Obstetricians and Gynecologists (ACOG). Induction of labor. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Aug. 12 p. (ACOG practice bulletin; no. 107).

• American College of Obstetricians and Gynecologists (ACOG). Management of Intrapartum Fetal Heart Rate Tracings. Clinical Management Guidelines for Obstetrician-Gynecologists. Practice Bulletin Number 116, November 2010.

• Bakker, Jannet JH, van der Goes, Birgit Y, Pel, Maria, Mol, Ben Willem J, van der Post, Joris AM. Morning versus evening induction of labour for improving outcomes. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD007707. DOI: 10.1002/14651858.CD007707.pub2.

• Boulvain, Michel, Stan, Catalin M, Irion, Olivier. Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000451. DOI: 10.1002/14651858.CD000451.pub2.

• Bricker, Leanne, Luckas, Murray. Amniotomy alone for induction of labour. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD002862. DOI: 10.1002/14651858.CD002862.

• Clark, Steven et al. Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes. American Journal of Obstetrics and Gynecology, November 2007.

• Dodd, Jodie M, Crowther, Caroline A. Elective repeat caesarean section versus induction of labour for women with a previous caesarean birth. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD004906. DOI: 10.1002/14651858.CD004906.pub3.

• French, Linda. Oral prostaglandin E2 for induction of labour. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD003098. DOI: 10.1002/14651858.CD003098.

• Gülmezoglu, A Metin, Crowther, Caroline A, Middleton, Philippa, Heatley, Emer. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub3.

References• Irion, Olivier, Boulvain, Michel. Induction of labour for suspected fetal macrosomia. Cochrane Database of Systematic Reviews 1998, Issue 2. Art.

No.: CD000938. DOI: 10.1002/14651858.CD000938.

• Kavanagh, Josephine, Kelly, Anthony J, Thomas, Jane. Breast stimulation for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003392. DOI: 10.1002/14651858.CD003392.pub2.

• King, T. L. The Pitocin Wars: Evidence-Based Use of Oxytocin for Induction and Augmentation of Labor. UCSF Medical Center Presentation, June 8, 2012.

• Rice-Simpson, Kathleen. Cervical Ripening and Labor Induction and Augmentation; 4th Edition. AWHONN, 2013.

• Rev Obstet Gynecol. 2008 Fall; 1(4): 186–192.

• Smith, Caroline A, Crowther, Caroline A. Acupuncture for induction of labour. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002962. DOI: 10.1002/14651858.CD002962.pub2.

• Smith, Caroline A. Homoeopathy for induction of labour. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003399. DOI: 10.1002/14651858.CD003399.

• Wing, Deborah A. Induction of Labor. Official Report from UpToDate, Walters Kluwer Health, July 14, 2014.

• SORIA CASI VERDE: marzo 2011soriacasiverde.blogspot.com Images for slides

• Elective IOL Guideline: www.acog.org/About...I/~/.../20120120_ElectiveIOLGuideline.ashx Jan 20, 2012

• Author Andrew J Satin, MD, FACOG Latent phase of labor July 1 2013

• Goldberg Aaron E. Cervical Ripening. Medscape Reference, March 26, 2012.

• Division of Standards and Practice: Clinical Standards and Documents Section Approved by the ACNM Board of Directors: June 2012 Replaces ACNM Clinical Bulletin: Treatment of GBS

• National Guideline Clearinghouse (NGC). Guideline synthesis: Induction of labor. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (

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Thank you!