LEC 6: Induction and Augmentation of Labour

Question 1

Induction

Answer 1

The initiation of contractions in the pregnant woman not in labour

Question 2

Augmentation

Answer 2

Enhancement of contractions in the pregnant woman already in labour

Question 3

Cervical Ripening

Answer 3

Use of pharmacological other means to soften, efface and/or dilate the cervix to increase likelihood of vaginal delivery when induction is indicated

Question 4

Indications of Labour

Answer 4

• Postterm pregnancy
• Hypertensice disorders (pre-eclampsia)
• Diabetes mellitus
• Significant maternal disease not responding to treatment
• Significant, but stable antepartum bleeding
• Chorioamnionitis
• Post-dates pregnancy of 41 or more weeks gestation (confirmed dates)
• Rh Isoimmunization at/or near term
• IUGR
• PROM at or nreat term (especially if GBS positive)
• Intrauterine fetal death
• Logistical concerns
• Intrauterine death in previous pregnancy

Question 5

Indications to Induce Labour: Postmaturity

Answer 5

• SOGC recommends that women should be offered induction between 41 and 42 weeks because there is a decrease in prenatal mortality without an inccreased risk of C-section. If women wait beyond that- mindful of fetal well being- doing a non-stress test, amniotic fluid testing.
• Risk for inducing someone who has had 5 babies
  
  • The labour can end u being fast
  • Risky for mom and baby
• Cautions if thecervix has not dropped
• Known malpresentation- brow or face- more difficult delivery about induction as well- uterus overly distended has trouble with contractions, less effecctive
• Existing care- extremely cautious because at risk of uterine rupture

Question 6

What does postmaturity mean?

Answer 6

• Post date or post term
• Certainty about dates

Question 7

What are the risk of psot-term?

Answer 7

• Maternal
• Fetal
  
  • Fluid can drop increased the risk of cord prolapse

Question 8

Cautions for Induction

Answer 8

• Grand multiparity
  
  • G5
• Vertex not fixed in the pelvis
• Unfavourable or unripe cervix
• Brow or face presentation
• Over distention of uterus (polyhydramnios or multiples)
• Lower segment uterine scar (extreme caution)
• Pre-existing hypertonus
• Prior hisotry of difficult labour and/or traumatic delivery
• Availability of C-section delivery
• Any contradiction ot labour or vaginal delivery

Question 9

Contraindications to Induction

Answer 9

• Placental
  
  • Complete placenta previa
• Cord
  
  • Presentation or proplapse
• Fetal malpresentation (transverse lie, breech)
• History
  
  • Previous uterine surgery or classical c/s
  • Pelvic abnormalities/ absolute CPD (cefal pelvic dispeprotion)
  • Gyne/ Obs/ Medical condition
• Not going to induce for convenience- hsa to be a reason

Question 10

Bishop Score

Answer 10

• Score cervial ripening (pre-induction)
• A cervix that is soft and effaces is the most important contributor to the success of induction
  
  • Unvavourable is a socre of <6

Question 12

Methods to Induction

Answer 12

• Nipple Stimulation
  
  • Initiate the hormones
• Sexual intercourse
  
  • Initiate the hormones
• Acupuncture
• Enema, castor oil
• Herbal supplements
• Also….stripping/sweeping, amniotomy, mechanical, pharmacological

Question 14

Stripping/ Sweeping Membranes

Answer 14

• Mechanical separation of membranes from cervix or uterus
• Does not require monitoring or other assessments
• Do not use for induction when there are high priority indications
• Effectivness
  
  • Does not always work
  • Going between the embryotic mebrane and the cervix; sometimes its done with a plan and sometimes its not done with a plan
  • If it works- go into labour in 48 hours
  • Will end up getting crampy- if they do it- usually between 31 and 38 weeks
  • Gloved finger- rotates 360 degress all the way around

Question 15

What are the risk of stripping/ Sweeping membranes?

Answer 15

• Cause bleeding
• Inadvertent rupture of membranes
• Puts persone at risk for infection

Question 16

Amniotomy: AROM

Answer 16

• Augment or induce labour
• Committed to delivery because created a portal for risk of infection
• Apply internal fetal or contraction monitors
• Obtain fetal scalp blood sample for pH monitoring
• Will rupture the membranes when they give oxytocin
• If ruptured- need to monitor the fetus both during and after the procedure
• Cord prolapse is a risk
• Document the time the membrane ruptured- look at colour and composition of membrane

Question 18

Mechanical Dilation

Answer 18

• Cervical ripening ballon (CRB)
• Laminaria (Seaweed)
  
  • Sterilized seaweed that is highly absorbent
• Foley

Question 19

Pharmacological Cervical Ripening

Answer 19

• Prostaglandin Induction
  
  • Prostin (Prostaglandin E2 1-2 mg. gel) into posterior fornix of vagina​
    
    • Produced naturally in the body- but would be artificial
  • Cervidil (Prostaglandin E2 10 mg. vaginal insert) into posterior fornix - continuous slow release
  • Like a tampon that gets inserted BUT is slow release
  • Benefit: If you end up hyper stimulating you can remove- if you use gel cannot remove
  • Promote effacement and softening of the cervixe = ripening of the cervix
  • Might speed up the labour BUT may hyper stimulate the delivery
  • Many people chose this option because its more of a natural way to starting labour
• Misoprostol/Cytotec (Prostaglandin E1 synthetic-tablet) 50mcg orally or 25mcg vaginally - approved for induction in Canada in 2013
  
  • Has other uses such as helping terminate a pregnancy, help with hemorrhage

Question 20

Advantafes of Prostaglandin

Answer 20

• Less invasive, more physiologically like labour
• Simple administration, increase acceptance
• Cervidil
  
  • May be able to go home post isertion
• Generally used for induction, not augmentation
• Nursing care per unit policy (includes fetral assessment; VS; teaching)

Question 22

Pharmacological: Uterotonic

Answer 22

• Oxytocin Infusion
  
  • ​Syntocinon/ Pitocin
  • Used fro both induction and augmentation
  • Half-life is aroun 7 to 12 minutes
  • Given IV via pump as secondary line
    
    • Want it clost to patient- do not want a bunch of oxytocin in the line incacse hyper-stimlation occurs- want to attach it as close as possible to the patient
  • Protocol requires gradual increase >30 minute incremetns
  • Patient needs to signs a consent from if used fro induction; don’t need a consent if used fro augmentation

Question 24

Nursing Care with Oxxytocin Induction

Answer 24

• Continuous ovservation by an RN as per facility protocol
• Assess contractions and FHR q15 minutes
• Maternal vital signs q15-30 minutes
• Fetal Surveillance
  
  • ​When a normal tracing is identified, it may be appropriate to interrupt the EFM tracing for up to 30 minutes to facilitate ambulation, bathing, position changes providing the maternal – fetal condition is stable and infusion rate has not been increased

Question 25

During Labour

Answer 25

• Hyperstimulation
  
  • Excessive uterine activity often with atypical or abnormal FHR tracing
• Tachysystole
  
  • >5 contractions in 10 minutes
• Hypertonus
  
  • Abnormally high resting tone (uterus that wont relax)
• Tetanic
  
  • Contraction lasting more than 120 seconds
• Any of these things will decrease perfusion to the fetus
• Important to assess resting tone and FHR

Question 26

Hyperstimulation Can Result in:

Answer 26

• Abruption of placenta
• Hypoxia to fetus
• Preciptious delivery
• PP uterine atony

Question 27

What do you do if hyperstimulation occurs?

Answer 27

• Reduce contraction/ reduce uterine stimulation
  
  • Stop oxytocin
  • Take out prosteglandin
  • Wip our the prostin gel
• Open IV
• O2 per mask
• Continue to monitor
• Administer ordered tocolytic
• Provide support and reassurance
• Can use a tocalytic if the fetus is being compromised (Nitrogen)

Question 28

After Delivery

Answer 28

• Risk of postpartum hemorrhage/ PP atony is increased with induction (monitor)
  
  • More at risk because if the uterus was not doing it them- ot is not doing it now
• Watch for signs of PPH
• Consider continued infusion of oxytocin titrated to findus/ flow

Question 29

Augmentation

Answer 29

• Interventions include rupture of membranes (amniotomy) and pharmacological (oxytocin only)
• Nursing measures as per induction
• Note:
  
  • These interventions increase the likelihood of vaginal delivery when done for active labour dystocia
  • These interventions increase the likehood of Cesarean section when done for slow progress in latent labour

Question 30

Labour Dystocia

Answer 30

Non-progression in active labour

Question 31

What are the 6 care practices that support normal birth?

Answer 31

1. Labor begins on its own
2. Freedom of movement thoughout labour
3. Continuous labour supprots
4. No routine interventions
5. Spontaneous pushing in upright or gravity-neutral positions
6. No seperation of mother and baby, with unlimited opportunities for breastfeeding