Presentation on theme: "Cervical Ripening and Induction/Augmentation of Labor"— Presentation transcript:
1 Cervical Ripening and Induction/Augmentation of Labor Daren Sachet, RNC/MPA
2 ObjectivesList 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.
3 Definitions What is cervical ripening? What is induction? Preparation of an unfavorable cervix for labor inductionWhat is induction?Stimulation of uterine contractions before the spontaneous onset of laborWhat is augmentation?Correcting ineffective uterine contractions or hypocontractility
4 Incidence in the United States National Center for Health Statistics (NCHS) year 2000 dataInduction of labor- 19.9%labor augmentation-17.9%National Center for Health Statistics (NCHS) year 2009 dataInduction of labor %Labor augmentation %Since 1989, this represents a 137% increase in induction and a 75% increase in augmentation rates.NCHS, 2009
5 Risk-Benefit Risk of Cesarean Birth for Nulliparous Women: 17.2% spontaneous labor30.4% induced labor77.7% increase for inductionReisner et al., 2009Use of pharmacologic agents increases risk for tachysystole, indeterminate or abnormal FHR patterns and failure to progress
6 Cascade of Interventions Related to Induction of Labor IVBedrestContinuous EFMAmniotomySignificant PainEpiduralProlonged LaborSimpson, 2009
7 Economic Costs Spontaneous Labor/vaginal birth $4000 Induction of labor/vaginal birth$5000Cesarean Birth/scheduled$7000Cesarean Birth/failed induction$7500Simpson, KR., 2009Simpson, 2009
8 Indeterminate/Abnormal FHR (Category II and Category III FHR) Nearly twice the risk, possibly related to:TachysystoleEarly AmniotomyLabor DystociaLonger LaborLess Fetal ToleranceGlantz, 2005, Simpson, KR., 2009
9 Risks to the Infant Respiratory Distress Syndrome TTN Hypoglycemia SepsisAdmission to higher level of nursery care> LOSTita, 2007
10 Indications for Cervical Ripening and Induction of Labor MedicalPremature rupture of membranes, post term pregnancy, preeclampsia, hypertension of various types including transient, diabetes or abnormal GTT, fetal compromise, coagulation issues, multiple gestation, suspected fetal disease/compromise, fetal death, polyor oligo, poor fetal growth, infection, etc. Table Number 11.07: Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (Ver. 2011A) Code ICD-9-CM Description Shortened DescriptionInduction 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 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 weeks.JC 2010Decrease the rate in patients with elective delivery at 37 to 39 weeks gestation.Joint Commission National Quality Core Measure PC-01
11 Contraindications-Induction of Labor Generally, the contraindications for labor induction are the same as those for spontaneous labor and vaginal birthVasa previa or complete placenta previaTransverse fetal lieUmbilical cord prolapsePrevious transfundal uterine incisionActive genital herpes infectionPelvic structural deformitiesInvasive cervical cancer
12 Situations Requiring Special Attention One or more previous low-transverse cesarean birthsBreech presentationMaternal heart diseaseMultifetal pregnancyPolyhydramniosPresenting part above the pelvic inletSevere hypertensionAbnormal FHR patterns requiring emergent birthA trial of labor after a previous cesarean birth or history of prior uterine scarACOG 2009, 2002
13 Indications for Augmentation of Labor DystociaUterine HypocontractilityUterine hypocontractility should be augmented only after both the maternal pelvis and fetal presentation have been assessed.ACOG 2009
14 Pre-induction/Ripening Criteria Availability of trained nursing and provider staffCervical ripening agents should be administered at or near the labor and birth suite where uterine activity and FHR can be monitored continuallyAssessment of gestational age, cervical status, pelvic adequacy, fetal size and presentationA physician capable of performing a cesarean birth should be readily available.ACOG 2009A physician capable of performing a cesarean birth should be readily available.
15 Criteria continued Considerations to any risks to mother or fetus Patient counseling regarding indications, agents/methods, and possibility of repeat induction or cesarean birthThe medical record should document that a discussion was held between the pregnant woman and her health care providerACOG 2009
16 Bishop Score Has been shown to be an important determinant of the success or failure of induction Dilate cmEfface%StationConsistencyPos CxClosed0-30-3FirmPost11-240-50-2Medmid23-460-70-1/0SoftAnt35-680+1/+2___Cervical status is the most important factor predicting the success of induction of laborBishop score>5 multips or >7 primips, increases success of induction. If less consider ripening firstJennifer:Cx :closed 0Eff:50% 1Sta:-2 1Consistency: med 1Position cx: post 0_________Bishop Score: 3SarahCx :1 1Eff:70% 2Sta:-2 1Consistency: med 1Position cx: ant 27
17 Cervical StatusIncludes documentation of the Bishop score and the presence or absence of uterine activityFor women at term, a Bishop score of 6 or more may be useful in predicting onset of spontaneous labor within 7 daysRozenberg, Goffinet & Hessabi, 2000
18 Cervical Ripening Agents These agents may soften the cervix, change the Bishop scoreMechanical/Non pharmacologic MethodsLaminaria tentsSynthetic hygroscopic dilators (Lamicel and Dilapan)Balloon cathetersPharmacologic MethodsProstaglandins (E1 & E2)Oxytocin
19 Synthetic Osmotic Dilators Mechanical DilatorsLaminaria TentsSynthetic Osmotic DilatorsCervical Ripening BalloonsAll mechanical Devices are Placed in endocervical canal under direct visualization using aseptic technique Inserted by providerMay be appropriate for women for whom pharmacologic agents for cervical ripening are contraindicatedWho might these patient’s be? Too many contractions-
20 Laminaria Tents Stems of cold water seaweed Available in various sizes from 2-6mm in diameter and 60mm in lengthAbsorb fluid from the cervical tissuesSwell two to three times diameter in 6-12 hoursCause mechanical dilation and local prostaglandin release
21 Synthetic Osmotic Dilators LamicelDilapanPolyvinyl alcohol polymer sponge soaked in 450 mg of magnesium sulfateAbsorb fluid from cervical tissuesSwell to 3-4 times diameter in 2-4 hoursMultiple serial applications possibleCause mechanical dilation and local prostaglandin release
22 Balloon Catheters and Extraamniotic Saline Infusion Foley CatheterExtraamniotic saline infusion- balloon catheterDouble Balloon Cervical Ripening CatheterResults seen within 8-12 hours after insertionNext slide for details
23 Mechanical Ripening Devices Double balloon deviceFoley catheterFoleyflush g indwelling urinary (Foley) catheter with sterile NS prior to insertion.Practitioner places it in cervical canal above internal cervical os.catheter balloon inflated above internal os with 30-40ml of sterile normal salineSome places put NS in the collection bag to add traction, others just tape the tubing to the mother’s leg to supply traction. Foley catheter: Clamp tubing and tape to Mom’s leg, unless extraamniotic infusion of NS will occur.Extraamniotic Saline Infusion or Prostin E2 infusion:22 gauge foley inserted through external cervical os. Balloon inflated with 30 cc sterile water.The saline or PGE2 solution is infused through the catheter port at a constant rate by infusion pump. with normal saline infusion at 1 ml/min (60ml/hr) into extraamniotic space.Fluid allowed to spill out of vaginalEvery hour RN checks for balloon displacement with a gentle tug.Cause direct pressure and overstretching of the lower uterine segment and cervix as well as local prostaglandin releaseMaximum time of 12 hours or when SROM or spontaneous expulsion (8-12 hr average)Double balloon cathetersInsert into cervix until both balloons have advanced into the cervical canal.Place 40 mL NS in balloon port marked U (uterus), tug to bring it up against the os and the other balloon will become visible in the vagina.Fill balloon port marked V(vagina) with 20 mL NS. May tape extended tubing to Mom’s leg.Add additional 20 mL NS at a time to each balloon for a total of 80 mL in each balloon.Do not leave in place for more than 12 hours.Remove if SROM while in place.
24 Pharmacologic Methods Not recommended for use in women with history prior c-birth or uterine scar Prostaglandin E1: Misoprostol (Cytotec)Oral, sublingual or vaginal useWide variations exist in time of onset of uterine contractionsPeak action is approximately 1-2 hours but can be up to 4-6 hoursAvailable in 100 mcg & 200 mcg tablets. 100mcg tablet is not scored; dose should be prepared by pharmacy, not cut by the nurse.Vaginal 25 mcg inserted into posterior vaginal fornix and repeated every 3-6 hours up to 6 doses in 24 hours for vaginal route. Maximum of 150 mcg/24hrOral mcg orally Reduces the need for repeated vaginal examsIs effective at achieving vaginal delivery although not as quickly as vaginal placementRates of tachysystole are lower when using comparable dosesOral dose may need 50 mcg though most protocols call for 25 mcg to startWeeks & Alfirevic, 2006Wide variation in onset of uterine ctx’s. Peak action is approximately 1-2 hours when administered intravaginally, but can be up to 4 to 6 hours for some women.
25 Re-dosing Parameters Re-dosing is permissible if: Still unripe cervix? Happy baby?Redosing is withheld if:Redosing is permissible if:Redose if:Cervical condition remains unfavorableUterine activity is minimalFHR is reassuringIt has been at least 3 hours since last doseWithheld if:There are two or more contractions in 10 minutesAdequate cervical ripening is achieved (Bishop score of 8 or greater)Patient enters active laborFHR is indeterminate or abnormalACOG, 1999
27 Prostaglandin E2-Dinoprostone PrepidilPerform speculum exam, introduce gel just below cervical osPatient should remain recumbent for at least 30 minutesUterine contractions usually occur within one hour of administration- peak activity within 4 hGel is introduced into the cervical canal just below the internal os with a catheter provided in the kit. If cervix not effaced, use 20 mm shielded endocervical catheterIf cervix is > or = 50% effaced, use 10 mm catheterStorage and Preparation- store in refer (stable up to 2 years when stored at 2-8 degrees C)Bring to room temperature just before administration. Do not use warm water bath or microwave as heat may cause inactivationUterine ctx’s usually occur within one hour of administrationPeak activity occurs within four hoursIf no response, increase dose by 0.5 mg every 6 hours (comes in 0.5 mg PGE2 to a 3 gram syringe)Maximum cumulative dose is 1.5 mg (three doses) over 24 h.Rate of tachysystole is 1-5% usually occurs within one hour of administration
28 Prostaglandin E2-Dinoprostone CervidilControlled-release vaginal insert with removable cord is easy to administer and does not require speculum examKeep frozen until immediately before use, no warming requiredPatient should remain supine for 2 hours following insertion- then can ambulate if EFM telemetry availableUterine contractions usually occur within 5-7 hoursRemove after 12 h or at onset of laborRate of tachysystole is about 5%; usually occurs within 1 h of administration but may occur up to 9.5 h after administrationNot appropriate for outpatient cervical ripeningACOG, 1999a; Rayburn et al.,2000)
29 Cervical Ripening Agents Minimum safe interval from prostaglandin to oxytocin administration not establishedManufacturers guidelines recommendMisoprostol- at least 4 hours after last dosePrepidil hours after last doseCervidil minutes after removal of vaginal insertNot contraindicated with PROM
30 Induction and Augmentation of Labor Mechanical methods of Induction of LaborStripping the MembranesDigital separation of the chorioamnionic membrane from the wall of the cervix and lower uterine segment during a vaginal examination (aka sweeping the membranes)A finger is inserted into the cervical os and rotated 360 degrees.Exact mechanism is unknown- thought to release prostaglandins locally from the amnion/chorion/deciduaRisks include the potential for intraamniotic infection, unplanned rupture of membranes, disruption of an undiagnosed placenta previa and precipitous labor and birthACOG, 1999a; Hadi, 2000
31 Amniotomy Artificial rupture of membranes NURSES DO NOT PERFORM AMNIOTOMYSuccessful in multiparous women with cervical dilation of greater than 2 cmMay preclude need for oxytocinEarly amniotomy contraindicated when maternal infection is present (HIV, active herpes simplex)AWHONN, 2002Newer literature states early amniotomy markedly increases the risk for cesarean birth and may only decrease length of labor by 1-2 hoursSimpson & Thorman, 2005Risks of amniotomy:Umbilical cord prolapseIntraamniotic infectionFetal injuryBleeding from an undiagnosed vasa previaCommitment to labor with an uncertain outcomeDocumentation & amniotomyMedical record documentation should include the indication for amniotomyAmount,color and odor of amniotic fluidCharacteristics of the FHR before amniotomyFetal response following the procedureCervical status and fetal station
32 OxytocinMost commonly used induction agent in the United States and worldwideKelly & Tan, 2001Synthetic oxytocin is chemically and physiologically identical to endogenous oxytocinHalf life between minutesDawood, 1995a; Arias, 20003 – 4 half-lives to reach steady stateFull effects of oxytocin cannot be determined until steady-state concentration has been achieved.Physiologic steady state 40 min, basis for dosing interval.Pitocin Pit Vitamin P
33 Endogenous Oxytocin First Stage Labor Maternal circulating concentration 2-4 mU/minFetal Contribution3 mU/minCombined effects = 5-7 mU/minSecond Stage LaborSurge of oxytocin at Ferguson’s reflexSimpson, KR, 2009
34 Response to OxytocinOxytocin receptor sites decrease significantly during prolonged exposure to oxytocin for induction/augmentation compared with spontaneous laborDesensitization is related to dose rate and length of administrationMore oxytocin for dysfunctional labor will cause further desensitization, so you should give your patient a rest period of 1-2 hours.Phaneuf et al., 2000Continued oxytocin after active labor is established will not shorten labor. Active labor is self-sustaining.
35 Oxytocin DosingConsiderable controversy exists about dosage and rate increase intervals-there is no consensus in the literatureLow dose regimes and less frequent increases in dose are associated with decreased uterine tachysystoleHigher doses and shorter intervals do not result in a clinically significant decrease in length of labor or in the rate of C/birthACOG, 2009A cervical dilation rate of 0.5-1cm/h in the active phase of labor indicates that labor is progressing sufficiently and that oxytocin administration is adequateAWHONN, 2002
36 Oxytocin Dosing Only increase oxytocin rate if: FHR is normal Labor has not progressed cm/hrContractions are no closer than every 2-3 minutesExcessive uterine activity over the course of 1 hour in first stage of labor is associated with an umbilical artery pH ≤ 7.11 at birthDecrease or discontinue oxytocin in active laborSimpson, KR, 2009
37 Physiologic Dosage Start with doses of 0.5-1 mU/min Increase in 1-2 mU/min increments every 30-40minutes until contractions are every 2-3 minutes apart and labor is progressing ACOG, 1999a, SOGC, 2001Current literature suggests that 90% of pregnant women at term will have labor successfully induced with 6mU/min or less of oxytocinDawood, 1995a, 1995b; Seitchik, Amico et al., 1984
38 Oxytocin Administration No maximal dose of oxytocin has been firmly establishedDoses 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, 2006Many policies require a bedside evaluation by the LIP if oxytocin is to exceed 20 mu/min.
39 High Dose OxytocinAccording to ACOG (2009), protocols that involve “high-dose” oxytocin are acceptable; however, high-dose oxytocin is associated with more uterine tachysystoleSOGC recommends using the minimum dose to achieve active labor, increasing the dosage no more frequently than every 30 minutes and reevaluating the clinical situation if the oxytocin dosage rate reaches 20 mU/minHigh dose oxytocin protocols seem to have the advantage of decreasing the length of labor somewhat, compared with low-dose protocols. It does not appear to decrease C/S rates. Not harmful but more tachysystole.Original study called active management of laborNullip in active labor, singleton, vtx, reassuring1:1 RNAmniotomyIf no labor then start pit at 6 mu/min, increase by 6 to achieve adequate laborAvoid more than 7 contr in 15 min.
40 Oxytocin and Medication Safety August 2007 the Institute for Safe Medication Practices added oxytocin to the High Alert Medication list. There are only 10 others on the list.Joint Commission Standard MM.7.10The organization develops processes for managing high-risk or high-alert medicationsThe organization must develop additional processes for selecting, procuring, storing, ordering, transcribing, preparing, dispensing, administering and monitoring these high-risk or high-alert medications.Some safe practices:Use IV pumps, preferably with a drug library feature, never free flow for labor.Oxytocin is never hung as the primary line in labor. It must be a secondary line piggybacked into the main line at the port closest to the IV siteUse only premixed, standard concentrationsLabel clearlyConsider using a concentration that gives a 1/1 ratio. For example, add 15 units to 250 mL of fluid or 30 units to 500 mL
41 Nursing responsibilities Titrate oxytocin infusion drip to achieve three contractions in 10 minutes with a duration of secondsClosely monitor fetal response, uterine activity and resting toneMonitor maternal vital signs and fluid balanceClosely monitor mean with dose changes, assess every 15 min. If a nurse cannot clinically evaluate the effects of medication at least every 15 minutes (AAP7ACOG, 2007) the oxytocin infusion should be discontinued until this level of maternal and fetal care can be provided (AWHONN Simpson, 2009) and Guidelines for Perinatal Care.Staffing Guidelines for women receiving oxytocin should be 1:1 care during induction/augmentation. Be sure to document every 15 minutes, and whenever you change the rate, at the least. (Guidelines for Professional Registered Nurse Staffing for Perinatal Units, AWHONN, 2010)
42 Potential Complications-Oxytocin TachysystoleAbruptio placentaeUterine ruptureHyponatremia (water intoxicaiton)Tachysystole (as defined by NICHD 2008)>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.Hyponatremia:When infused in high doses, oxytocin infusion rate ≥ 20 mU/min over time, there is a potential for oxytocin cross-reactivity with the vasopressin receptor located in the kidney as oxytocin is similar in structure to vasopressin (antidiuretic hormone). Activation of vasopressin receptor results in water retention and a dilutional hyponatremia.Isotonic solution recommendedS/SConfusionConvulsionsComaCongestive heart failureDeathStrict monitoring of I/O’s recommended
43 Nursing Interventions for Tachysystole with Normal FHR pattern Lateral positioning of motherIncrease IV fluid (LR)If uterine activity not returned to normal after 10 minutes, oxytocin by halfIf tachysystole persists, D/C oxytocin until tachysystole resolvesConsider terbutaline 0.25 mg SQ, with orderACOG, 2010, AWHONN, 2008
44 Nursing Interventions for Tachysystole with Indeterminate or Abnormal FHR pattern Discontinue or reduce oxytocinLateral positioning of MotherIV fluid bolus (LR)If hypotensive, (as with epidural) contact anesthesia provider, prepare to administer epinephrine, with orderOxygen, 10 LPM, non-rebreather maskConsider terbutaline 0.25 SQ, with orderIf unresolved, inform provider immediately, possibly prepare for C/S.(ACOG 2010)
45 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 statusIf oxytocin was discontinued >30-40 minutes resume at initial dose ordered
46 Women attempting VBACShould women with a previous cesarean birth undergo induction or augmentation of labor?Spontaneous labor more likely to result in successful VBACSome 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 RECOMMENDEDACOG, 2010Increase in rupture may be more if woman has never had a vaginal birth before, if cervix is not ripe.
47 VBAC Success RatesStudy performed by the Maternal-Fetal Medicine Units Network – 4 year multicenter prospective observational study of 14,529 women undergoing trial of labor prior cesarean delivery.Induced labor- 67% success rateAugmented labor-74% success rateSpontaneous labor-81% success rateSmith & Merrill, 2006
48 VBAC InductionPhysician and surgical team must be immediately available throughout active laborRecommend 1:1 nursing care with an experienced RNContinuous EFMMust have ability to perform emergency C/birth
49 Nursing Implications with VBAC Induction/Augmentation Access to operating room readily availableMonitor as for high riskSigns and symptoms of uterine rupture/dehiscence of prior scarPatient c/o increasing pain and tenderness even with epiduralPresentation 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 rateInternal VS external monitoring, either OK, evidence suggests that IUPC does not assist in the dx of uterine rupture (ACOG 2010 bulletin 115), however FSE may be useful because acute signs include fetal bradycardia, abnormal FHR pattern
50 Management Maternal stabilization and immediate cesarean birth Key to diagnosis is suspicion of uterine ruptureSimpson, K.R & Creehan, P., 2001
51 Conflict? No way! Common reasons for response Areas for conflict:Interpreting FHR patternsHow to treat indeterminate and abnormal FHR patternsHow to respond to tachysystoleCommon responsesAvoidWork AroundGoing along to get alongDeceptionStress/AnxietySimpson, KR., 2009Common reasons for responseDisrespectful or disruptive clinical behaviorIntimidation, belittling, yelling, temper tantrum, nonverbal devaluation such as eye rolling, sighing, etcLack of administrative response when reporting behaviorsFear of relatiationRepeat reporting but no apparent action or change in behavior
52 SummaryEvidence suggests that cervical ripening can increase the chances of successful inductionMisoprostol (cytotec) is becoming more widely used for cervical ripening and labor inductionNo elective inductions before 39 completed weeks of gestationProtocols should be based on ACOG/AHWONN standards and guidelinesMultiple factors contribute to the steady increase in the rate of induction in the United StatesConsider implementation of an Induction of Labor Patient Safety Bundle.Consider implementation of an induction of labor safety Bundle include:Staff & Medical Staff education (everyone on the same page)PoliciesOrder setsConsentInformation for the patient re scheduling proceduresPre-induction checklistIn-use checklist
53 ReferencesAmerican 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 dataAmerican 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 Obstetrician-Gynecologists, Number115, Washington DC: Author.Association of Women’s Health Obstetric and Neonatal Nurses. (2010). Guidelines for Professional Registered Nurse Staffing for Perinatal Units, Washington DC: AuthorsGlantz, J (April 2005). Elective Induction vs. spontaneous labor Associations and Outcomes. Ele Med. 50(4):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)Joint Commission. (2010). Specifications Manual for Joint Commission Quality Core MeasuresPhaneuf S., et al, Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocin-augmented labour. Journal of Reproduction & Fertility 2000;120(1):91-97.Simpson, K.R., (2008). Cervical Ripening and Induction and Augmentation of Labor. 3rd edition. Association of Women’s Health, Obstetric and Neonatal Nurses. Washington DC.Tita, A.,et al. (2009). Timing of elective preterm and neonatal outcomes. (Electronic Version). NEJM. 360:2,