Induction of Labour Pres Mutai

8/2/2019 Induction of Labour Pres Mutai

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HNS221 Assignment: induction of

labour1. MBOGORI MAURICE MURUGU P30/1088/2010

2. MUTAI K. JOSPHAT P30/1073/2010

3. NGARI DENNIS MUGAMBI P30S/7174/2010

4. MURIITHI PATRICK MUGAMBI P30/1027/2009

5. MUITA KENNEDY MUNIKO P30/1085/2010

6. MAPESA AMOS P30/1745/2010

7. KIRUI MOSES P30/1083/2010

8. KHALAYI ELIZABETH NAFULA(GROUP REP)

P30S/7160/2010

Tuesday, April 03, 2012 courtesy of group 9 1


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labour

The process of uterine contractionsleading to progressive effacement anddilatation of the cervix and birth of the

baby


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Induction of labour

Artificial stimulation of uterine contractionsbefore spontaneous onset of labour withthe purpose of accomplishing successful

vaginal delivery

This includes both women with intactmembranes and women with spontaneous

rupture of the membranes but who are notin labour.


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Augmentation of labor refers to the

stimulation of ineffective uterine contractions

that are considered inadequate because of

failure of progressive dilatation and fetal

descend after spontaneous onset of labor.


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Indications for induction of labour

When the woman's life or well-being is in

danger, or if the fetus may be compromised by

remaining in the uterus any longer. Maternal:

Severe preeclampsia or hypertension(urgent)

Fetal death Chorio-amnionitis( urgent)


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-PROM

-Postterm preg

-Abruptio placenta-Medical conditions-DM,Heart ds, Renal ds

- significant APH(urgent)


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Fetal (usually for pregnancy termination due

to significant fetal compromise)

IUFD

Fetal anomaly incompatible with life

Severe IUGR(urgent0

Rh isoimmunisation Macrosomia


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Isoimmunization


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Logistical:

History/risk of rapid labors

Distance from hospital

Psychosocial indications


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Severe hydrocephalous

Hx of uterine surgery involving myometrium

Genital herpex infection

Cervical cancer

Distorted maternal size


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Complications for Induction of Labour

Maternal

Emotional: fear, anxiety

Uterine inertia ;

prolonged labour

Intrapartum infection

Violent labour ;

abruptio placentae;

uterine rupture;


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Complications ctnd.

cervical laceration

Hypofibrinogenaemia

Amniotic fluid embolism Postpartum haemorrhage


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Complications for Induction of Labour

Fetal

Hypoxia

Iatrogenic prematurity [wrong dates]

Prolapse cord

Infection


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Indications for Augmentation

Uterine hypocontractility, after the maternal

pelvis and fetal presentation have been

assessed


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Contraindications for Augmentation

Placenta or vasa previa

Umbilical cord presentation

Prior classical uterine incision

Active genital herpes infection

Pelvic structural deformities

Invasive cervical cancer


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Pre-induction cervix ripening

Cervical ripening is the process of effecting

physical softening and dilatation of the cervix

in preparation for labor and delivery.

Condition of the cx is important to the success

of labour induction.


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A predictive method of an outcome of labour isknown as Bishops Core.( was described byBishop 1964).

Highest score= 13

A score of 9 indicates a high likelihood forsuccessful induction. Await for spontaneouslabour.

A score< 6- ripen the cervix

Bishop score of


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Bishop scoring system used for

assessment of inducibilityFactor

score Dilatation(cm) Effacemen

t (%)

Station(-3 to

+3)

Cervix

consistency

Cervix

position

0 closed 0-30 -3 Firm Posterior

1 1-2 40-50 -2 Medium Mid-

position

2 3-4 60-70 -1 Soft Anterior

3 5 >80 +1, +2 ---------- --------


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Most midwifes will induce labour if

Cx-2cm dilated

80% effaced

Soft

Midposition

Fetal position is atleast at -1


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Techniques for cx Dilatation

Divided into two

1.pharmacological techniques

o Prostaglandin E2(dinoprostone)

o Prostaglandin E1( misoprostol)

2. mechanical techniques

o Transcervical catheter and extra amniotic saline

infusiono Hygroscopic cervical dilators

o Membrane stripping


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Methods of ripening cervix

Cervical massage is done. It help in release oflocal prostaglandin

Stripping/sweeping the membranes and time

is allowed for ripening at 41wksProstaglandin E2 eg misoprostol ,dinoprostone

are given vaginaly. 12hrs is allowed for cervical

ripeningFoleys catheter inserted through the cervix

and placed in the extra-amniotic space

Tuesday, April 03, 2012 22courtesy of group 9


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Walking

Forced cervical dilatation

Whatever method used > works byrelease of prostaglandins


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1.prostaglandins

M/A :Act on the cervix to enable ripeningby a number of different mechanisms.

They alter the extracellular groundsubstance of the cervix, and PG increasesthe activity of collagenase in the cervix.


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Moa of prostaglandis ctd..

They cause an increase in elastase,glycosaminoglycan, dermatan sulfate, andhyaluronic acid levels in the cervix. A

relaxation of cervical smooth musclefacilitates dilation.

prostaglandins allow for an increase in

intracellular calcium levels, causingcontraction of myometrial muscle


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1a.Prostaglandin E2

administered intracervically or vaginally

0.5mg intracervically; 10mg vaginal insertion

Should be administered at or near labor anddelivery/birthing suite (to monitor fetal and

uterine status (continue monitoring for 30

minutes to 2 hours after administration)

Oxytocin should be delayed for 6 to 12 hours

after last dose of gel


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Complication uterine hyperstimulation


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1b.Prostaglandin E1

Misoprostol (Cytotec) is a tablet containingprostaglandins.

Should be administered at or near the labor

and delivery/birthing suite to allowcontinuous monitoring of fetal and uterinestatus.

Uterine hyper-stimulation is a complication Oxytocin is administered 4hrs after the last

dose.


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2.Stripping the Membranes

Stripping of the membranes causes anincrease in the activity of phospholipaseand prostaglandin as well as causing

mechanical dilation of the cervix, whichreleases prostaglandins. The membranesare stripped by inserting the examiningfinger through the internal cervical os and

moving it in a circular direction to detachthe inferior pole of the membranes fromthe lower uterine segment


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Risks of this technique include

infection,

bleeding,

accidental rupture of the membranes,

and patient discomfort


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Complications include

maternal/fetal infection,

PPROM,

umbilical cord prolapse,

precipitous labor and birth, and

personal discomfort


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Before induction;

Obtain a 20-minute NST to assess fetal well-

being.

Evaluate maternal vital signs, especially BP.

Evaluate the patency of the I.V. site, if I.V.

ordered


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Ctn b4 induction

Establish indication clearly

Informed consent

Conformation of gestational age

Assessment of fetal size & presentation

Pelvic assessment

Cervical assessment (BISHOPs score)

Availability of trained personnel


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Methods of induction

NATURALBreast/nipple stimulationSexual intercourseMembrane stripping

AmniotomyAcupuncture/acupressure

MECHANICAL

Balloon cathetersLamineria tentsSynthetic osmotic dilators


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CHEMICAL

NONHORMONAL Herbs,evening primrose oil Homeopathic prep

Enemas Castor oil

HORMONAL Oxytocin

ProstaglandinsPGE2,Misoprostol Relaxin Nitric oxide donors mifepristone

A Amniotomy (Artificial Rupture of


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A.Amniotomy (Artificial Rupture of

Membranes [AROM])

Vulva is cleaned, vaginal examination done,

amniohook is inserted through the cervix, and

membranes are ruptured after the fetal

presentation is evaluated. Fluid should beclear or cloudy without odor.

FHRs are assessed continually for at least the

next 20 minutes


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Complications include;

umbilical cord prolapse or compression,

maternal or fetal infection,

and/or distorted fetal head


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B. oxytocin

An I.V. is mixed with oxytocin

The goal is to establish a regular labor pattern

that will produce cervical dilatation of 1

cm/hour in the active phase of labor.


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Complications include uterine

hyperstimulation (more than five contractions

in 10 minutes),

uterine hypertonus (uterine resting tone

greater than 25 to 30 mm Hg, depending on

the type of intrauterine pressure catheter),

contractions longer than 90 seconds in

duration,


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coupling of contractions,

fetal distress

increased incidence of cesarean delivery,

neonatal hyperbilirubinemia possibly from

red blood cell trauma from intense

contractions or decreased maturity of the

neonate.


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Monitoring labour after oxytocin

induction

Oxytocin is given after cervix has ripen

Monitor labour progress using the partograph

book the mother in case cervix doesnt

respond to ripening and induction



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After the Administration of Oxytocin

Continuously monitor FHR and uterineactivity, especially uterine resting tone,frequency, and duration.

Assess maternal vital signs. Temperature istaken every 2 to 4 hours, unless an amniotomyhas been performed, and then every 1 to 2hours.

Limit vaginal examinations, especially after themembranes have ruptured.


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Maintain intake and output records, and

watch for signs of water intoxication

(dizziness, headache, confusion, nausea,

vomiting, hypotension, tachycardia, decreasedurine output)

Evaluate I.V. site for patency and rate control

for correct rate at least hourly.

Nursing Diagnoses during induction of


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Nursing Diagnoses during induction of

labour

1) Anxiety related to planned childbirth and

outcome

2) Ineffective Tissue Perfusion: Uteroplacental

with altered oxygen to fetus related to

strength of uterine contractions

3) Acute Pain related to uterine activity


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Nursing Interventions

1. Decreasing Anxiety

Teach or review the use of relaxation and

distraction techniques.

Before beginning any new procedure, explain

the procedure to the woman and her support

person.

Answer questions that the woman and family

may have


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2. Promoting Tissue Perfusion and OxygenSupply to Fetus

Assess fetal status and uterine contractionsthrough the use of a monitor or

auscultation/palpation. Assess for signs ofuteroplacental insufficiency (decreasedvariability, abnormal baseline FHR, latedecelerations).

Place patient in lateral position to enhanceplacental perfusion.

.


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Have oxygen set up with a mask ready, andadminister as prescribed (8 to 12 L/minute byface mask) if decelerations occur.

If hyperstimulation of the uterus or fetalcompromise (late decelerations,nonreassuring variable decelerations, orabsent STV) occurs, discontinue the infusion,

maintain the primary I.V., and notify thehealth care provider immediately.


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Administer adequate fluid volume

3. Controlling Pain

Encourage use of breathing techniques,

distraction, and nonpharmacologic comfortmeasures.

Administer analgesia/anesthesia as

prescribed. Maintain positive outlook and support as

labor progresses

E l i E d O


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Evaluation: Expected Outcomes

Verbalizes understanding of the induction

process

No evidence of hyperstimulation or fetal

compromise

Labor progressing with pain controlled

i d i i d i


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nursing management during induction

of labour.

Explain and weigh with the mother the risk ofinduction verses risk of expectant management

Explain available methods advantages and their

disadvantages +cost. Give a written formalexplanation for later reading

obtain consent and reassess appropriacy vaginaldelivery

Reassess your knowledge and skills in entiremethods of induction, there sequence andcontraindication


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Nursing mgt ctd.

Anticipate complication and be ready to respondappropriately

ensure asepsis during the procedure to preventinfections

In hyperstimulation give tocolytics or discontinue.Monitor fetal wellbeing

In fetal distress tocolysis is considered.

Perform VE before and after ARM to minimize risk of

cord prolapse Titrate oxytocics to 6-7 contractions every 15 minutes.Oxytocics are started immediately after ARM to reducechances of PPH


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Management conti..

In absences of liguor close fetal monitoring

and amnioinfusion may be done

Prostaglandins more preferred when

membranes are intact

If ripening is done perform bishops score

after 6 hrs. ensure mothers for the success

Place prostaglandin tablet at posterior fornix

and wait for 6 hrs


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Management conti.

Assess the meconium after ARM

On failure of induction refer patient for

cesarean section depending on urgency. And

discourage routine elective induction of

labour

Prepare mother for cesarean section


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KEY POINTS

Risks of of induction should be weigh with continuingwith pregnancy

Ensure mother is fully informed and consent obtained

Ripen cervix first if bishops score is less than 6

If cervix is unfavorable prostaglandin is used to ripen ,if favorable ARM + syntocinon is favored most

If induction was for some less pressing reason e.g apost date, it si reasonable to consider a conservativeapproach


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Key points ctd

Membrane sweep involve dilating the cervix andseparating the membranes from lower uterinesegment prior to induction of labor

Ant-progestrone eg mifepristone but not clinicallyused can be used to ripen cervix in combinationwith misoprostol

In extra amniotic saline infusion volume should

be limited to 1500mlNever induce labor in presences of uterine

contractions/activity


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Key points ctd.

Some evidence show that maternal

satisfaction is greater with prostaglandin use

Almost 90% o f women suitable for ARM will

enter lobor sponteneusly following the

procedure

Ensure comfort especially during membrane

sweep method of induction


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Patient family education

Risks associated with induction of labour

Induction of labour options and their

expected outcome

Newborn characteristics and care

Review breast feeding options

Avoid exposure to teratogenic substances

Importance of attending postnatal clinics



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references

.11. Mogwan, Brian a.(2009) clinaical

obstetrics and gynaecology. Elsevier

.22. Sabaratnam, arulkumaran(2004),essentials of obstetrics. jaypee

Induction of Labour Pres Mutai

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