HNS221 Assignment: induction of labour

1. MBOGORI MAURICE MURUGU 2. MUTAI K. JOSPHAT P30/1088/2010 P30/1073/2010 P30S/7174/2010 P30/1027/2009 P30/1085/2010 P30/1745/2010 P30/1083/2010 P30S/7160/2010 3. NGARI DENNIS MUGAMBI 4. MURIITHI PATRICK MUGAMBI 5. MUITA KENNEDY MUNIKO 6. MAPESA AMOS

7. KIRUI MOSES 8. KHALAYI ELIZABETH NAFULA (GROUP REP)

Tuesday, April 03, 2012

courtesy of group 9

labour
The process of uterine contractions leading to progressive effacement and dilatation of the cervix and birth of the baby

Induction of labour
Artificial stimulation of uterine contractions before spontaneous onset of labour with the purpose of accomplishing successful vaginal delivery This includes both women with intact membranes and women with spontaneous rupture of the membranes but who are not in labour.

 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.

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)

-PROM -Postterm preg -Abruptio placenta -Medical conditions-DM,Heart ds, Renal ds - significant APH(urgent)

 Fetal (usually for pregnancy termination due to significant fetal compromise) IUFD Fetal anomaly incompatible with life Severe IUGR(urgent0 Rh isoimmunisation Macrosomia

 Isoimmunization

 Logistical:
History/risk of rapid labors Distance from hospital Psychosocial indications

contraindications
(Generally the same for spontaneous labor and vaginal birth.) Vaginal bleeding, known complete placenta previa or vasa previa Abnormal fetal position (transverse) Classic uterine incision Umbilical cord prolapse macrosomia

Severe hydrocephalous Hx of uterine surgery involving myometrium Genital herpex infection Cervical cancer Distorted maternal size

Complications for Induction of Labour

Maternal Emotional: fear, anxiety Uterine inertia ; prolonged labour Intrapartum infection Violent labour ; abruptio placentae; uterine rupture;

Complications ctnd.
cervical laceration Hypofibrinogenaemia Amniotic fluid embolism Postpartum haemorrhage

Complications for Induction of Labour

Fetal Hypoxia Iatrogenic prematurity [wrong dates] Prolapse cord Infection

Indications for Augmentation

Uterine hypocontractility, after the maternal pelvis and fetal presentation have been assessed

Contraindications for Augmentation

Placenta or vasa previa Umbilical cord presentation Prior classical uterine incision Active genital herpes infection Pelvic structural deformities Invasive cervical cancer

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.

 A predictive method of an outcome of labour is known as Bishops Core.( was described by Bishop 1964). Highest score= 13 A score of 9 indicates a high likelihood for successful induction. Await for spontaneous labour. A score< 6- ripen the cervix Bishop score of <4 indicates unfavourable cx A score of zero- managed for c/s

Bishop scoring system used for assessment of inducibility

Factor
score Dilatation(cm) Effacemen t (%)
closed 0-30

Station(-3 to Cervix +3) consistency

-3 Firm

Cervix position
Posterior

1-2

40-50

-2

Medium

Midposition Anterior

3-4

60-70

-1

Soft

>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

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 infusion o Hygroscopic cervical dilators o Membrane stripping

Methods of ripening cervix

Cervical massage is done. It help in release of local prostaglandin Stripping/sweeping the membranes and time is allowed for ripening at 41wks Prostaglandin E2 eg misoprostol ,dinoprostone are given vaginaly. 12hrs is allowed for cervical ripening Foleys catheter inserted through the cervix and placed in the extra-amniotic space
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 Walking Forced cervical dilatation Whatever method used > works by release of prostaglandins

1.prostaglandins
M/A :Act on the cervix to enable ripening by a number of different mechanisms. They alter the extracellular ground substance of the cervix, and PG increases the activity of collagenase in the cervix.

Moa of prostaglandis ctd..

They cause an increase in elastase, glycosaminoglycan, dermatan sulfate, and hyaluronic acid levels in the cervix. A relaxation of cervical smooth muscle facilitates dilation. prostaglandins allow for an increase in intracellular calcium levels, causing contraction of myometrial muscle

1a.Prostaglandin E2
administered intracervically or vaginally 0.5mg intracervically; 10mg vaginal insertion Should be administered at or near labor and delivery/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

 Complication uterine hyperstimulation

1b.Prostaglandin E1
Misoprostol (Cytotec) is a tablet containing prostaglandins. Should be administered at or near the labor and delivery/birthing suite to allow continuous monitoring of fetal and uterine status. Uterine hyper-stimulation is a complication Oxytocin is administered 4hrs after the last dose.

2.Stripping the Membranes

Stripping of the membranes causes an increase in the activity of phospholipase and prostaglandin as well as causing mechanical dilation of the cervix, which releases prostaglandins. The membranes are stripped by inserting the examining finger through the internal cervical os and moving it in a circular direction to detach the inferior pole of the membranes from the lower uterine segment

 Risks of this technique include infection, bleeding, accidental rupture of the membranes, and patient discomfort

 Complications include maternal/fetal infection, PPROM, umbilical cord prolapse, precipitous labor and birth, and personal discomfort

Before induction;
Obtain a 20-minute NST to assess fetal wellbeing. Evaluate maternal vital signs, especially BP. Evaluate the patency of the I.V. site, if I.V. ordered

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

Methods of induction
NATURAL Breast/nipple stimulation Sexual intercourse Membrane stripping Amniotomy Acupuncture/acupressure MECHANICAL Balloon catheters Lamineria tents Synthetic osmotic dilators

CHEMICAL NONHORMONAL Herbs,evening primrose oil Homeopathic prep Enemas Castor oil HORMONAL Oxytocin Prostaglandins PGE2,Misoprostol Relaxin Nitric oxide donors mifepristone

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 be clear or cloudy without odor. FHRs are assessed continually for at least the next 20 minutes

 Complications include; umbilical cord prolapse or compression, maternal or fetal infection, and/or distorted fetal head

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.

 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,

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.

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

Tuesday, April 03, 2012

courtesy of group 9

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After the Administration of Oxytocin

Continuously monitor FHR and uterine activity, especially uterine resting tone, frequency, and duration. Assess maternal vital signs. Temperature is taken every 2 to 4 hours, unless an amniotomy has been performed, and then every 1 to 2 hours. Limit vaginal examinations, especially after the membranes have ruptured.

 Maintain intake and output records, and watch for signs of water intoxication (dizziness, headache, confusion, nausea, vomiting, hypotension, tachycardia, decreased urine output) Evaluate I.V. site for patency and rate control for correct rate at least hourly.

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

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

 2. Promoting Tissue Perfusion and Oxygen Supply to Fetus Assess fetal status and uterine contractions through the use of a monitor or auscultation/palpation. Assess for signs of uteroplacental insufficiency (decreased variability, abnormal baseline FHR, late decelerations). Place patient in lateral position to enhance placental perfusion. .

 Have oxygen set up with a mask ready, and administer as prescribed (8 to 12 L/minute by face mask) if decelerations occur. If hyperstimulation of the uterus or fetal compromise (late decelerations, nonreassuring variable decelerations, or absent STV) occurs, discontinue the infusion, maintain the primary I.V., and notify the health care provider immediately.

 Administer adequate fluid volume 3. Controlling Pain Encourage use of breathing techniques, distraction, and nonpharmacologic comfort measures. Administer analgesia/anesthesia as prescribed. Maintain positive outlook and support as labor progresses

Evaluation: Expected Outcomes

Verbalizes understanding of the induction process No evidence of hyperstimulation or fetal compromise Labor progressing with pain controlled

nursing management during induction of labour.

Explain and weigh with the mother the risk of induction verses risk of expectant management Explain available methods advantages and their disadvantages +cost. Give a written formal explanation for later reading obtain consent and reassess appropriacy vaginal delivery Reassess your knowledge and skills in entire methods of induction, there sequence and contraindication

Nursing mgt ctd.

Anticipate complication and be ready to respond appropriately ensure asepsis during the procedure to prevent infections 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 reduce chances of PPH

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

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

 KEY POINTS Risks of of induction should be weigh with continuing with 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 a post date, it si reasonable to consider a conservative approach

Key points ctd

Membrane sweep involve dilating the cervix and separating the membranes from lower uterine segment prior to induction of labor Ant-progestrone eg mifepristone but not clinically used can be used to ripen cervix in combination with misoprostol In extra amniotic saline infusion volume should be limited to 1500ml Never induce labor in presences of uterine contractions/activity

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

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
1. Mogwan, Brian a.(2009) clinaical .1 obstetrics and gynaecology. Elsevier 2. Sabaratnam, arulkumaran(2004), .2 essentials of obstetrics. jaypee