Cervical Ripening and Induction

1. Cervical Ripening andInduction/Augmentation of Labor

2. Objectives List 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? Preparation of an unfavorable cervix for labor induction What is induction? Stimulation of uterine contractions before the spontaneous onset of labor What is augmentation? Correcting ineffective uterine contractions or hypocontractility

4. Incidence in the United States Since 1989, there has been 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 labor 30.4% induced labor 77.7% increase for induction Reisner et al., 2009 Use 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

7. Economic Costs Spontaneous Labor/vaginal birth $4000 Induction of labor/vaginal birth $5000 Cesarean Birth/scheduled $7000 Cesarean Birth/failed induction $7500 Simpson, KR., 2009 Simpson, 2009

8. Indeterminate/Abnormal FHR(Category II and Category III FHR) Nearly twice the risk, possibly related to: Tachysystole Early Amniotomy Labor Dystocia Longer Labor Less Fetal Tolerance Glantz, 2005, Simpson, KR., 2009

9. Risks to the Infant

10. Indications for Cervical Ripening and Induction of Labor

11. Contraindications-Induction of Labor Generally, the contraindications for labor induction are the same as those for spontaneous labor and vaginal birth Vasa previa or complete placenta previa Transverse fetal lie Umbilical cord prolapse Previous transfundal uterine incision Active genital herpes infection Pelvic structural deformities Invasive cervical cancer

12. Situations Requiring Special Attention One or more previous low-transverse cesarean births Breech presentation Maternal heart disease Multifetal pregnancy Polyhydramnios Presenting part above the pelvic inlet Severe hypertension Abnormal FHR patterns requiring emergent birth A trial of labor after a previous cesarean birth or history of prior uterine scar ACOG 2009, 2002

13. Indications for Augmentation of Labor Dystocia Uterine Hypocontractility Uterine 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 staff Cervical ripening agents should be administered at or near the labor and birth suite where uterine activity and FHR can be monitored continually Assessment of gestational age, cervical status, pelvic adequacy, fetal size and presentation A physician capable of performing a cesarean birth should be readily available. ACOG 2009

15. Criteria continued Considerations to any risks to mother or fetus Patient counseling regarding indications, agents/methods, and possibility of repeat induction or cesarean birth The medical record should document that a discussion was held between the pregnant woman and her health care provider ACOG 2009

16. Bishop ScoreHas been shown to be an important determinant of the success or failure of induction

17. Cervical Status For women at term, a Bishop score of 6 or more may be useful in predicting onset of spontaneous labor within 7 days Rozenberg, Goffinet & Hessabi, 2000

18. Cervical Ripening Agents These agents may soften the cervix and change the Bishop score Mechanical/Non pharmacologic Methods Pharmacologic Methods

19. Mechanical Dilators Laminaria Tents Synthetic Osmotic Dilators Foley Catheter Double Balloon Cervical Ripening Catheter Extraamniotic saline infusion- balloon catheter

20. Pharmacologic MethodsNot recommended for use in women with history prior c-birth or uterine scar Prostaglandin E1: Misoprostol (Cytotec) Oral or vaginal use Wide variations exist in time of onset of uterine contractions Peak action is approximately 1-2 hours but can be up to 4-6 hours May re-dose only if parameters met

21. Complications with Misoprostol (Cytotech) Tachysystole Indeterminate/Abnormal FHR pattern Precipitous Labors Uterine Rupture Need careful maternal/fetal assessments Need consent/protocols ACOG, 2009

22. Prostaglandin E2-Dinoprostone Prepidil Cervidil

23. Cervical Ripening Agents Minimum safe interval from prostaglandin to oxytocin administration not established Manufacturers guidelines recommend Misoprostol- at least 4 hours after last dose Prepidil- 6-12 hours after last dose Cervidil-30-60 minutes after removal of vaginal insert Not contraindicated with PROM

24. Induction and Augmentation of Labor Mechanical methods of Induction of Labor Stripping the Membranes Amniotomy Digital 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/decidua Risks include the potential for intraamniotic infection, unplanned rupture of membranes, disruption of an undiagnosed placenta previa and precipitous labor and birth ACOG, 1999a; Hadi, 2000Digital 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/decidua Risks include the potential for intraamniotic infection, unplanned rupture of membranes, disruption of an undiagnosed placenta previa and precipitous labor and birth ACOG, 1999a; Hadi, 2000

25. Oxytocin Most commonly used induction agent in the United States and worldwide Kelly & Tan, 2001 Synthetic oxytocin is chemically and physiologically identical to endogenous oxytocin Half life between 10-12 minutes Dawood, 1995a; Arias, 2000 3 � 4 half-lives to reach steady state Full effects of oxytocin cannot be determined until steady-state concentration has been achieved. Physiologic steady state 40 min, basis for dosing interval.

26. Endogenous Oxytocin First Stage Labor Maternal circulating concentration 2-4 mU/min Fetal Contribution 3 mU/min Combined effects = 5-7 mU/min Second Stage Labor Surge of oxytocin at Ferguson�s reflex Simpson, KR, 2009

27. Response to Oxytocin Prolonged exposure ? ? Oxytocin receptor sites compared with spontaneous labor More oxytocin for dysfunctional labor will cause further desensitization. A rest period of 1-2 hours is recommended Phaneuf et al., 2000 Continued oxytocin after active labor is established will not shorten labor. Active labor is self-sustaining.

28. Oxytocin Dosing Considerable controversy exists about dosage and rate increase intervals-there is no consensus in the literature You take the high road � and I�ll take the low road

29. Oxytocin Dosing Only increase oxytocin rate if: FHR is normal Labor has not progressed 0.5 -1 cm/hr Contractions are no closer than every 2-3 minutes Excessive uterine activity over the course of 1 hour in first stage of labor is associated with an umbilical artery pH = 7.11 at birth Decrease or discontinue oxytocin in active labor Simpson, KR, 2009

30. 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, 2009 SOGC, 2001 Current literature suggests that 90% of pregnant women at term will have labor successfully induced with 6mU/min or less of oxytocin Dawood, 1995a, 1995b; Seitchik, Amico et al., 1984

31. Oxytocin Administration No maximal dose of oxytocin has been firmly established Doses 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, 2006

32. High Dose Oxytocin According to ACOG (2009), protocols that involve �high-dose� oxytocin are acceptable; however, high-dose oxytocin is associated with more uterine tachysystole

33. Oxytocin and Medication Safety

34. Nursing responsibilities Titrate oxytocin infusion drip to achieve three contractions in 10 minutes with a duration of 60-90 seconds Closely monitor fetal response, uterine activity and resting tone Monitor maternal vital signs and fluid balance Closely monitor mean with dose changes, assess every 15 min, may summarize every 30 min when no more dose change.Closely monitor mean with dose changes, assess every 15 min, may summarize every 30 min when no more dose change.

35. Potential Complications-Oxytocin Tachysystole >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. Abruptio placentae Uterine rupture Hyponatremia (water intoxicaiton) I & O when on oxytocin

36. Nursing Interventions for Tachysystole with Normal FHR pattern Lateral positioning of mother Increase IV fluid (LR) If uterine activity not returned to normal after 10 minutes, ? oxytocin by half If tachysystole persists, D/C oxytocin until tachysystole resolves Consider terbutaline 0.25 mg SQ, with order ACOG, 2010, AWHONN, 2008

37. Nursing Interventions for Tachysystole with Indeterminate or Abnormal FHR pattern Discontinue or reduce oxytocin Lateral positioning of Mother IV fluid bolus (LR) If hypotensive, (as with epidural) contact anesthesia provider, prepare to administer epinephrine, with order Oxygen, 10 LPM, non-rebreather mask Consider terbutaline 0.25 SQ, with order If unresolved, inform provider immediately, possibly prepare for C/S. (ACOG 2010)

38. Resuming Oxytocin

39. Women attempting VBAC Should women with a previous cesarean birth undergo induction or augmentation of labor? Spontaneous labor more likely to result in successful VBAC Some 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 RECOMMENDED ACOG, 2010

40. VBAC Success Rates

41. VBAC Induction Physician and surgical team must be immediately available throughout active labor Recommend 1:1 nursing care with an experienced RN Continuous EFM Must have ability to perform emergency C/birth

42. Nursing Implications with VBAC Induction/Augmentation Access to operating room readily available Monitor as for high risk Signs and symptoms of uterine rupture/dehiscence of prior scar Patient c/o increasing pain and tenderness even with epidural Presentation 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 rate

43. Management Maternal stabilization and immediate cesarean birth Key to diagnosis is suspicion of uterine rupture Simpson, K.R & Creehan, P., 2001

44. Conflict? No way!

45. Summary Evidence suggests that cervical ripening can increase the chances of successful induction Misoprostol (cytotec) is becoming more widely used for cervical ripening and labor induction No elective inductions before 39 completed weeks of gestation Protocols should be based on ACOG/AHWONN standards and guidelines Multiple factors contribute to the steady increase in the rate of induction in the United States Consider implementation of an Induction of Labor Patient Safety Bundle.

46. References American 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. 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. American 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 2000 - 2009 data Tita, A.,et al. (2009). Timing of elective preterm and neonatal outcomes. (Electronic Version). NEJM. 360:2, 111-120 Joint Commission. (2010). Specifications Manual for Joint Commission Quality Core Measures http://jointcommission.org/releases/TJC2010A/MIF0166.html Phaneuf S., et al, Loss of myometrial oxytocin receptors during oxytocin-induced and oxytocin-augmented labour. Journal of Reproduction & Fertility 2000;120(1):91-97. Glantz, J (April 2005). Elective Induction vs. spontaneous labor Associations and Outcomes. Ele Med. 50(4):235-240. 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)