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Course: Maternity Nursing

Topic: Induction and Augmentation of Labour

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Module Goals

The learner will be able to:

Define induction and augmentation of labour
Identify indications for induction and augmentation of labour
Describe the management of induction and augmentation of labour

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Induction of Labour

Defined as artificially stimulating the uterus for the purpose of starting labour

Normally spontaneous labour is experienced by pregnant women at term, however sometimes induction of labour is indicated

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Induction of Labour: Indications

Confirmed gestational age of 41 weeks (40 weeks plus seven days or more)
Prelabour rupture of membranes (PROM) at term (gestational age of 37 weeks)
Severe preeclampsia at a gestational age when the fetus is not viable
Preeclampsia or gestational hypertension at term, or earlier as clinically indicated
Vaginal bleeding at term, or earlier as clinically indicated
Chorioamnionitis at term, or earlier as clinically indicated
Fetal growth restriction at term or earlier as clinically indicated
Fetal demise or anomalous fetus

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Induction of Labour: Contraindications

Contraindications:

Placenta Previa
Transverse fetal lie
Prolapsed umbilical cord
Prior classical (vertical) uterine incision
Cephalopelvic disproportion

Induction of labour is not recommended for:

Women with uncomplicated pregnancy and gestational age of less than 41 weeks
Gestational diabetes is the only abnormality, but is well controlled, and gestational age is below 41 weeks
Suspected fetal macrosomia at term is the only indication

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Induction of Labour: Assessment of the Cervix

The success of induction of labour is related to the condition of the cervix at the start of the induction
Cervical examination is performed and scored as follows:

Factor	Rating
	0	1	2	3
Dilation (cm)	closed	1-2	3-4	more than 5
Length of cervix (cm)	more than 4	3-4	1-2	Less than 1
Consistency	firm	average	soft	N/A
Position	posterior	mid	anterior	N/A

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Induction of Labour: Methods

Sweeping membranes

Prostaglandins

Foley/Balloon catheter

Oxytocin

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Induction of Labour: Sweeping Membranes

Skilled provider sweeps their finger around cervix during internal examination to separate membranes of the amniotic sac from the cervix, which releases hormones (prostaglandins) that may induce labour

May reduce the need for formal induction of labour

Suitable for non-urgent indications for pregnancy termination

Sterile technique is used to prevent infection

Rupture of membrane should be avoided

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According to WHO (2017) Managing complications in pregnancy and childbirth:

In areas where HIV and/or hepatitis are highly prevalent, it is prudent to leave the membranes intact for as long as possible to reduce prenatal transmission.

Performing membrane sweep:

Listen to the fetal heart rate.
Ask the woman to lie on her back, displacing the uterus by performing a left lateral tilt (e.g rolled blanket under right hip), with her legs bent, feet together and knees apart.
Wearing sterile gloves, use one hand to assess the cervix and not the consistency, position, effacement, and dilation.
Using the examining hand, rotate one finger against the wall of the uterus beyond the internal cervical os, taking care to avoid rupture of membranes.
After membrane sweeping, listen to the fetal heart rate during and after a contraction, and manage accordingly.

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Induction of Labour: Prostaglandins

Highly effective in ripening the cervix during induction of labour
Uterine contractions and fetal heart rate (FHR) must be monitored in women undergoing induction of labour with prostaglandins
Prostaglandin preparations available:

Prostaglandin E2 available as 3 mg pessary or 2-3 mg gel
Prostaglandin is placed high in the posterior fornix of the vagina and may be repeated after 6 hours if required
Misoprostol is a synthetic analogue of prostaglandin E1

Misoprostol should not be used for women with previous caesarean, who are at increased risk of uterine rupture

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Induction of Labour: Prostaglandins

Possible routes Misoprostol administration:

Prostaglandins discontinued and Oxytocin infusion started if:

Membranes rupture
Cervical ripening has been achieved, or 12 hours have passed

Route	Dose	If required repeat after
Oral	25 mcg (dissolved on 200 mcg tablet in 200 mL of water and administer 25 mL of that solution as a single dose	2 hours
Vaginal (into the posterior fornix)	25 mcg (only if Misoprostol is available in the form of a 25 mcg tablet) Do not divide or cut 200 mcg tablet into smaller pieces, as this is inaccurate	6 hours

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Induction of Labour: Foley/Balloon Catheter

Recommended alone or in combination with Oxytocin as alternative method of induction of labour if prostaglandins are not available or are contraindicated
Associated with lower risk of uterine hyperstimulation and uterine rupture
May be preferred for women with a previous cesarean section.
Contraindicated in:

Cervicitis or vaginitis
History of bleeding or ruptured membranes

Oxytocin infusion can be started with a balloon catheter in place or after its removal

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According to WHO (2017) Managing complications in pregnancy and childbirth:

Foley/balloon catheter insertion:

· Check, record woman’s pulse, BP contractions, and fetal heart rate

· review for indications

· Obtain oral informed consent from the woman before proceeding

· gently insert a high-level disinfected or sterile speculum into the vagina

· hold the catheter just below the tip with a high level-disinfected or sterile forceps and gently introduce it through the cervix. Ensure that the inflatable bulb of the catheter is beyond the internal cervical os.

· Inflate the bulb with 30-50 ml of water, depending on the size of the balloon.

· Coil the rest of the catheter and place it into the vagina.

· Leave the catheter in place for at least 12 hours, or until contractions begin.

· Monitor woman, fetus, contractions, and progress of labour.

· Deflate the bulb before removing the catheter.

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Induction of Labour: Oxytocin Infusion

Infuse 2.5 units in 500 ml of dextrose (or normal saline) at 2.5 mIU/min

(i.e 0.5 mL/min or 10 drops/min through giving set with drop factor of 20 drops/mL)

Increase infusion rate by 2.5 mIU/min every 30 minutes until a good contraction pattern is established (3 contractions in 10 minutes, each lasting more than 40 seconds)
Once a good contraction pattern is established (3 contractions in 10 minutes, each lasting more than 40 seconds), maintain the rate; monitor pulse, BP, contractions, and FHR

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Induction of Labour: Oxytocin Infusion

If good contraction pattern has not been established with the infusion rate at 15 mIU,

Increase the Oxytocin concentration to 5 Units in 500 ml of dextrose (or normal saline) (i.e 10 mIU per mL) and adjust the infusion rate to 15 mIU per minute
Increase the infusion rate by 5 mIU every 30 minutes until a good contraction pattern is established or the maximum rate of 30 mIU/min is reached

Do not use Oxytocin 10 units in 500 mL (i.e 20 mIU/L) in multigravidae and women with previous caesarean birth

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Induction of Labour: Oxytocin Infusion

If a good contraction pattern still has not been established using the higher concentrations of Oxytocin:

In multigravidae and women with previous cesarean scars, induction has failed; caesarean is performed
In primigravida:

Infuse Oxytocin 10 units in 500 mL.at 30 mIU/min
Increase the infusion rate by 10 mIU every 30 minutes until a good contraction pattern is established or the maximum rate of 60 mIU/min is reached
If good contractions are not established at maximum dose, cesarean is performed

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Oxytocin Infusion Rates for Induction of Labour

Rapid Escalation for Primigravida Only:

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Case study:

A multigravida woman arrives at the clinic. She is now 40 weeks pregnant. Vaginal exam shows cervix 1 cm dilated and 90 percent effaced, 3 cm in length, mid position. She has had intermittent Braxton-Hicks contractions for the past few days that are very painful. Her pregnancy is uncomplicated thus far.

Based on the WHO guidelines, how should this patient be managed?

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Augmentation of Labour

Process of stimulating the uterus to increase frequency, duration and intensity of contractions after the onset of spontaneous labour

Aimed to shorten labour to prevent complications related to slowed labour and to avert caesarean birth

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Augmentation of Labour: Indications

Review for indications:

Unsatisfactory progress or delay of labour
False labour has been ruled out
No signs of cephalopelvic disproportions or obstruction
Inadequate contractions are the most likely cause of unsatisfactory progress of labour

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Augmentation of Labour with Oxytocin

The stage and phase of labour is confirmed

Informed consent is obtained

Oxytocin is initiated

For treatment of confirmed delay in labour, performing amniotomy together with administration of Oxytocin is appropriate

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Augmentation of Labour with Amniotomy

Review for indications

If membranes are intact, amniotomy may be considered for augmentation in combination with Oxytocin infusion

Rupture of membranes (amniotomy), whether spontaneous or artificial often initiates the following chain of events:

Amniotic fluid is expelled
Uterine volume is decreased
Prostaglandins are produced, stimulating labour
Uterine contractions begin (if the woman is not in labour) or become stronger (if she is already in labour)

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Performed by a skilled practitioner and according to national and professional scope of practice regulations

According to WHO (2017) Managing complications in pregnancy and childbirth:

Amniotomy alone is not recommended either for the induction of labour or the treatment of delay in labour.

In areas where HIV and/or hepatitis are highly prevalent, it is prudent to leave the membranes intact for as long as possible to reduce perinatal transmission.

Performing amniotomy:

· Review for indications

· Obtain oral informed consent from the woman before proceeding.

· Listen to and note the fetal heart rate

· Ask the woman to lie on her back, displacing the uterus by performing a left lateral tilt (e.g rolled blanket under right hip), with her legs bent, feet together and knees apart.

· Wearing sterile gloves, use one hand to assess the cervix and note the consistency, position and effacement, and dilation

· Use the other hand to insert an amniotic hook or a Kocher clamp into the vagina

· Guide the hook or clamp towards the membranes along with the fingers in the vagina.

· Place two fingers against the membranes and gently rupture the membranes with the instrument in the other hand. Allow the amniotic fluid to drain slowly around the fingers.

· Rupture membranes between contractions to prevent splashing of amniotic fluid.

· Note the colour of the fluid (clear, meconium-stained, blood-stained, greenish, purulent, foul-smelling). If thick meconium is present, suspect fetal distress and manage accordingly.

· After amniotomy, listen to the fetal heart rate during and after a contraction. if the fetal heart rate is abnormal (less than 100 or more than 180 beats per minute), suspect fetal distress., and manage accordingly.

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Hyperstimulation During Induction and Augmentation

If contractions lasts longer than 60 seconds, or if there are more than 5 contractions in 10 minutes:

Stop the infusion
Remain with the woman until normal uterine activity is achieved
Position the woman on her left side (left lateral position)
Assess the FHR:
If FHR is normal (between 100 -180 beats/min), observe for improvement in uterine activity and monitor FHR
If FHR is abnormal (<100 or >180 beats/min), manage fetal distress and relax the uterus using betamimetics: terbutaline 250 mcg IV slowly over 5 minutes OR salbutamol 10 mg in 1 L IV fluids (normal saline or Ringer’s lactate) at 10 drops per minute

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Hyperstimulation During Induction and Augmentation

Observe for the improvement in uterine activity and monitor the FHR:

If the normal activity is not established within 20 minutes and betamimetics have not been administered, relax the uterus using betamimetics
If the FHR becomes reassuring and normal uterine activity is established for a period of at least 30 minutes, cautiously recommence Oxytocin infusion

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Induction and Augmentation of Labour

Facilities for assessing maternal and fetal wellbeing must be available
Presence of personnel skilled with uterotonic drugs and management of maternal and fetal complications
Facility should have the capacity to manage potential adverse effects and failure to achieve vaginal birth
Supportive care should be provided continuously;
Women receiving Oxytocin, Misoprostol or other prostaglandins should never be left unattended
Infusion rate of Oxytocin should be continually and closely monitored
Betamimetics should be available in event of uterine hyperstimulation

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Case study:

The nurse is preparing a labouring patient for amniotomy procedure.

What are the indications for amniotomy?

What are the possible complications from this procedure that the nurse should be aware?

How should the nurse educate and prepare the patient?

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Answer:

Amniotomy is indicated if findings are suggestive of unsatisfactory progress or delay of labour with all of the following criteria:

· False labour has been ruled out

· There are no signs of cephalopelvic disproportions or obstruction

· Inadequate contractions are the most likely cause of unsatisfactory progress of labour

Possible complications from amniotomy that the nurse should be aware of are the risk of infection of reproductive organs and fetus and cord prolapse.

The nurse should educate the patient about the procedure by describing the procedure and why it is performed, and what is the patient can expect once it is performed.

The nurse will prepare the patient for the procedure as follows:

Ensure informed consent is obtained from the patient for the procedure
If possible ensure facilities for managing potential adverse effects and failure to achieve vaginal birth are available
Ensure betamimetics are available in case of uterine hyperstimulation
Fetal heart rate is assessed and noted
Ensure woman is put in lateral tilt for the procedure

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Reference:

NHS UK (November 2017). Inducing labour. Retrieved from: https://www.nhs.uk/conditions/pregnancy-and-baby/induction-labour/

Sanchez-Ramos, L., & Kaunitz, A. (2009). Global Library of Women’s Medicine. Retrieved from: https://www.glowm.com/section_view/heading/induction-of-labor/item/130

WHO (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors (2nd ed.) Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

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