Transcript Induction of labor Ibtesam

Done By:
Ibtesam.U.Jahlan
Induction of labor:
Is the planned initiation of labor prior
to the onset of spontaneous labor. It
is an obstetric intervention that should
be used when elective birth beneficial
to mother and baby.
*It includes several methods: Medical
and Surgical methods.
Augmentation of labor:
*Is refers to intervention to correct
slow progress in labor.
* Correction of ineffective uterine
contraction includes Amniotomy
and/or Oxytocin infusion.
Indications for induction of labor:
Maternal indications:
*Post-term (main indication)
*P.I.H (Timing depend )on the severity)
*Diabetes Mellitus (increase risk of baby loss
and mortality rate)
*Medical conditions (as renal, respiratory and
cardiac diseases)
*Placenta insufficiency (as moderate or sever
placenta abruption but commonly C.S)
*Prolonged pre-labor rupture of membranes.
*Rheuses isoimmunization.
*Maternal request.
Continue Indications for
Induction of Labor:
Fetal Indications:
*Suspected fetal
compromise (I.U.G.R )
*Intrauterine death
(I.U.F.D).
Before Induction, the following
conditions must be present:
Sure estimation of weeks
of gestation.
Evidence of fetal maturity.
Absence of cephalopelvic
disproportion.
An engaged head in
longitudinal lie.
Cervix is ready for
delivery.
High score Bishop's
score.
Apply Induction with cautiously
with the following conditions:
Multiple pregnancy.
Hydraminos.
Grand parity.
Maternal age of >35years.
Previous cesarean section.
*Those conditions are at risk for ruptured
of uterus.
Contraindications for I.O.L:
Placenta previa.
Cord presentation or
cord prolapse.
Cephalopelvic
disproportion.
Severe fetal
compromise.
Continue Contraindications for
I.O.L:
Malpresentation
(as transverse
or compound
presentation)
Active genital
herpes infection.
Psychological.
The Bishop score:
Bishop score is producing a scoring system to
quantify the state of readiness of the cervix and
fetus. High scores (a favourable cervix) are
associated with an easier shorter induction.
Cervix
Dilatation of cervix
Consistency of cervix
Score
0
1
2
3
0
1 or 2
3 or 4
5 or
more
Firm
Mediu
m
soft
-
2-1
1-0.5
<0.5
Mid
Anterior
-
-2
-1_0
+1_+2
>2
Length of cervix (cm)
Posterior
Position of cervix
-3
Station of presenting
part
Methods of Induction of Labor:
A)-Medical:
1-Prostaglandins.
2-Oxytocin Infusion.
B)-Surgical:
1-Amniotomy (ARM).
A)-Prostaglandins:
Prostaglandins used when the cervix closed.
Prostaglandins Preparations are available
Vaginal (gel or tablets form), extra-aminiotic,
Intravenous, Oral.
How?
It is inserted close to the cervix within the
posterior fornix of the vagina, then it is
absorbed.
Results:
Prostaglandins results in changes which can be
assessed on vaginal examination, increasing
the Bishop's score.
PGE2 dose should not exceed 6 mg.
Nursing Interventions:
1-Review patient history before admenistiration (to
ensure there are no contraindications or any
caution).
2-Fetal heart rate and uterine contractions should
be monitored continuously for 30-60minutes
after administration. (there is a risk of uterine
hyperstimulation and ruptured of uterus with or
without fetal distress)
3-Instruct woman to pass urine before
administering prostaglandin (because she will
stay for long time in bed)
4-The mother should remain in lateral or supine
position with hip tilt for 30 to 60minutes after
administration of gel, for 2 hours after insertion
of vaginal tablets. (to minimize leakage and
improve effectiveness).
Continue Nursing Interventions:
5-Assess cervical dilatation 6 hours after insertion. (If
no cervical response and no adverse effects, the
dose may be repeated)
6-Monitor side effects of prostaglandins: Pyrexia,
warm feeling in vagina, vomiting, diarrhea, and
back pain.
7-It is necessary to allow at least 2 hours to elapse
between the last prostaglandin dose and starting
Syntocinon infusion, (because Prostaglandin
increase the sensitivity of the uterus to
Syntocinon).
8-If any adverse reactions occur notify doctor to
remove gel or suppository if possible.
B)-Amniotomy (ARM):
It involve the splitting liquor. It can be used
alone or in combination with Oxytocin.
of the amnion and chorion to release the
How?
ARM carried out during a vaginal examination
using an amnihook, a tool with a small hook
at one end, or specialized gloves contain in
one finger hook.
Why?
performed to induce labor, to augment
contractions, to shortening the duration of
labor, to visualize the color of the liquor, or
to attach a fetal scalp electrode for the fetal
heart rate.
When?
ARM done when the cervix is favorable (high
Bishop's score)
Nursing Interventions:
Before ARM:
1-Informed consent obtain.
2-Do abdominal palpation to confirm
fetal presentation, position and
degree of engagement of the
presenting part.
3-Fetal heart rate and uterine
contraction should be noted and
recorded in patient record.
4-Apply Aseptic technique.
Continue Nursing Interventions:
After ARM:
1-The midwife should exclude the presence
of cord prolapse.
2-Note color, odor, consistency, and quantity
of amniotic fluid (to identify if there is any
meconium or blood in liquor).
3-Note presentation, position and station.
4-Monitor temperature q2h (to detect
developing infection).
Continue Nursing Interventions:
After ARM:
5-Clean and dry the perineum and change the
disposable underpad (to remove warm, moist
medium suitable for infection).
6-Monitor strict sterile technique during vaginal
examination and keep vaginal examination at
minimum (to Prevent infection).
7-Maintain bed rest (to decrease chance for cord
prolapse and infection).
8-Monitor ARM hazards: intrauterine infection, early
deceleration, cord prolapse, bleeding (low-lying
placenta).
C)-Oxytocin Infusion:
Oytocin infusion in
an isotonic solution
is used to stimulate
uterine contractions
after rupture of the
membranes. The
dose and increasing
rate depend on each
agency protocols.
Example as
P.S.F.H.protocol:
Time
Rate of 5U Oxy.
(minutes) In 500 ml normal
saline
0
6ml/hr
30
12 ml/hr
60
24 ml/hr
90
48 ml/hr
120
96 ml/hr
Oxytocin (Syntocinon):
Action
Acts directly
on
myofibrils,
producing
uterine
contraction.
Stimulate
milk ejection
by the
breast.
Side effects
Hypo- or
hyper-tention,
dysrhythmia,
Abruptio
placenta,
decreases
uterine blood
flow,
convulsions,
nausea,
vomiting,
Asphyxia for
baby.
Nursing role
1-Assess:
-respiration, BP, Pulse,
-length, intensity, duration
of contraction.
-FHR (acceleration,
deceleration, distress)
-Signs of water
intoxication: (confusion,
anuria, drowsiness,
headache.
2-Teach patient to: report
increase blood loss,
abdominal cramp, fever,
foul-smelling lochia.
Oxytocin Infusion: Preparing And
Administering:
Interventions
Rational
1-Explain procedure.
1-to reduce anxiety
2-Apply fetal monitor
and monitor FHR.
2-To establish baseline
and ensure fetal
activity.
3-To minimizes the risk
of water intoxication.
3-Start an
electrolytes
solution I.V infusion
(primary line)
Continue Oxytocin Infusion:
Interventions
Rational
4-Prepare a second I.V and
add the prescribed amount of
oxytocin (usually
10U/1000ml).
The I.V tubing is inserted into
I.V pump.
4-Oxytocin must be
administered with an
infusion pump to
ensure accurate dose
administration.
5-Connect the secondary line
to the primary line at the port
closest to the needle
insertion site and turn on at
the prescribed rate.
5-If there is an
indication to stop the
oxytocin infusion, it
can be done without
affecting the primary
fluid infusion.
Continue Oxytocin Infusion:
Interventions
Rational
6-Monitor FHR, uterine contraction
(frequency, duration, and intensity),
BP,and Pulse and record at
intervals comparable to the dosage
regimen. All observation and
increases or decreases in oxytocin
are documented on the fetal heart
tracing and mother chart.
6-If uterus become
hyperstimulated, blood flow
to uteroplacental site will be
decreased and fetus will
suffer from hypoxia.
7- Once the desired frequency of
contractions has been reached
(every 2 to 3 minutes and 45 to 60
second's duration. oxytocin may be
stop or reduced the increases of
the rate.
7-Sensitivity to oxytocin
increases as labor
progresses.
These results indicate that
the pattern of normal labor
has been established.
Signs of Hyperstimulation of the uterus:
Contraction occur more frequently than every 2 minutes.
Duration of contraction is longer than 90 seconds.
Elevation of resting tone of uterus is greater than 15 to 20
mmHg over her baseline of intrauterine pressure.
Blood pressure increases when contractions increase in
frequency, duration, and intensity because of decrease in
uteroplacental circulation.
Client experience increasing pain because of increased
frequency, duration, and intensity of contractions.
Sustained tetanic contractions occur.
Signs of Fetal Distress:
Tachycardia or bradycardia.
Late decelerations, variable
decelerations, or prolonged
deceleration.
Loss of variability.
Increased fetal activity.
Excessive molding or caputsuccedaneum formation.
Meconium stained amniotic fluid in
cephalic presentation.
Nursing Interventions if Uterine
Hyperstimulation or Fetal Distress
Occur:
Interventions
Rational
1-Turn off immediately
oxytocin infusion
1-To prevent fetal anoxia
and uterine rupture.
2-Turn woman on her
left side.
2-To improve fetalplacental blood flow.
3-Increase primary I.V
3-To provide adequate
rate up to 200 ml/hr
intravascular volume,
unless contraindicated. support maternal BP, and
I.V route for emergency
medications.
Continue Nursing Interventions if
Uterine Hyperstimulation or Fetal
Distress Occur:
Interventions
Rational
4-Give oxygen 6 to 10 4-To saturate the blood with
l/min ( per protocol)
oxygen as much as possible to
by face mask.
prevent fetal anoxia.
5-Notify doctor
5-This indicate induction
failed. If membrane intact
discontinue induction and
try again later. If
membrane ruptured
cesarean birth may be
necessary.
Other Complications may Occur
during Oxytocin Infusion:
In addition to hyper-stimulation of uterus and
fetal distress those complications may
occur:
Ruptured uterus as a result of overstimulation if any cephalopelvic
disproportion present.
Amniotic fluid embolism is rare which may
caused by strong, tumultuous contractions.
(usually occur in 3rd stage after placenta
separation and with tetanic condition of
uterus)