Induction of Labour

Induction of Labour (IOL)Maternal Newborn Orientation Learning ModuleReproductive Care Program of Nova Scotia, 2013

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Reproductive Care Program of Nova Scotia, March 2012http://rcp.nshealth.ca/publications/induction-labour-nova-scotia

2ObjectivesReview the following topics related to induction of labour:Definition, indications, and implications for women and the health care systemMethods, with emphasis on prostaglandin and oxytocin Practices to promote patient safety

3DefinitionsInduction is the artificial initiation of labour before its spontaneous onset. (SOGC, 2001)Includes those methods applied to stimulate contractions and progress in early labour.Augmentation refers to the process of stimulating contractions when progress in active labour has slowed or stopped.Active labour has begun when contractions that are frequent and/or regular have led to effacement and dilatation of the cervix, at least 3-4 cm. (ALARM, 2012)

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5What Has Contributed to the Increased Rate of Induction?Changing demographicGuidelines interpretationMaternal choice

6Benefits of InductionInduction can enable vaginal birth when delivery is indicated before the onset of spontaneous labour.Medical indications include postterm pregnancy*, diabetes, HDP, PROM (without delay if GBS+), IUGR, chorioamnionitis, suspected fetal compromise, hx of precipitous birth

*Postterm pregnancy is by definition > 42+0 weeks gestation. Induction for postterm pregnancy should not be initiated before 41+0 weeks.

7Risks of InductionInadvertent delivery before termProlonged labour Cesarean SectionOperative vaginal birthPostpartum hemorrhage

Implications for WomenWomen told us during focus groups..Induction allows control.Induced labour is more painful.In 2005 to 2009, 38.3% of women who laboured spontaneously received epidural analgesia; 67.6% of women induced.Labour is less natural during induction; increases likelihood of more interventions.If IOL is followed by C/S, contact with baby at and following birth might be limited.

9Implications for the Health Care SystemCesarean Section:8.3% of women with spontaneous labour21.7% of women inducedOper. Vaginal Delivery:7.1% of women with spontaneous labour12.2% of women induced Healthcare costs

10Making the Decision to InduceWhen the maternal/fetal benefits outweigh the risk of induction (SOGC)Many Labour and Birth Units maintain an induction list with inductions prioritized according to urgency of need for delivery.Additional considerations include gestation or cervical readiness for labour.

11Cervical Readiness for LabourBishop score: Points (0 to 3) are assigned for dilatation, effacement, consistency and position of the cervix, and fetal station. A score of 6 is unfavorable; if delivery is indicated, cervical ripening is recommended as part of the induction.

12Cervical RipeningCervical ripening:Mechanical methods Foley catheter, cervical ripening balloonOnly option for cervical ripening for a woman with a previous cesarean section Allows simultaneous administration of oxytocin for induction

13Cervical RipeningProstaglandin E2 (PGE2)Prostin (vaginal application) initially 1 mg followed by 2 mg in 6 hours, as necessaryCervidil (controlled-release vaginal insert) 10 mg; contraindicated if membranes rupturedPrepidil (intracervical administration) 0.5 mgRisks of PGE2 are tachysystole or hypertonus with or without abnormal FHR and rarely, uterine rupture.

14Recommendations for Care Related to PGE2 Following administration, a minimum of one to two hours of electronic fetal monitoring is suggested.Practices related to outpatient use of PGE2 vary across Canada; in some facilities use of Cervidil requires hospital admission.Oxytocin can be initiated 30 to 60 minutes following removal of Cervidil and 6 or more hours following administration of either Prostin or Prepidil.

15One Final Note about Cervical RipeningMisoprostol (PGE1) is used in the United States; however, it is currently not recommended in Canada except for ripening (and/or induction) following IUFD.

16Methods of InductionAmniotomy / ARM (artificial rupture of the membranes)Results in increased levels of prostaglandinRisks include variable decelerations, infection and prolapsed cordOxytocin

17OxytocinOxytocin binds to receptor cells distributed throughout the myometrium, stimulating contractions.Uterine response to oxytocin is widely variable.Oxytocin is one of 12 high-alert medications identified by the Institute of Safe Medication Practices (ISMP).

18Safe Practices Related to Use of OxytocinOxytocin is administered by IV infusion, ordered and documented in mU/min.The dosage is carefully titrated according to a clearly prescribed protocol, and maternal and/or fetal response.A single protocol should be used consistently by all members of the team.10 units of oxytocin added to 1 litre of R/L or N/S:1 mU/min = 6 ml/hour

19Oxytocin ProtocolsLow-dose protocol: initiate at 0.5 to 2 mU/min and increase by 1 to 2 mU/min q 30 to 60 minutesHigh-dose protocol: initiate at 4 to 6 mU/min and increase by 4 to 6 mU/min q 15 to 30 minutes *Always titrated according to maternal and/or fetal response

20Electronic Fetal Monitoring The SOGC (2007) recommends:During induction:Continuous monitoring while the rate of oxytocin infusion is being titratedInterrupting continuous monitoring for periods of up to 30 minutes (for ambulation, personal care and hydrotherapy) once the infusion is stable and provided the tracing is normalDuring augmentation:Continuous monitoring

Recommendations from the RCP QA Review re: OxytocinThere should be a single protocol for mixing and administering oxytocin within each Labour and Birth Unit.Oxytocin should be initiated at a low dose and maintained at the lowest level possible to induce contractions of normal frequency, strength and duration.The infusion should be reduced or discontinued if adverse effects occur.Care providers should be prepared to reduce the rate as active labour is established.

22Abnormal Uterine Response to Oxytocin

Tachysystole more than 5 contractions in 10 minutes, averaged over 30 minutes

Hypertonus resting tone > 20 to 25 mmHg

23Tachystole or Hypertonus: Recommended Actions The oxytocin infusion should be quickly adjusted downward until a normal contraction pattern (q2-3 minutes with 30-60 seconds of relaxation in between) is reestablished.The infusion should be discontinued if the abnormal pattern persists for 10 minutes or more, or if the FHR becomes atypical or abnormal.

24Restarting the InfusionAWHONN suggests:If discontinued for < 30 minutes, the oxytocin should be restarted at the rate at which the adverse response occurred.If discontinued for > 30 minutes, oxytocin should be restarted at the initial dose.

25True or FalseInduction for postterm pregnancy should be carried out between 40+0 and 41+0 weeks.T FInduction of labour increases the likelihood of having a cesarean section.T FProstin is contraindicated if membranes have ruptured.T FOxytocin infusion should be increased steadily unless FHR decelerations occur.T F

26True or False - AnswersInduction for postterm pregnancy should be carried out between 40+0 and 41+0 weeks.T FInduction of labour increases the likelihood of having a cesarean section.T FProstin is contraindicated if membranes have ruptured.T FOxytocin infusion should be increased steadily unless FHR decelerations occur.T F

27Final MessagesInduction allows for labour and vaginal birth when delivery is indicated prior to spontaneous labour.Careful attention must be made to carrying out induction safely, including administration of induction medications and assessment of maternal and fetal response.Accurate documentation and good communication among team members are essential.

28Thank you!

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