induction of labour pres mutai
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HNS221 Assignment: induction of
labour1. MBOGORI MAURICE MURUGU P30/1088/2010
2. MUTAI K. JOSPHAT P30/1073/2010
3. NGARI DENNIS MUGAMBI P30S/7174/2010
4. MURIITHI PATRICK MUGAMBI P30/1027/2009
5. MUITA KENNEDY MUNIKO P30/1085/2010
6. MAPESA AMOS P30/1745/2010
7. KIRUI MOSES P30/1083/2010
8. KHALAYI ELIZABETH NAFULA(GROUP REP)
P30S/7160/2010
Tuesday, April 03, 2012 courtesy of group 9 1
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labour
The process of uterine contractionsleading to progressive effacement anddilatation of the cervix and birth of the
baby
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Induction of labour
Artificial stimulation of uterine contractionsbefore spontaneous onset of labour withthe purpose of accomplishing successful
vaginal delivery
This includes both women with intactmembranes and women with spontaneous
rupture of the membranes but who are notin labour.
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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.
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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)
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-PROM
-Postterm preg
-Abruptio placenta-Medical conditions-DM,Heart ds, Renal ds
- significant APH(urgent)
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Fetal (usually for pregnancy termination due
to significant fetal compromise)
IUFD
Fetal anomaly incompatible with life
Severe IUGR(urgent0
Rh isoimmunisation Macrosomia
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Isoimmunization
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Logistical:
History/risk of rapid labors
Distance from hospital
Psychosocial indications
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Severe hydrocephalous
Hx of uterine surgery involving myometrium
Genital herpex infection
Cervical cancer
Distorted maternal size
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Complications for Induction of Labour
Maternal
Emotional: fear, anxiety
Uterine inertia ;
prolonged labour
Intrapartum infection
Violent labour ;
abruptio placentae;
uterine rupture;
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Complications ctnd.
cervical laceration
Hypofibrinogenaemia
Amniotic fluid embolism Postpartum haemorrhage
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Complications for Induction of Labour
Fetal
Hypoxia
Iatrogenic prematurity [wrong dates]
Prolapse cord
Infection
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Indications for Augmentation
Uterine hypocontractility, after the maternal
pelvis and fetal presentation have been
assessed
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Contraindications for Augmentation
Placenta or vasa previa
Umbilical cord presentation
Prior classical uterine incision
Active genital herpes infection
Pelvic structural deformities
Invasive cervical cancer
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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.
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A predictive method of an outcome of labour isknown as Bishops Core.( was described byBishop 1964).
Highest score= 13
A score of 9 indicates a high likelihood forsuccessful induction. Await for spontaneouslabour.
A score< 6- ripen the cervix
Bishop score of
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Bishop scoring system used for
assessment of inducibilityFactor
score Dilatation(cm) Effacemen
t (%)
Station(-3 to
+3)
Cervix
consistency
Cervix
position
0 closed 0-30 -3 Firm Posterior
1 1-2 40-50 -2 Medium Mid-
position
2 3-4 60-70 -1 Soft Anterior
3 5 >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
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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
infusiono Hygroscopic cervical dilators
o Membrane stripping
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Methods of ripening cervix
Cervical massage is done. It help in release oflocal prostaglandin
Stripping/sweeping the membranes and time
is allowed for ripening at 41wksProstaglandin E2 eg misoprostol ,dinoprostone
are given vaginaly. 12hrs is allowed for cervical
ripeningFoleys catheter inserted through the cervix
and placed in the extra-amniotic space
Tuesday, April 03, 2012 22courtesy of group 9
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Walking
Forced cervical dilatation
Whatever method used > works byrelease of prostaglandins
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1.prostaglandins
M/A :Act on the cervix to enable ripeningby a number of different mechanisms.
They alter the extracellular groundsubstance of the cervix, and PG increasesthe activity of collagenase in the cervix.
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Moa of prostaglandis ctd..
They cause an increase in elastase,glycosaminoglycan, dermatan sulfate, andhyaluronic acid levels in the cervix. A
relaxation of cervical smooth musclefacilitates dilation.
prostaglandins allow for an increase in
intracellular calcium levels, causingcontraction of myometrial muscle
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1a.Prostaglandin E2
administered intracervically or vaginally
0.5mg intracervically; 10mg vaginal insertion
Should be administered at or near labor anddelivery/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
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Complication uterine hyperstimulation
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1b.Prostaglandin E1
Misoprostol (Cytotec) is a tablet containingprostaglandins.
Should be administered at or near the labor
and delivery/birthing suite to allowcontinuous monitoring of fetal and uterinestatus.
Uterine hyper-stimulation is a complication Oxytocin is administered 4hrs after the last
dose.
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2.Stripping the Membranes
Stripping of the membranes causes anincrease in the activity of phospholipaseand prostaglandin as well as causing
mechanical dilation of the cervix, whichreleases prostaglandins. The membranesare stripped by inserting the examiningfinger through the internal cervical os and
moving it in a circular direction to detachthe inferior pole of the membranes fromthe lower uterine segment
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Risks of this technique include
infection,
bleeding,
accidental rupture of the membranes,
and patient discomfort
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Complications include
maternal/fetal infection,
PPROM,
umbilical cord prolapse,
precipitous labor and birth, and
personal discomfort
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Before induction;
Obtain a 20-minute NST to assess fetal well-
being.
Evaluate maternal vital signs, especially BP.
Evaluate the patency of the I.V. site, if I.V.
ordered
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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
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Methods of induction
NATURALBreast/nipple stimulationSexual intercourseMembrane stripping
AmniotomyAcupuncture/acupressure
MECHANICAL
Balloon cathetersLamineria tentsSynthetic osmotic dilators
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CHEMICAL
NONHORMONAL Herbs,evening primrose oil Homeopathic prep
Enemas Castor oil
HORMONAL Oxytocin
ProstaglandinsPGE2,Misoprostol Relaxin Nitric oxide donors mifepristone
A Amniotomy (Artificial Rupture of
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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 beclear or cloudy without odor.
FHRs are assessed continually for at least the
next 20 minutes
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Complications include;
umbilical cord prolapse or compression,
maternal or fetal infection,
and/or distorted fetal head
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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.
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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,
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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.
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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 41courtesy of group 9
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After the Administration of Oxytocin
Continuously monitor FHR and uterineactivity, especially uterine resting tone,frequency, and duration.
Assess maternal vital signs. Temperature istaken every 2 to 4 hours, unless an amniotomyhas been performed, and then every 1 to 2hours.
Limit vaginal examinations, especially after themembranes have ruptured.
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Maintain intake and output records, and
watch for signs of water intoxication
(dizziness, headache, confusion, nausea,
vomiting, hypotension, tachycardia, decreasedurine output)
Evaluate I.V. site for patency and rate control
for correct rate at least hourly.
Nursing Diagnoses during induction of
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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
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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
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2. Promoting Tissue Perfusion and OxygenSupply to Fetus
Assess fetal status and uterine contractionsthrough the use of a monitor or
auscultation/palpation. Assess for signs ofuteroplacental insufficiency (decreasedvariability, abnormal baseline FHR, latedecelerations).
Place patient in lateral position to enhanceplacental perfusion.
.
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Have oxygen set up with a mask ready, andadminister as prescribed (8 to 12 L/minute byface mask) if decelerations occur.
If hyperstimulation of the uterus or fetalcompromise (late decelerations,nonreassuring variable decelerations, orabsent STV) occurs, discontinue the infusion,
maintain the primary I.V., and notify thehealth care provider immediately.
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Administer adequate fluid volume
3. Controlling Pain
Encourage use of breathing techniques,
distraction, and nonpharmacologic comfortmeasures.
Administer analgesia/anesthesia as
prescribed. Maintain positive outlook and support as
labor progresses
E l i E d O
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Evaluation: Expected Outcomes
Verbalizes understanding of the induction
process
No evidence of hyperstimulation or fetal
compromise
Labor progressing with pain controlled
i d i i d i
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nursing management during induction
of labour.
Explain and weigh with the mother the risk ofinduction verses risk of expectant management
Explain available methods advantages and their
disadvantages +cost. Give a written formalexplanation for later reading
obtain consent and reassess appropriacy vaginaldelivery
Reassess your knowledge and skills in entiremethods of induction, there sequence andcontraindication
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Nursing mgt ctd.
Anticipate complication and be ready to respondappropriately
ensure asepsis during the procedure to preventinfections
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 reducechances of PPH
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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
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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
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KEY POINTS
Risks of of induction should be weigh with continuingwith 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 apost date, it si reasonable to consider a conservativeapproach
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Key points ctd
Membrane sweep involve dilating the cervix andseparating the membranes from lower uterinesegment prior to induction of labor
Ant-progestrone eg mifepristone but not clinicallyused can be used to ripen cervix in combinationwith misoprostol
In extra amniotic saline infusion volume should
be limited to 1500mlNever induce labor in presences of uterine
contractions/activity
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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
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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
.11. Mogwan, Brian a.(2009) clinaical
obstetrics and gynaecology. Elsevier
.22. Sabaratnam, arulkumaran(2004),essentials of obstetrics. jaypee