What are your nursing responsibilities during induction of labor?
Prostaglandin preparations are hormonal medications used to promote cervical ripening and desired cervical change Show
To anticipate potential problems associated with the use of prostaglandins The recommended method of oxytocin administration To anticipate potential problems of oxytocin administration The recommended nursing interventions when problems arise with the use of oxytocin or prostaglandins The conditions necessary for safe administering of oxytocin including staffing ratios, assessment frequencies, and medical record documentation for inducing/augmenting labor Key Terms When you have completed this module, you should be able to recall the meaning of the following terms. You should also be able to use the terms when consulting with other health professionals. The terms are defined in this module or in the glossary at the end of this book.
Induction and Augmentation of Labor
Induction of labor is the artificial stimulation of uterine contractions before spontaneous onset of labor for the purpose of accomplishing vaginal birth. The goal of labor induction is to achieve vaginal delivery.
Before 41 0/7 weeks’ induction of labor should generally be performed based on maternal or fetal indications. After 41 0/7 weeks’ induction of labor should be performed to reduce the risk of cesarean and the risk of perinatal morbidity and mortality.
Augmentation of labor is the stimulation of uterine contraction when spontaneous contractions have failed to result in progressive cervical dilatation or descent of the fetus. Since uterine activity is characterized by frequency, intensity, and duration of contractions, it may be desirable to augment these forces in a patient who is in labor but not progressing adequately.
Oxytocin is a hormone, a peptide consisting of nine amino acids that is synthesized by the hypothalamus then transported to the posterior pituitary gland where it is released into the maternal circulation in a pulsatile fashion. Oxytocin is released in response to breast stimulation, cervical stretching, and stimulation of the lower genital tract. Oxytocin released in response to vaginal and cervical stretching results in uterine contractions. Oxytocin is the most common pharmacologic agent used for both induction and augmentation of labor in the United States. It is also the hormone responsible for the “let down” of milk from alveolar cells in the breast during the postpartum period.
Oxytocin increases free intracellular calcium, which is essential for smooth muscle activity. To exert its effect, oxytocin must bind with the oxytocin receptors. Oxytocin receptors in the uterus increase throughout gestation to reach their maximal levels at term. In fact, oxytocin receptors at term are increased 300 times over nonpregnant level. Additionally, the increase of actual receptors is also accompanied by an increase in uterine responsiveness to oxytocin at term., It is important to note that although oxytocin is an effective induction agent for women with a favorable cervix, it is not effective as a cervical ripening agent.
The pharmacokinetic half-life of oxytocin is generally accepted to be between 10 and 12 minutes.,,, Three to four half-lives of oxytocin are needed to reach steady-state plasma concentrations. Uterine response to IV oxytocin administration occurs within 3 to 5 minutes of IV administration, and within 40 minutes a steady-state plasma concentration is achieved. This information led Seitchik et al. to recommend at least a 40-minute interval between increases of oxytocin to allow time for the oxytocin to reach a steady state and exert its full effect on the uterus. This dosing regime is intended to prevent women from receiving higher doses of oxytocin than are necessary. Risks associated with oxytocin are generally dose related and the most common side effect is tachysystole. While oxytocin is the most common medication used for labor induction and augmentation, it is also the drug most commonly associated with preventable adverse events during childbirth.
Tachysystole is now the preferred term to describe excessive uterine activity. Tachysystole is defined as:
NOTE: Other terms like hypertonus and hyperstimulation are not well defined and should be avoided. Common Techniques for Induction and Augmentation of Labor Common methods of inducing or augmenting labor include the following:
Amniotomy is done when the cervix is effaced and dilated. The head of the fetus should be against the lower uterine segment and at least dipping into the pelvis. It is essential to confirm the fetal vertex is the presenting part. Risks include umbilical cord prolapse, cesarean section, variable decelerations, intra-amniotic infection, fetal injury, bleeding from undiagnosed vasa previa, and commitment to labor with uncertain outcome, cesarean birth. Early amniotomy is contraindicated when there is maternal infection, such as HIV or viral hepatitis.
Medical Indications for Induction/Augmentation of Labor Indications for induction of labor are not absolute and should take into consideration maternal and fetal conditions, gestational age, cervical status, and other factors. The following are examples of maternal and fetal conditions that may be indications for induction of labor:
Prerequisites for Induction/Augmentation of Labor
The woman should not have any of the contraindications for induction/augmentation. In addition it is recommended that the following occur,:
Initiating an elective induction of labor for reasons of convenience, although very common, should not be encouraged by healthcare providers or hospitals. The pregnant woman should be at least 39 completed weeks’ gestation to avoid the risk of iatrogenic prematurity. Healthcare providers should discuss the risks and benefits with the patient prior to admission. Perinatal nurses should confirm the woman has been fully informed of the risks, benefits, and alternatives. (See ) FIGURE 8.1 Induction of Labor Checklist. (Adapted from Patient Safety Checklist from ACOG No 5: Scheduling Induction of Labor.) Display 8.1 Contraindications to Induction/Augmentation Vasa previa Complete placenta previa Transverse fetal lie Umbilical cord prolapse Previous classical cesarean delivery Active genital herpes infection Previous myomectomy entering the endometrial cavity
No, although induction and augmentation have become a safer procedure for both women and their fetuses, there are some women for whom induction and augmentation carry an unacceptable risk. Contraindications for Induction/Augmentation of Labor Listed in Display 8.1 are clinical situations in which induction/augmentation should not be attempted. This list is the same as the clinical situations contraindicated for spontaneous labor and vaginal birth.
KEEP IN mind: For indeterminate fetal status (category II or category III FHR tracing) each contraction of the uterus, decreases blood circulation and oxygen supply to the placenta and the fetus. Because oxytocin increases the intensity and frequency of the contractions, there can be an even greater interruption of oxygen to the fetus. If the fetus shows signs of stress, it might not be able to tolerate the additional intensity of induced/augmented contractions. Conditions That Require Special Attention during Induction/Augmentation There are some situations in which induction/augmentation of labor might present problems. These women require careful administration of a uterine stimulant and close monitoring (Display 8.2).
Display 8.2 Relative Contraindications to Induction/Augmentation Trial of labor after a previous cesarean Presenting part not engaged in pelvis Severe maternal hypertension Grand multiparity Multiple gestations Polyhydramnios Abnormal or indeterminate fetal heart rate patterns (not requiring emergent intervention) Maternal heart disease
Active management of labor (AML) is an augmentation protocol used in many institutions as a strategy to decrease cesarean births for labor dystocia. The goal is to establish effective contractions and accomplish a vaginal delivery within 12 hours of admission. Although active management is often considered a high-dose oxytocin protocol, it is really a labor management protocol and oxytocin administration is just one component of a whole program of labor. The term active management of labor is interpreted differently from one institution to another. Many of the protocols are based on the belief that once labor had been diagnosed, the rate of cervical dilatation should be 1 cm/hr. Two key management strategies are: if cervical dilatation does not progress at least 1 cm/hr, oxytocin augmentation is initiated, and if membranes have not spontaneously ruptured within 1 hour after labor has been diagnosed, amniotomy is performed. The original protocol was developed in Dublin, Ireland, to shorten labor and conserve resources in maternity hospitals. All aspects of their protocol are not included in many U. S. hospitals. The following criteria are used for identification of patients for inclusion in AML protocols. What is your nursing responsibility as a nurse in monitoring progress of labor?Monitor the vital signs of the mother and the heart rate of the baby; Monitor for potentially dangerous complications of medications commonly given during labor and delivery; Communicate with the doctor to provide timely and accurate information; Identify complications and notify the doctor; and.
What are the nursing care of the client experiencing labor and delivery process?The nursing care plan for a client in labor includes providing information regarding labor and birth, providing comfort and pain relief measures, monitoring the client's vital signs and fetal heart rate, facilitating postpartum care, and preventing complications after birth.
What are the nursing responsibilities when a patient arrives to the hospital in active labor?If you arrive at the hospital in labor, a labor and delivery nurse will ask you questions about your contractions, check your vital signs, assess your contractions, and see how your baby is doing. He or she might also do a vaginal exam to check your cervical dilation.
What nursing responsibilities are involved during the administration of oxytocin during labor?Now, nurses are responsible for safely administering oxytocin during labor, avoiding excessive stimulation to the uterus or harm to the fetus. So, before starting the infusion, be sure to review the client's medical record to be sure there are no contraindications to administration.
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