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Induction of Labour (IOL)

Induction of Labour (IOL). Maternal Newborn Orientation Learning Module Reproductive Care Program of Nova Scotia, 2013. Reproductive Care Program of Nova Scotia, March 2012. http://rcp.nshealth.ca/publications/induction-labour-nova-scotia. Objectives.

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Induction of Labour (IOL)

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  1. Induction of Labour (IOL) Maternal Newborn Orientation Learning Module Reproductive Care Program of Nova Scotia, 2013

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

  3. Objectives Review the following topics related to induction of labour: • Definition, indications, and implications for women and the health care system • Methods, with emphasis on prostaglandin and oxytocin • Practices to promote patient safety

  4. Definitions Induction 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)

  5. What Has Contributed to the Increased Rate of Induction? • Changing demographic • Guidelines interpretation • Maternal choice

  6. Benefits of Induction Induction 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.

  7. Risks of Induction • Inadvertent delivery before term • Prolonged labour • Cesarean Section • Operative vaginal birth • Postpartum hemorrhage

  8. Implications for Women Women 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.

  9. Implications for the Health Care System Cesarean Section: • 8.3% of women with spontaneous labour • 21.7% of women induced Oper. Vaginal Delivery: • 7.1% of women with spontaneous labour • 12.2% of women induced  Healthcare costs

  10. Making the Decision to Induce When 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.

  11. Cervical Readiness for Labour Bishop 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.

  12. Cervical Ripening Cervical ripening: • Mechanical methods – Foley catheter, cervical ripening balloon • Only option for cervical ripening for a woman with a previous cesarean section • Allows simultaneous administration of oxytocin for induction

  13. Cervical Ripening Prostaglandin E2 (PGE2) • Prostin® (vaginal application) – initially 1 mg followed by 2 mg in ≥6 hours, as necessary • Cervidil® (controlled-release vaginal insert) – 10 mg; contraindicated if membranes ruptured • Prepidil® (intracervical administration) – 0.5 mg Risks of PGE2 are tachysystole or hypertonus with or without abnormal FHR and rarely, uterine rupture.

  14. Recommendations 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®.

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

  16. Methods of Induction • Amniotomy / ARM (artificial rupture of the membranes) • Results in increased levels of prostaglandin • Risks include variable decelerations, infection and prolapsed cord • Oxytocin

  17. Oxytocin Oxytocin 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).

  18. Safe Practices Related to Use of Oxytocin • Oxytocin 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

  19. Oxytocin Protocols Low-dose protocol: • initiate at 0.5 to 2 mU/min and increase by 1 to 2 mU/min q 30 to 60 minutes High-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

  20. Electronic Fetal Monitoring The SOGC (2007) recommends: During induction: • Continuous monitoring while the rate of oxytocin infusion is being titrated • Interrupting 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 normal During augmentation: • Continuous monitoring

  21. Recommendations from the RCP QA Review re: Oxytocin • There 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.

  22. Abnormal Uterine Response to Oxytocin Tachysystole – more than 5 contractions in 10 minutes, averaged over 30 minutes Hypertonus – resting tone > 20 to 25 mmHg

  23. Tachystole 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.

  24. Restarting the Infusion AWHONN suggests: • If discontinued for < 30 minutes, the oxytocin should be restarted at ½ the rate at which the adverse response occurred. • If discontinued for > 30 minutes, oxytocin should be restarted at the initial dose.

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

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

  27. Final Messages… • Induction 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.

  28. Thank you! We welcome your feedback. Please take a few moments to complete a short evaluation: http://rcp.nshealth.ca/education/learning-modules/evaluation If you have any questions, please contact the RCP office at rcp@iwk.nshealth.ca or 902-470-6798

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