Labor Variations

Cervical Ripening 

A process that prepares the cervix for labor induction 

Laboe induction

A procedure that stimulates contractions to start labor

augmentation

stimulates uterine contractions after labor has already started

Induction of Labor (IOL)

artificial initiation of labor before spontaneous onset.

When is induction of labor useful?

when benefit of delivery outweighs benefit of a continued pregnancy

Nursing role of induction of labor

Ensure well-documented discussion of risks, benefits and alternatives (r/b/a)

○ Include rationale for induction, method of induction and risks

Maternal indications

○ Premature rupture of membranes (PROM)

○ Hypertensive disorders of pregnancy

○ Gestational Diabetes

○ Post-term pregnancy

○ Elective

○ Many more

Fetal indications

● Post-term pregnancy

● Maternal diabetes (pre-gestational or insulin dependent)

● Fetal growth restriction (FGR)

● Macrosomia

● Oligohydramnios

● Many more

IOL Contraindications

● Complete placenta previa- placenta covering the cerix, risk of bleeding

● Non Cephalic presentation

● Previous classical cesarean (usually)

● Prior uterine rupture

● Active genital herpes

what can we do if we can’t induce labor?

c section

Starting an Induction: Vaginal Exam

● Palpation of cervix

● Presentation

● Position

● Membranes

● Pelvic assessment

● Fetopelvic relationship

What number on the bishop score requires a cervical ripening

6 or less

Bishop score minimum and maximum

0-15

dilation

the gradual opening of the cervix measured in centimeters from 0-10 cm

Mechanical ripening methods

cervical ripening balloons work by applying direct pressure to the internal cervical os, stimulating endogenous prostaglandin release and promoting mechanical cervical dilation

• foley balloon

• cook balloon

Foley Balloon:

A single balloon filled with saline that gently stretches the cervix to help it open. It’s affordable and commonly used.

Cook Balloon

Has two balloons—one inside and one outside the cervix—for more even pressure. It may be easier to place and can be more effective in some cases

pharmacologic methods if cervical ripening

•Prostaglandins:

•help soften and open the cervix by triggering inflammatory responses. They increase cytokines like interleukin-8, which attract white blood cells and promote collagen breakdown and tissue remodeling

• cervidil (dinoprostone)

• misoprotol (cytotec)

• contraindiacation c section

Contraindications of pharmacologic method

previous c section/uterine surgery

• risk tachsystole (uterine hyperstimulation) 

Cervidil (Dinoprostone)

vaginal insert that releases prostaglandins slowly to soften and dilate the cervix.

•Considered gentler and more controllable, with fewer risks of uterine overstimulation

Misoprostol (Cytotec)

Used off-label for labor induction. It’s a tablet (oral or vaginal) that acts faster and is more potent, but carries a higher risk of uterine hyperstimulation

Adverse Effects of Prostaglandins

tachysystole can occur with overstimulation

Nursing interventions Adverse Effects of Prostaglandins

• position change—sideline

• Monitor breathing, HR, BP

• discontinue cervidil (if applicable)

• turn off pitocin (if running)

• fluid bolus- rehydrates the body and muscle. dilutes the medication

K.H is a 28 year old G1P0 who presents to L&D for induction of labor due to pre-eclampsia without severe features at 37w0d. Her cervix is assessed by the nurse and found to be 1cm/50%/-3, posterior, firm.

○ What is her bishop score?

○ Does she need cervical ripening?

2

yes less than 6 

Z.B is a 33 year old G2P1001 at 41w2d who presents for IOL due to post-term pregnancy. Her cervix is assessed to be 3cm/70%/0, mid, soft.

○ What is her bishop score?

○ Does she need cervical ripening?

9

no 

Which of the following patients is NOT a candidate for cervical ripening with

prostaglandins?

A. G1P000, gestational diabetic this pregnancy

B. G2P1001, first baby born via cesarean section

C. G2P1001, first baby born vaginally

G2P1001, first baby born via cesarean section

Methods of augmentation

○ Pitocin (most common)

○ Artificial rupture of membranes (AROM)

Pitocin route

IV

Pitocin

is a synthetic version of oxytocin (natural labor inducer produced by the body), used for labor induction.

○ It works by binding to oxytocin receptors in the uterine muscle, triggering rhythmic contractions that help dilate the cervix

effect of pitocin

causes uterine contractions

dangers of pitocin

○ Tachysystole

○ Uterine rupture

○ Uterine atony and PPH

○ Fetal distress

IV Oxytocin (Pitocin) Infusion

Hung as a secondary line

○ Should be inserted into the primary (maintenance) IV line as close as possible to the venipuncture site (proximal port) to limit the amount of drug infused after stopping it

○ Start at a low dose, and increase every ~30 minutes until uterine contractions are regular (check facility protocol)

Nursing considerations when giving pitocin

○ Monitor patient’s BP and HR q30 minutes (or per site protocol)

○ Must do continuous monitoring of fetal HR and contractions

Pitocin use and non-reassuring fetal heart tones

● Reduce or Stop Pitocin infusion

● Increase rate of primary IV line (typically LR)

● Move patient to side-lying position

● Continue to assess fetal heart rate and contractions

● Administer Terbutaline (tocolytic) if ordered (stops contractions)

Artificial rupture of membranes (AROM) via Amniotomy risk

○ Cord prolapse

■ If fetal head not well engaged cord can slip when fluid is relased leading to cord compression and reducted fetal oxygenation

○ Chorioamnionitis (infection)

■ Protective barrier now gone, particularly with frequent vaginal exams

○ Fetal Distress

Artificial rupture of membranes (AROM) via Amniotomy reasons to use

Labor induction/Augmentation

■ Other: Internal fetal monitoring needed

Artificial rupture of membranes (AROM) via Amniotomy procedure 

Amnihook perforated amniotic sac

Nursing role with amniotomy (AROM)

○ Fetal Heart Rate:

■ Obtain baseline fetal heart rate tracing (20-30 min) before procedure

■ Monitor fetal heart rate for at least 1 full minute after procedure; report abnormal finding to provider immediately (I advise more time)

○ Provide supplies: towels, amnihook, sterile glove, sterile lubricant

○ Chart color, quantity, and odor of fluid

○ Assess for signs of infection

■ Take patient’s temperature on interval determined by unit

● Report temp > 100.4 F

■ Monitor for fetal tachycardia (sustained rate >160 bpm)

types of vaginal delivery

• vacuum 

• forceps

indication for vaginal delivery

• Prolonged second stage of labor

• Maternal exhaustion or medical conditions limiting pushing

• Signs of fetal distress requiring expedited deliver

mechanism forceps delivery

Metal instruments are placed around the baby’s head to guide it out during contractions

benefits forceps delivery

Offers strong traction and control, especially useful for rotating the baby’s head

risk of forceps delivery

Higher chance of maternal perineal tears and fetal facial injuries (e.g., bruising, nerve palsy

vacuum delivery mechanism 

A suction cup is placed on the baby’s head to assist with pulling during

contractions

vacuum delivery benefits 

Easier to learn and less invasive for the mother

vacuum delivery risk 

Increased risk of fetal scalp injuries like cephalohematoma, intracranial fetal

hemorrhage, and jaundice, also higher risk of maternal perineal tears

Operative vaginal- RN considerations mother

● Patient’s bladder should be empty (typically by straight cath)

● Assess FHR

● After birth, observe for trauma of patient or baby

● Cold application to perineum/ vagina for the first 12 hours may reduce pain and limit bruising and edema

Operative vaginal- RN considerations newborn

○ Assess for skin breaks; if present, keep them clean

○ Assess for facial asymmetry that may suggest nerve injury (typically temporary)

○ Assess for neurologic abnormalities such as seizures which suggest intracranial hemorrhage, hypoglycemia, or sepsis

○ Scalp edema after vacuum extraction is common; facial bruising after forceps is common

■ Both will resolve without treatment

TOLAC

trial of labor after cesarean

VBAC

-vaginal birth after cesarean

TOLAC trial of labor after cesarean

○ Small, but significant risk of uterine rupture (1/100)

○ Advised in setting with access to emergency services: OR, anesthesia

○ Prostaglandin cervical ripening methods contraindicated

○ Pitocin can be used

○ Electronic fetal monitoring needed

TOLAC benefits

● Lower Maternal Risk:

○ Successful TOLAC (resulting in VBAC) is associated with less bleeding,

fewer infections, and shorter recovery time compared to repeat cesarean delivery.

● Fewer Future Complications:

○ VBAC reduces the risk of placenta previa, placenta accreta, and surgical complications in future pregnancies.

● Avoids Major Surgery:

○ TOLAC offers a chance to avoid another cesarean, which is a major abdominal surgery with its own risks.

● Supports Birth Preferences:

○ It allows birthing individual who prefer vaginal birth the opportunity to achieve that goal.

● Reduces Cesarean Rates:

○ On a population level, successful TOLAC helps lower overall cesarean

delivery rates, which benefits maternal health systems.

Episiotomy

A small surgical cut made in the perineum during vaginal delivery to widen the opening

Episiotomy risk

pain, infection, and longer healing time

Episiotomy benefit

prevent severe tearing or speed up delivery in emergencies.

External Cephalic Version (ECV)

A procedure done around 37 weeks to manually turn a breech baby to a head-down position

External Cephalic Version (ECV) benefits

Can reduce the need for cesarean delivery and increase chances of vaginal birth

External Cephalic Version (ECV) risk

low but may include fetal distress or emergency C-section in rare cases

C section indications that occur 50% of the time

• labor dystocia 

• abnormal/indeterminate fetal heart rate tracing 

c section indications

○ Labor dystocia

○ abnormal/indeterminate fetal heart rate tracing

○ Fetal malpresentation

○ Multiple gestation

○ Suspected macrosomia

○ Active genital herpes

○ Various placental abnormalities (complete previa, vasa previa)

○ Cord prolapse

○ Elective/Repeat cesarean

○ More

c section risk

○ Major hemorrhage

○ Uterine rupture

○ Anesthetic complications

○ Shock

○ Cardiac arrest

○ Infection

○ Wound disruption

○ Injury to newborn

C/S: pre-op nursing interventions

● Assess time of last oral intake

● Allergies

● Current medications (including last dose)

● Informed consent must be signed

● Obtain lab work: CBC, blood type and screen

● Pre-op teaching

● Start IV and bolus

● Clip abdominal hair

● Administer prep-op antibiotic (Ancef typical)

● Administer ordered medication to control gastric secretions

○ Commonly Bicitra or pepcid

● Insert catheter

● Assist patient onto the table; place wedge under hip

● Apply grounding pad for electrocautery

● Do sterile prep of abdomen