Chapter 19 Notes: Labor Induction, Augmentation, and Related Procedures

Amniotomy (AROM)

  • Purpose

    • Often done in conjunction with induction of labor

    • Enables internal electronic fetal monitoring (EFM)

  • Risks

    • Prolapse and compression of the umbilical cord

    • Infection risk increases the longer the membranes have been ruptured (chorioamnionitis)

    • Abruptio placentae risk if polyhydramnios

  • Technique

    • Amnihook

  • Nursing considerations

    • FHR assessed with Doppler or EFM

    • Document color, quantity, odor of amniotic fluid

Labor Induction and Augmentation

  • Definitions

    • Induction: stimulating contractions via medical or surgical means

    • Augmentation: enhancing ineffective contractions after labor has begun

  • Indications

    • Prolonged gestation

    • Prolonged premature rupture of membranes (PROM)

    • Gestational hypertension

    • Cardiac disease

    • Renal disease

    • Chorioamnionitis

    • Dystocia

    • Intrauterine fetal demise

    • Isoimmunization

    • Diabetes

  • Contraindications

    • Placenta previa

    • Vasa previa

    • Abnormal presentation

    • Umbilical cord prolapse

    • Previous uterine surgery

    • Nonreassuring fetal heart rate patterns

  • Therapeutic management

    • Bishop’s score (see next slide)

    • Herbal agents, castor oil, hot baths, enemas

    • Sexual intercourse with breast stimulation

    • Cervical ripening

    • Mechanical methods ( Foley catheter in cervix )

    • Surgical methods (stripping membranes, AROM)

    • Intravaginal prostaglandins for cervical ripening (Cervidil, Cytotec, misoprostol) – may also start contractions

    • Oxytocin (Pitocin) – for induction or augmentation

Bishop’s Scoring System

  • Induction considered favorable with higher scores (5 or higher for multiparas; 7 or higher for primiparas)

  • Scoring table:

    • Dilation: 0 cm → 0; 1–2 cm → 1; 3–4 cm → 2; 5–6 cm → 3

    • Effacement: 0%–30% → 0; 40%–50% → 1; 60%–70% → 2; ≥80% → 3

    • Fetus station: −3 → 0; −2 → 1; −1 or 0 → 2; +1 or +2 → 3

    • Cervical consistency: Firm → 0; Medium → 1; Soft → 2

    • Cervical position: Posterior → 0; Middle → 1; Anterior → 2

  • Note: Higher scores indicate a more favorable cervix for induction

Adverse effects of pitocin

  • Possible adverse effects: extnausea,extvomiting,extcardiacarrhythmias,extuterinehypertonicity,exttetaniccontractions,extuterinerupture(withexcessivedosages),extseverewaterintoxication,extfetalbradycardiaext{nausea}, ext{vomiting}, ext{cardiac arrhythmias}, ext{uterine hypertonicity}, ext{tetanic contractions}, ext{uterine rupture (with excessive dosages)}, ext{severe water intoxication}, ext{fetal bradycardia}

Signs of Tachysystole

  • Contractions lasting longer than 90 seconds

  • Contractions occurring less than 2 minutes apart (more than 5 contractions in 10 minutes)

  • Uterine resting tone above 20 mm Hg or peak pressure higher than 90 mm Hg during first-stage labor

  • Montevideo units greater than 400400

  • FHR pattern of late decelerations accompanying hypertonic uterine activity

Nursing Actions for Tachysystole

  • Stop or reduce oxytocin infusion (and LIONJ: Left lateral, Increase IV fluids, Oxygen, Notify provider)

  • Additional steps (as per protocol):

    • Increase rate of the primary nonadditive infusion

    • Turn the patient to the left lateral position

    • Administer oxygen via snug facemask (8–10 L/min)

    • Notify the physician or nurse midwife

    • Assess fetal status and uterine activity continuously

Labor Induction and Augmentation: Assessment and Management

  • Nursing Management

    • Calculate dosage of Pitocin and maintain IV infusion

    • Pitocin run on its own IV pump channel, attached to a mainline IV at the hub closest to the patient

    • Frequent monitoring of maternal vital signs and uterine activity

    • Continuous EFM

    • Pain relief and support

  • When to turn Pitocin off

    • Fetal distress

    • Uterine tetany (contractions > 90 seconds)

    • Uterine hyperstimulation/tachysystole (contractions < 2 minutes apart)

    • In addition to stopping Pitocin: turn woman on left side, provide oxygen with a non-rebreather mask, and give a fluid bolus

Monitor: Contraction assessment

  • Components to monitor: duration (in seconds), time between contractions

  • Contraction phases:

    • Acme (peak)

    • Beginning

    • End

    • Increment/decrement (rise and fall in intensity)

    • Duration (length of each contraction)

    • Frequency (how often contractions occur)

    • Period of relaxation (between contractions)

Version

  • External version (cephalic presentation change by external manipulation)

    • External cephalic version (ECV) performed at 37 weeks gestation or later

    • Effectiveness about 58% of the time

    • Internal version used to change presentation of the second twin after the birth of the first

  • Pre-procedure considerations

    • Ultrasound and NST performed prior to procedure

    • A tocolytic is administered to relax the uterus

    • A saline lock may be placed in case of emergency

    • Observation with EFM for an hour after procedure

    • RhoGAM is given if mom is Rh− (to prevent Rh isoimmunization)

  • Risks

    • Uncommon but can include fetal compromise and need for cesarean birth (cord entanglement, abruptio placentae)

Amnioinfusion

  • Definition: Technique in which warmed, sterile normal saline or Ringer’s lactate is infused transcervically through an intrauterine pressure catheter to increase amniotic fluid volume when oligohydramnios is present

  • Indications

    • Severe variable decelerations due to cord compression

    • Oligohydramnios due to placental insufficiency

    • Postmaturity or rupture of membranes

    • Preterm labor with PROM

    • Thick meconium fluid

  • Protocols

    • No universal standard protocol; follow institutional guidelines

    • Typical infusion: 250–500 mL warmed NS or LR over 20–30 minutes

  • Nursing Management

    • Assess contractions, FHR, leakage, intake/output

    • Provide patient teaching; prepare for possible cesarean birth

Forceps- or Vacuum-Assisted Birth (operative vaginal birth)

  • Definition: Application of traction to fetal head

  • Indications

    • Prolonged second stage of labor

    • Nonreassuring FHR pattern

    • Failure of presenting part to fully rotate and descend

    • Limited sensation or inability to push effectively

    • Presumed fetal jeopardy or fetal distress

    • Maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, infection

  • Risks

    • Tissue trauma to mother and newborn

  • Pre-procedure preparation

    • Mother’s bladder should be emptied via catheterization prior to procedure

    • Prevention is key

Trauma Associated with Operative Delivery

  • Maternal trauma: Laceration, hematoma, ecchymosis, lacerations, abrasions, facial nerve injury

  • Infant trauma: Intracranial hemorrhage or subgaleal hematoma

Cesarean Birth (C‑section)

  • Definition: Major surgical procedure with accompanying risks

  • Nursing assessment: history and physical examination for maternal and fetal indications

  • Indications: see list below

Possible Indications for Cesarean Section

  • Active genital herpes

  • Fetal macrosomia

  • Fetopelvic disproportion

  • Prolapsed umbilical cord

  • Placental abnormality (placenta previa or abruptio placentae)

  • Previous classic uterine incision or scar (vertical uterine incision)

  • Eclampsia

  • Fetal indications include:

    • Malpresentation (nonvertex presentation)

    • Congenital anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects)

    • Fetal distress

    • Diabetes

    • HIV

Categories of cesarean sections

  • Categories

    • Elective: Scheduled

    • Urgent / Emergency

  • Category 1

    • Decision to delivery interval: < 30 min

    • Indications: Fetal distress/persistent fetal bradycardia; cord prolapse; severe placental abruption; antepartum hemorrhage with maternal hypovolemia; uterine rupture and scar dehiscence; failed instrumental delivery with fetal distress

  • Category 2

    • Decision to delivery interval: 30–45 min

    • Indications: APH without maternal hypovolemia; failed induction of labor; abnormal Doppler; nonreassuring CTG; previous LSCS in labor; CPD; Breech in early labor; LSCS on demand

  • Category 3

    • Decision to delivery interval: 45–75 min

  • Category 4

    • Decision to delivery interval: no specific time (> 75 min)

Preoperative and Intraoperative Nursing Care (Cesarean)

  • Pre-Op considerations (as urgency allows)

    • Last oral intake, allergies, meds taken

    • Consent forms

    • Labs (CBC, PT, PTT, blood type and screen or cross-match)

    • Pre-op teaching

    • Electric shave or clip operative site

    • Start IV

    • Give pre-op meds as ordered (famotidine or sodium citrate to reduce stomach acid, prophylactic IV cephazolin)

    • Assist with transfer to OR, positioning, epidural or spinal

    • Insert Foley catheter

    • Prep and draping

    • Grounding pad for electrocautery

    • Notify nursery personnel

    • Assist with time-out

    • Function as circulating nurse

Incisions for Cesarean Birth

  • Skin incisions

    • Vertical skin incision

    • Advantages: Quicker to perform; better visualization of uterus; can quickly extend upward for greater exposure; often more appropriate for obese women

    • Disadvantages: Easily visible when healed; greater risk of dehiscence and hernia formation

    • Pfannenstiel (low transverse) incision

    • Advantages: Less visibility when healed; pubic hair regrows; less chance of dehiscence or hernia formation

    • Disadvantages: Less visualization of the uterus; cannot be done as quickly (important in emergencies); cannot easily extend to enlarge exposure; re-entry at subsequent cesarean birth may require more time

  • Uterine incisions

    • Low Transverse

    • Advantages: Less blood loss; easier to repair; less adhesion formation; VBAC possible for subsequent pregnancy

    • Disadvantages: Limited ability to extend laterally to enlarge the incision

    • Low Vertical

    • Advantages: May be the only choice in certain situations (placental previa on lower anterior wall, dense adhesions, transverse lie with shoulder impacted)

    • Disadvantages: Slightly more likely to rupture during a subsequent birth; a tear may extend the incision downward into the cervix

    • Classic (vertical upper uterine segment incision)

    • Advantages: Can be extended upward for larger exposure; may be necessary with certain fetal/metal presentations

    • Disadvantages: Most likely of the incisions to rupture during a subsequent birth; eliminates VBAC as an option for future births

Postoperative Nursing Care (Post‑Op: BUBBLE)

  • Postpartum Assessment: BUBBLE

    • B: Breasts

    • U: Uterus

    • B: Bowel function

    • B: Bladder function

    • L: Lochia

    • E: Episiotomy/Laceration or C‑section incision

    • Nursing care specific to cesarean vs vaginal birth

Vaginal Birth After Cesarean (VBAC)

  • Controversy relates to risk of uterine rupture and hemorrhage

  • Contraindications

    • Prior classic uterine incision

    • Prior transfundal uterine surgery (myomectomy)

    • Uterine scar other than low-transverse cesarean scar

    • Contracted pelvis

    • Inadequate staff or facility for emergency cesarean if rupture occurs

  • Special areas of focus

    • Consent, documentation, surveillance, readiness for emergency

    • Nurses as advocates; expertise in reading fetal monitoring to identify nonreassuring patterns and institute emergency delivery measures

Practice Questions and Rationale (from the transcript)

  • Question (Page 28): A nurse is caring for a laboring client receiving oxytocin for induction. The fetal monitor shows five contractions in 10 minutes, each lasting 90–100 seconds with late decelerations. What is the priority nursing action?

    • A. Notify the healthcare provider immediately

    • B. Discontinue the oxytocin infusion

    • C. Administer terbutaline to relax the uterus

    • D. Assist the client to ambulate and empty her bladder

  • Correct Answer: B

  • Rationale: Tachysystole (more than 5 contractions in 10 minutes) with nonreassuring FHR patterns. The first priority is to stop the oxytocin infusion to decrease uterine activity and improve fetal oxygenation.

  • Question (Page 30): Following an amniotomy, which assessment finding requires the most immediate nursing intervention?

    • A. Clear amniotic fluid with moderate amount

    • B. Fetal heart rate of 100 bpm detected on monitor

    • C. Client reports increased contraction intensity

    • D. Amniotic fluid with a mild odor

  • Correct Answer: B

  • Rationale: FHR < 110 bpm indicates bradycardia and may suggest umbilical cord prolapse or compression, especially immediately after amniotomy. Requires immediate assessment/intervention.

  • Question (Page 32): A nurse is assisting with an external cephalic version at 37 weeks gestation. Which post-procedure nursing action is most important?

    • A. Administer IM RhoGAM to all patients

    • B. Encourage ambulation to help fetal descent

    • C. Monitor uterine tone and fetal heart rate

    • D. Start Pitocin to initiate labor

  • Correct Answer: C

  • Rationale: After ECV, risk of fetal compromise, uterine irritability, or rupture exists. Continuous fetal monitoring and uterine tone assessment for at least an hour post-procedure are essential. RhoGAM is only indicated for Rh-negative patients.

  • Additional resources noted in the transcript:

    • External version video link: https://www.youtube.com/watch?v=qT2jBxVoOQc

    • External cephalic version article: https://www.ncbi.nlm.nih.gov/books/NBK482475/

This set of notes consolidates the major and minor points from the provided transcript, including definitions, indications/contraindications, management steps, nursing considerations, and practice questions with rationales. It covers amniotomy, induction and augmentation, cervical ripening, tachysystole management, version procedures, amnioinfusion, operative delivery, cesarean sections, VBAC considerations, and postoperative care.