Alterations in Labor
Amniotomy: artificial rupture of membranes
• Indications
o Induce labor
o Augment labor
o Allow internal fetal monitoring
• Risks
o Prolapsed cord & compression
o Infection (more likely when ruptured >24 hr)
o Abruptio placenta
• Technique
o Performed by physician or nurse midwife
o Amnio hook snags membrane
• Nursing Care
o Obtain baseline info
§ Fetal heart rate 20 – 30 min before procedure
o Assist w/ procedure
§ Place absorbent pads, equipment
o Provide care after procedure
§ Identify complications
§ Provide comfort
Version
• Indications
o External cephalic version
§ Change the fetal position from a breech, shoulder
o Internal version (uncommon)
§ Change position of second twin in a vaginal birth
• Contraindications
o Uterine malformations
o Previous C section
o Placenta abnormalities
o 3rd trimester bleeding
o Cephalopelvic disproportion
o Multifetal gestation
o Oligohydramnios
o Intrauterine growth restriction
o Uteroplacental insufficiency
o Engagement of fetal head into pelvis
• Risks
o Complications occur in 1-2% of attempted versions
o Changes to FHR common, but usually return to normal
o Serious risks to fetus
, § Umbilical cord entanglement
§ Fetal hypoxia
§ Abruptio placentae
o Maternal sensitization to fetal blood type
• Techniques (ECV)
o Nonstress test to evaluate fetal well-being
o Determine gestational age beyond 37 weeks
o Administer tocolytic drug to relax uterus
o Use ultrasound to guide manipulations
o Rho(D) immune globulin (RhoGAM) given if indicated
• Nursing Care
o Provide info
o Promote maternal & fetal health
§ Assess mom & fetus
o Reduce anxiety
Induction & Augmentation of Labor
• Artificial methods to stimulate uterine contractions
• Induction rates more than doubled from 1990 to 2010, reaching all-time high of 23.8%
• Inductions associated w/ higher c section rate
• Focus on waiting until 39 weeks for elective inductions has reduced c section rate
§ Indications
o Hostile intrauterine environment
o Spontaneous rupture of the membranes
o Post term pregnancy
o Chorioamnionitis
o HTN
o Abtruptio placentae
o Maternal medical conditions that worsen w/ continuation of pregnancy
o Fetal demise
§ Contraindications
o Placenta previa
o Vasa previa
o Umbilical cord prolapse
o Abnormal fetal presentation
o Active genital herpes
o Previous uterine surgery
o Breech presentation
o Overdistended uterus d/t multifetal pregnancy or polyhydramnios
o Severe maternal conditions such as heart disease & severe HTN
o Fetal presenting part above the pelvic inlet
, § Risks
o Excessive uterine activity
o Uterine rupture
o Maternal water intoxication
o Chorioamnionitis
o C section
o PP hemorrhage
§ Techniques
o Determining whether
induction is indicated
§ Cervical
assessment
(Bishop score)
o Cervical ripening
§ Pharmacologic or mechanical methods
§ Pharmacological Cervical Ripening
o Misoprostol
o Dinoprostone
§ Mechanical Cervical Ripening
o Membrane stripping
o Cervical balloon catheter
o Hydroscopic inserts (Laminarai)
§ Oxytocin Administration
o Dilute in an isotonic solution
o Secondary (piggyback) infusion
o Insert oxytocin into the primary IV line
o Start slowly, increase gradually
o Monitor uterine activity, FHR, fetal heart patterns frequently
§ Nursing Care
o Observe fetal response
§ Tachysystole reduces placental blood flow
§ Assess FHR pattern
§ Reduce or stop infusion for nonreassuring FHR
§ Side lying position
§ O2 by face mask
o Observe mother’s response
§ Assess uterine activity
§ Assess BP & pulse
§ Be aware of pain management techniques
§ Record intake & output
§ Observe for signs of water intoxication
§ Assess for uterine atony in pp period
Amniotomy: artificial rupture of membranes
• Indications
o Induce labor
o Augment labor
o Allow internal fetal monitoring
• Risks
o Prolapsed cord & compression
o Infection (more likely when ruptured >24 hr)
o Abruptio placenta
• Technique
o Performed by physician or nurse midwife
o Amnio hook snags membrane
• Nursing Care
o Obtain baseline info
§ Fetal heart rate 20 – 30 min before procedure
o Assist w/ procedure
§ Place absorbent pads, equipment
o Provide care after procedure
§ Identify complications
§ Provide comfort
Version
• Indications
o External cephalic version
§ Change the fetal position from a breech, shoulder
o Internal version (uncommon)
§ Change position of second twin in a vaginal birth
• Contraindications
o Uterine malformations
o Previous C section
o Placenta abnormalities
o 3rd trimester bleeding
o Cephalopelvic disproportion
o Multifetal gestation
o Oligohydramnios
o Intrauterine growth restriction
o Uteroplacental insufficiency
o Engagement of fetal head into pelvis
• Risks
o Complications occur in 1-2% of attempted versions
o Changes to FHR common, but usually return to normal
o Serious risks to fetus
, § Umbilical cord entanglement
§ Fetal hypoxia
§ Abruptio placentae
o Maternal sensitization to fetal blood type
• Techniques (ECV)
o Nonstress test to evaluate fetal well-being
o Determine gestational age beyond 37 weeks
o Administer tocolytic drug to relax uterus
o Use ultrasound to guide manipulations
o Rho(D) immune globulin (RhoGAM) given if indicated
• Nursing Care
o Provide info
o Promote maternal & fetal health
§ Assess mom & fetus
o Reduce anxiety
Induction & Augmentation of Labor
• Artificial methods to stimulate uterine contractions
• Induction rates more than doubled from 1990 to 2010, reaching all-time high of 23.8%
• Inductions associated w/ higher c section rate
• Focus on waiting until 39 weeks for elective inductions has reduced c section rate
§ Indications
o Hostile intrauterine environment
o Spontaneous rupture of the membranes
o Post term pregnancy
o Chorioamnionitis
o HTN
o Abtruptio placentae
o Maternal medical conditions that worsen w/ continuation of pregnancy
o Fetal demise
§ Contraindications
o Placenta previa
o Vasa previa
o Umbilical cord prolapse
o Abnormal fetal presentation
o Active genital herpes
o Previous uterine surgery
o Breech presentation
o Overdistended uterus d/t multifetal pregnancy or polyhydramnios
o Severe maternal conditions such as heart disease & severe HTN
o Fetal presenting part above the pelvic inlet
, § Risks
o Excessive uterine activity
o Uterine rupture
o Maternal water intoxication
o Chorioamnionitis
o C section
o PP hemorrhage
§ Techniques
o Determining whether
induction is indicated
§ Cervical
assessment
(Bishop score)
o Cervical ripening
§ Pharmacologic or mechanical methods
§ Pharmacological Cervical Ripening
o Misoprostol
o Dinoprostone
§ Mechanical Cervical Ripening
o Membrane stripping
o Cervical balloon catheter
o Hydroscopic inserts (Laminarai)
§ Oxytocin Administration
o Dilute in an isotonic solution
o Secondary (piggyback) infusion
o Insert oxytocin into the primary IV line
o Start slowly, increase gradually
o Monitor uterine activity, FHR, fetal heart patterns frequently
§ Nursing Care
o Observe fetal response
§ Tachysystole reduces placental blood flow
§ Assess FHR pattern
§ Reduce or stop infusion for nonreassuring FHR
§ Side lying position
§ O2 by face mask
o Observe mother’s response
§ Assess uterine activity
§ Assess BP & pulse
§ Be aware of pain management techniques
§ Record intake & output
§ Observe for signs of water intoxication
§ Assess for uterine atony in pp period
