Induction of labor is the process of artificially stimulating uterine contractions before spontaneous labor begins, with the goal of achieving a vaginal birth. It’s typically recommended when continuing the pregnancy poses more risk than delivering the baby.
Definition
Assisting in initiation of labor or uterine contraction by artificial means before the onset of spontaneous labor.
Indications
Maternal
- Post-term pregnancy.
- Hypertension including pre-eclampsia and eclampsia.
- Medical problems- renal, respiratory, and cardiac disease.
- Previous stillbirth.
- Premature rupture of membranes.
- Chronic polyhydramnios and maternal distress.
Foetal
- Placental insufficiency.
- Rh isoimmunization.
- Unstable lie, after correcting into longitudinal lie.
- Intrauterine death.
- Certain congenital anomalies.
- Postmaturity.
- Combined Indications
- Pre-eclampsia and eclampsia.
- Minor degree of placenta previa.
- Abruptio placentae.
- Chronic hypertension.
- Premature rupture of membranes.
Contraindications
- Contracted pelvis and cephalopelvic disproportion.
- Persistent malpresentation-transverse or compound presentation.
- Pregnancy with history of previous caesarean section.
- Elderly primigravida.
- High-risk pregnancy with compromised fetus.
- Cord presentation or cord prolapse.
- Placenta previa.
- Pelvic tumor.
Methods of induction
- Medical.
- Surgical.
- Combined.
Medical Induction
Medical induction is done by administration of drugs such as:
- Oxytocin/syntocinon.
- Prostaglandin.
Articles
- Foley catheter No. 16 Fr
- Distilled water
- Syringe 2 cc or 5 cc
- Bowl
- Bivalve speculum
- Sterile gloves
- Antiseptic solution
- Spot light
- Mask and apron
- Intravenous set
- Intravenous solution – normal saline or Ringer’s lactate
- Intravenous pump, if available to regulate the flow.
- Medication – oxytocin/syntocinon/cerviprime.
- Kocher’s forceps in case of surgical induction.
Methods of induction
- Oxytocin induction
Procedure
| Nursing actions | Rationale | |
| 1. | Explain to patient what will be done, the purpose of it, and how she may cooperate. | Reduces anxiety and promotes cooperation. |
| 2. | Wash hands. | Prevents transmission of infection. |
| 3. | Check the chart for doctor’s order. | |
| 4. | Instruct mother to empty bowel and bladder. | A full bladder interferes with contraction and descend of fetus. |
| 5. | Provide privacy. | Prevents embarrassment to the mother. |
| 6. | Prepare the perineal area as for labor. | |
| 7. | Check the FHR, uterine contraction rate, abdominal, and vaginal findings. | Identifies presence of any contraindication. |
| 8. | Maintain labor progress chart every 15 minutes and monitor blood pressure (BP) every 2 hours. | Detects an abnormal findings. |
| 9. | Set up the IV tubings, IV pump, and adjust the drops/minute. | For accurate fluid administration. |
| 10. | Add the loaded syntocinon in the IV bottle after adjusting the drops/min. Dose: 5 units of oxytocin in 500 mL of dextrose gives approximately 0.5 mU in one drop of infusion. Starting dose to be low as 5 mU/min increasing at intervals of 15-30 minute to a maximum of 30 mU/min. | Sudden increase or decrease in syntocinon concentration may lead to an abnormal uterine contraction. |
| 11. | Gradually increase the drops after ensuring that everything is normal. | Ensures safety of mother and fetus. |
| 12. | Indications for stopping: Strong contractions lasting over 60 seconds and occurring frequently with intervals less than 3 minutes. | Complications caused by increasing level of oxytocin may result in fetal distress. |
| Tonic uterine contractions. | ||
| Fetal distress. | Fetal movements will increase if fetal distress is present. | |
| Deterioration in the woman’s condition. | ||
| Occurrence of increased or decreased fetal movement. |
- Prostaglandin induction
| Nursing actions | Rationale | |
| 1. | Wash hands. | Prevents transmission of infection. |
| 2. | Check the chart for doctor’s order. | Ensures safety. |
| 3. | Instruct mother to empty bowel and bladder. | A full bladder interferes with contraction and descend of fetus. |
| 4. | Provide privacy. | Prevents embarrassment to the mother. |
| 5. | Prepare the perineal area as for labor. | Reduces chances of infection. |
| 6. | Perform vaginal examination. | To assess the progress of labor. |
| 7. | Insert 0.5-2 mg prostaglandin E2 or E1 (misoprostol) gel into the posterior fornix close to cervix. | Absorption of the medication is facilitated from posterior fornix. |
| 8. | Instruct the woman to stay recumbent as contractions begin. | Frequent, low intensity contractions begin as medication gets absorbed. |
| 9. | Monitor cervical changes using Bishop score. | Assesses the need for re-administration of prostaglandin. |
| 10. | Monitor uterine contractions and FHR continuously. | Assesses the progress of labor and fetal health. |
| 11. | Repeat the dose of E2 or E1 if required after 6-8 hours according to physician’s order. | Labor will result in 30-50% of women. |
Bishop score: It reflects the normal changes the cervix undergoes in parturition (the process of childbirth). The Bishop Score gives points to 5 measurements of the pelvic examination dilation, effacement of the cervix, station of the fetus, consistency of the cervix, and position of the cervix.
Surgical Induction
Surgical induction of labor is done by two methods:
Stripping of membranes:
- It is the digital separation of the chorioamniotic membranes from the wall of the cervix and lower uterine segment. It is thought to work by release of endogenous prostaglandins from the membranes and decidua.
- Stripping the membranes off its attachment from the lower segment is an effective procedure for induction, provided cervical score is favorable. It is used as a preliminary step prior to rupture of membranes. It is also used to make the cervix ripe.
- Manual exploration of the cervix triggers release of oxytocin from pituitary causing increased levels in plasma. Sweeping of the membranes is done prior to artificial rupture of membranes (ARM).
Artificial rupture of membranes.
Procedure
| Nursing actions | Rationale | |
| 1. | Wash hands using surgical asepsis. | Prevents risk of infection. |
| 2. | Help the mother to lie down in lithotomy position. | Ensures better visualization. |
| 3. | Follow strict aseptic technique. | Reduces chances of infection. |
| 4. | Wear sterile gloves, gown, and mask. | Avoids transfer of microorganisms. |
| 5. | Clean the perineum using aseptic technique. | Prevents chances of infection. |
| 6. | Physician introduces two fingers of left hand inside the vagina, up to the cervical canal and beyond the internal os. | Helps to guide the ARM forceps. |
| 7. | Physician assesses the membranes, and places palmar surface of the left hand upward. | Guiding hand will prevent injury to the cervix or vaginal tract. |
| 8. | Physician introduces a long Kocher’s forceps with blades closed up to the membranes along the palmar aspect and ruptures the membranes. | Avoids injury to maternal parts. |
| 9. | Assess FHR, note the color, amount of the amniotic fluid, and status of the cervix, station of head, and presence or absence of cord prolapse. | Identifies any complications at the earliest. |
| 10. | Administer prophylactic antibiotics as per order. | Acts as a prophylaxis against infection. |
| 11. | Record the date and time and the type of induction done. | Acts as a communication between staff members. |
Hazards of Artificial Rupture of Membranes
- Intrauterine infection, particularly iatrogenic from digital or instrumental contamination.
- Chance of umbilical cord prolapse.
- Bleeding from the following sources:
- Fetal vessels in the membranes in case of vasa previa.
- The friable vessels in the cervix.
- A low-lying placental site.
- Amniotic fluid embolism.
Combined Method
The combined medical and surgical methods are commonly used to increase the efficacy of induction by reducing the induction-delivery interval.
Special considerations
- Oxytocin should not be given as a bolus injection during labor because of the risk of hyperstimulation.
- Prolonged use of oxytocin causes uterine atony during the postpartum period.
- The rate of oxytocin administration should be closely monitored to ensure uterine activity that is adequate to maintain progress of labor.
- The midwife should be vigilant for signs of fetal distress such as suspicious or abnormal tracing or signs of meconium – stained liquor.
- Instruct the mother to lie on her sides to prevent aortocaval compression and to increase placental blood flow.
- Water retention and water intoxication can occur with prolonged use of oxytocin and care should be taken to identify the signs of water retention like hypotension, tachycardia, and cardiac dysrhythmias.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Annamma Jacob, Manual of Midwifery and Gynaecological Nursing, 4th Edition, 2023, Jaypee Publishers, ISBN: 978-9356961593
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