Question

Describe an evidence-based protocol for labor stimulation (augmentation and induction) and the nursing care management essential for the safe and compassionate implementation of the protocol.

Answer 1

As the end of pregnancy nears, the cervixnormally becomes soft (ripe) and begins to open (dilate) and thin (efface), preparing for labor and delivery. When labor does not naturally start on its own and vaginal delivery needs to happen soon, labor may be started artificially (induced). When labor is induced for medical reasons, it is usually because it's safer for you to have the baby now rather than risk further problems from staying pregnant.

labor may be induced for one of the following reasons:

• pregnancy has gone 1 to 2 weeks past the estimated due date.
• Have a condition (such as high blood pressure, placenta abruptio, infection, lung disease, preeclampsia, or diabetes) that may threaten your health or the health of your baby if the pregnancy continues.1
• water (amniotic sac) has broken but active labor contractions have not started.
• baby has a condition that needs treatment, and the risks of vaginal delivery are low. Induction and vaginal delivery are not attempted if the baby may be harmed or is in immediate danger. In such cases, a cesarean delivery (C-section) is usually done.

Even though inducing labor is a fairly common practice, childbirth educators encourage women to learn about it and about the medicine for stimulating a stalled labor (augmentation) so that the women can help decide what is right for them.

Continuous cardiotocographic monitoring of foetal wellbeing is essential during induced or augmented labour. Administration of Syntocinon (oxytocin) is by slow infusion, preferably using a pump with a drop counter.

Protocol for labor induction;

• oxytocin should not be started for 6 hours following administration of vaginal prostaglandins
• in women with intact membranes amniotomy should be performed where feasible prior to commencement of an infusion of oxytocin
• when induction of labour is undertaken with oxytocin the recommended regimen is:
  • a starting dose of 1-2 milliunits per minute
  • increased at intervals of 30 minutes or more
  • the minimum dose possible of oxytocin should be used and this should be titrated against uterine contractions aiming for a maximum of 3-4 contractions every 10 minutes
  • adequate contractions may be established at 12 milliunits per minute
  • in the summary of product characteristics (SPC) the licensed maximum dose is 20 milliunits per minute
  • if higher doses are used the maximum dose used should not exceed 32 milliunits per minute
• local protocols for delivery of oxytocin for induction of labour should:
  • specify and use the dose of oxytocin being delivered (milliunits per minute or mU/min) in preference to the volume of fluid being infused (millilitres per minute or ml/min). be delivered through a syringe driver or via an infusion pump with a non-return valve
• to reduce error, a standard dilution should always be used
  • suggested standardised dilutions and dose regimens include:
    • 30IU Oxytocin in 500mls of normal saline, hence 1ml/hr = 1 milliunit Oxytocin per minute
    • 10IU Oxytocin in 500mls of normal saline, hence 3mls/hr = 1 milliunit Oxytocin per minute

If there are any signs of foetal distress or hypertonic uterine activity then the infusion is stopped immediately. Otherwise the infusion should be continued until the third stage of labour is completed.

The summary of product characteristics, as well as reference to local and national guidelines, must be consulted before administration of a syntocinon (oxytocinon) infusion.

. The data reveal that misoprostol is as effective or more effective in inducing labor as are oxytocin and prostaglandin E2 (PGE 2), with less cost. Nurses need to understand the physiology of prostaglandins and management of misoprostol in labor. Nurses often must assess the safety of mother and fetus during a misoprostol induction without a protocol based on research findings.