1. Cervical Ripening Induction and Augmentation of Labor
Pam Jordan, PhD, RNC
October 2012

2. Cervical Ripening
The process of effecting physical softening and distensibility of the cervix in preparation for labor and birth
[American College of Obstetricians and Gynecologists. (1999a). Induction of labor (Practice Bulletin No. 10). Washington, DC: Author]

3. Induction of Labor
The stimulation of uterine contractions before the spontaneous onset of labor for the purpose of accomplishing vaginal birth
[American College of Obstetricians and Gynecologists. (1999a). Induction of labor (Practice Bulletin No. 10). Washington, DC: Author]

4. Augmentation of Labor
The stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus.
[American College of Obstetricians and Gynecologists. (2003). Dystocia and the augmentation of labor (Practice Bulletin No. 49). Washington, DC: Author]

5. Why mess with a normal process
Why mess with a normal process? Indications for cervical ripening/induction of labor
Legitimate reasons for cervical ripening/induction of labor are those situations in which the intrauterine environment is no longer best for the fetus or continued pregnancy puts the mother at significant risk
Sometimes there are logistical reasons, such as history of very rapid labor or distance from the hospital

6. Why mess with a normal process
Why mess with a normal process? Indications for cervical ripening/induction of labor (continued)
Unfortunately, there are still woman undergoing induction of labor for ‘maternal misery’ or convenience of the OB care provider
1/2 to 2/3 of labor inductions are for nonmedical reasons
Induction of labor is a leading cause of iatrogenic prematurity
In 2009, 23% of births were induced labors [

7. Why mess with a normal process
Why mess with a normal process? Indications for cervical ripening/induction of labor (continued)
Placental abruption [premature separation of the placenta from the uterine wall]
Chorioamnionitis [intraamniotic infection]
Fetal demise
Gestational hypertension
Pre-eclampsia/eclampsia
Premature rupture of membranes

8. Why mess with a normal process
Why mess with a normal process? Indications for cervical ripening/induction of labor (continued)
Postterm pregnancy
Maternal medical conditions [such as diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension]
Fetal compromise [such as severe fetal growth restriction or isoimmunization]

9. Cervical Ripening There are two different methods of cervical ripening
Mechanical
Pharmacological

10. Cervical Ripening: Mechanical Methods
Have been used for hundreds of years
Used when induction is indicated but there is little to no cervical effacement
Includes the insertion into the cervix of materials that absorb fluid from the cervical tissues and swell up, causing mechanical dilation of the cervix and the local release of prostaglandins
Laminaria
Lamicel
Dilapan

11. Cervical Ripening: Mechanical Methods (continued)
Balloon catheters [14 to 26 gauge Foley catheter with balloon inflated above the internal cervical os with 30-50cc of sterile water OR Cook catheter with two balloons both inflated with sterile water (with one inflated above the internal cervical os and the other inflated outside the external cervical os)]
The Cook catheter creates a ‘cervical sandwich’

12. Cervical Ripening: Mechanical Methods Cook Catheter

13. Cervical Ripening: Mechanical Methods (continued)
Balloon catheters cause direct pressure and overstretching of the lower uterine segment and cervix as well as local prostaglandin release
Women may be discharged after insertion and a period of initial monitoring of uterine activity and fetal heart rate
Results are usually seen within 8 to 12 hours of insertion
The balloon catheter usually falls out when the cervix is dilated to about 4 cm

14. Cervical Ripening: Mechanical Methods (continued)
Nursing care includes
Client education
Client support during placement of the material/device
Documentation of the type and size of the catheter and the volume(s) injected into the balloons
Initial monitoring of maternal and fetal response after placement of the material/device
Maternal vital signs
Maternal comfort level/coping status
Assessment of uterine contractions
Assessment of fetal heart rate

15. Cervical Ripening: Pharmacological Methods
Various hormonal preparations are available for cervical ripening
They may also lead to the onset of labor if the cervix is favorable

16. Why mess with a normal process
Why mess with a normal process? Indications for cervical ripening/induction of labor (continued)
Postterm pregnancy
Maternal medical conditions [such as diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension]
Fetal compromise [such as severe fetal growth restriction or isoimmunization]

17. Induction of Labor
The stimulation of uterine contractions before the spontaneous onset of labor for the purpose of accomplishing vaginal birth
[American College of Obstetricians and Gynecologists. (1999a). Induction of labor (Practice Bulletin No. 10). Washington, DC: Author]

18. Induction of Labor: Mechanical Methods
Stripping the membranes = digital separation of the chorioamnionic membrane from the wall of the cervix and lower uterine segment during a vaginal exam
Best results when vertex is well applied to the cervix in a term pregnancy
Seems most beneficial in first pregnancies

19. Induction of Labor: Mechanical Methods
Amniotomy = artificially rupturing the amniotic membranes
Does not result in a significant decrease in the length of labor
Removes the ‘padding’ of the baby’s head
Results in more variable FHR decelerations and an increased risk of cesarean birth for ‘nonreassuring’ FHR status

20. Induction of Labor: Mechanical Methods
Amniotomy = artificially rupturing the amniotic membranes
Risk of umbilical cord prolapse
Commits to labor/birth because of the increased risk of infection once the membranes are ruptured

21. Induction of Labor: Pharmacological Methods
The stimulation of uterine contractions before the spontaneous onset of labor for the purpose of accomplishing vaginal birth
[American College of Obstetricians and Gynecologists. (1999a). Induction of labor (Practice Bulletin No. 10). Washington, DC: Author]

22. Why mess with a normal process?
Labor induction is not an isolated intervention—It results in a cascade of other interventions and activities that have the potential to negatively affect the normal processes of labor and birth
Insertion of an intravenous line
Bedrest
Continuous electronic fetal monitoring
Amniotomy
Increased discomfort
Epidural analgesia/anesthesia
Increased likelihood of cesarean
Increased risk of postpartum hemorrhage
Prolonged stay on the labor unit

23. Induction of Labor
Bishop Scoring indicates the likelihood of success of labor induction. The higher the score, the more likely labor will occur.

24. Induction of Labor: Pharmacological Methods
Oxytocin
Most commonly used induction agent in the US and world
Often used after a cervical ripening agent
Half life of minutes
Uterine response usually occurs within 3-5 mins of initiating IV administration

25. Induction of Labor: Pharmacological Methods
Oxytocin
Dosing is in miliunits per minute
Causes uterine contractions that increase in frequency and intensity
Controversy continues over the ‘best’ increment of dosing and frequency of increasing dosing

26. Induction of Labor: Pharmacological Methods
Oxytocin
Risk of uterine tachysystole
Increases risk of postpartum hemorrhage due to saturation of oxytocin receptors in the uterus
Potentially highly dangerous drug

27. Augmentation of labor
The stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus.
[American College of Obstetricians and Gynecologists. (2003). Dystocia and the augmentation of labor (Practice Bulletin No. 49). Washington, DC: Author]

28. Why mess with a normal process? Indications for augmentation of labor
Dysfunctional labor [prolonged or arrested progress in cervical dilation during active labor or fetal descent during second stage]
Uterine hypocontractility [uterine contractions that are too infrequent or too weak to be effective]

29. Augmentation of labor
Similar to induction of labor because an oxytocin infusion is used to stimulate contractions
The difference between induction and augmentation is that with augmentation, labor has already begun and is being stimulated, while induction is used to start labor

30. Contraindications to Augmentation of Labor
Placenta or vasa previa
Umbilical cord presentation
Prior classical uterine incision [increased incidence of uterine rupture]
Active genital herpes infection
Pelvic structure deformities
Invasive cervical cancer

31. Nursing Care During Induction or Augmentation of Labor
Client education and ongoing support
Initial and ongoing monitoring of maternal and fetal response to oxytocin
Maternal vital signs
Maternal comfort level/coping status
Assessment of uterine contractions
Assessment of fetal heart rate
Preparation and administration of oxytocin
Interventions to promote comfort and progress in labor

32. Resource The primary resource for this PowerPoint set was…
Simpson, K. R. (2009). Cervical ripening and induction and augmentation of labor. (3rd ed., updated). Washington, DC: Association of Women’s Health, Obstetric, and Neonatal Nurses.
This is an example of the outstanding resources provided by nursing specialty organizations.