CANOSSA COLLEGE

College of Nursing

A Self Learning Module on Related Learning Experience

Focus: Care of At-Risk/ High Risk: Nursing Care of the Client during Labor and Delivery –
Alteration in Labor (Induction and Augmentation of Labor)

MODULE 5

Course Code: NCM 109

Level Offering: 2nd Semester, SY 2021 -2022
Clinical Area of Assignment: DR, LR
Date: March 25 -26, 2022, 6am-2pm
Topics:
• Induction and Augmentation of Labor
• Pharmacological management
• Monitoring of Fetal and Uterine activity

Module Overview:

This module is intended to provide an overview of various problems develop in the physiologic
processes that complications may arise threatening the well-being of the woman, the fetus, or both.
Nurses need to be able manage some mild conditions, or the woman may be referred to an
obstetrician for management of severe complications. The use of nursing process to plan and
provide care for client, the fetus and the family involved in intrapartum complications is explored.

Let’s review normal fetal heart rate, pharmacological drugs, partograph

and normal labor and delivery.

Alteration in Normal Labor

Although labor is a normal process, some women may require interventions such as labor
induction or labor augmentation.

Induction and Augmentation of Labor

Induction and augmentation of labor use artificial methods to stimulate uterine contractions.
Techniques and nursing care are similar for both induction and augmentation.
Induction of labor and augmentation of labor are performed for different indications, but the
methods are the same.
Induction of labor: stimulating the uterus to begin labor.
Augmentation of labor: stimulating the uterus during labor to increase the frequency,
duration, and strength of contractions.
Induction of labor is an increasingly common procedure in intrapartum units. Induction rates
more than double from 1990 to 2010, reaching an all-time high of 23.8% (Osterman & Martin,
2014). Data from National Vital Statistics System shows that after nearly 20 years of steady
increases, the rate is declining, as seen in the in the 2015 induction rate of 23.9% (Osterman &
Martin, 2014, National Center for Health Statistics – CHS, 2017).
Inductions have been associated with a higher cesarean birth rate. This increased risk for
cesarean section can be mitigated if the cervix is dilated (at least 2 cm) and somewhat effaced
before labor (Thorp & Laughon, 2014). Induction is more likely to be successful at term because
prelabor cervical changes favor dilation. In 2014, the cesarean rate was 32.2% for women of all
racial origins, which was 2% lower than the rate in 2013 (Hamilton, Martin, Osterman, Curtin,
&Mathews, 2015). This decline is partly attributed to the focus on reducing nonmedically
indicated (elective) cesarean sections and induction of labor before 39 weeks.

Indications
Induction of labor may be medically necessary for an obstetric, fetal, or other medical indication
or it may be elective performed at the convenience of the patient and/or provider). Labor
induction is not done if the fetus must be delivered more quickly than the process permits, in
which case a cesarean birth is performed. Induction is indicated in the following conditions
(ACOG, 2015a; Thorpe & Laughon, 2014):
The intrauterine environment is hostile to fetal well-being (e.g., intrauterine fetal growth
restriction, isoimmunization (maternal-fetal blood incompatibility, oligohydramnios)
SROM at or near term without onset of labor, also called premature rupture of the membranes
(PROM). If pregnancy is preterm, less than 37 weeks, the term preterm premature rupture of the
membranes (PPROM).
• Post term pregnancy
• Chorioamnionitis (infection and inflammation of the amniotic sac)
• Hypertension associated with pregnancy of hypertension, both of which are
associated with placental blood flow
• Placental abruption (large abruptions require immediate delivery)
• Maternal medical conditions that worsen with condition of the pregnancy (e.g.,
diabetes, hypertension, renal disease, heart disease, antiphospholipid syndrome)
• Fetal demise
Induction solely for convenience is not recommended. Factors such as having a history of rapid
labor and living a long distance from the hospital may be valid reasons to induce labor because
of the real possibility that the baby would be born in uncontrolled circumstances. (ACOG,2015a;
Simpson & O’Brien-Adel, 2014). Elective inductions have two major risks: twofold increase in
cesarean section compared with spontaneous labor and increased risk for neonatal respiratory
complications (Thorpe & Laughon, 2014). Therefore, confirmation of fetal gestational age is
paramount before elective induction. Recent recommendations suggest waiting until 40 to 41
weeks before considering elective induction (AWHONN, 2012, Spong et al., 2012; Thorp 014).
This gestational age is associated with decrease risk for cesarean delivery and neonatal
respiratory morbidity.
Prenatal testing sometimes identifies a fetal anomaly that will require specialized neonatal care at
a distant facility. The mother may be transported to that facility for labor induction or cesarean
birth.
Augmentation of labor with oxytocin is considered when labor has begun spontaneously but
progress has slowed or stopped, even if contractions seem to be adequate. Nonpharmacologic
augmentation may be possible with nipple stimulation (Cunningham et al., 2014; Thorp &
Laughon, 2014).

Contraindications
Any contraindication to labor and vaginal birth is contraindication to induction or augmentation
of labor. Possible contraindications and cautions associated with induction may include the
following (ACOG, 2015a; Benirschke, 2014: Simpson & O'Brien-Abel, 2014; Thorpe &
Laughon, 2014).
Placenta previa, placental implantation in the lower uterine segment, which could result in
hemorrhage during labor
Vasa previa, a velamentous insertion of the umbilical cord (umbilical cord vessels branch over
the amniotic membrane rather than inserting into the placenta, therefore lacking protection of
Wharton jelly); these vessels cross the cervical os, fetal hemorrhage is a possibility if the
membranes rupture
Umbilical cord prolapses, because immediate cesarean is indicated to stop cord compression
Abnormal fetal presentation for which vaginal birth is often more hazardous (ie., transverse
fetal lie)
Active genital herpes
Previous uterine surgery, such as previous classical cesarean incision or myomectomy
(removal of uterine fibroids) that entered the endometrial cavity
Other maternal or fetal conditions are not contraindications to induction but require individual
evaluation such as the following (ACOG, 2015b; Thorpe & Laughon, 2014).
One or more previous low transverse cesarean deliveries
Breech presentation
Conditions in which the uterus is overdistended, such as a multifetal pregnancy and
polyhydramnios, because the risk for uterine rupture is higher
Severe maternal conditions such as heart disease and severe hypertension
Fetal presenting part above the pelvic inlet, which may be associated with cephalopelvic
disproportion or a preterm fetus
Inability to adequately monitor the fetal status during labor or presence of indeterminate
or abnormal FHR
Uterine surgery, such as a Technique Pharmacologic and mechanical methods may be used for
labor induction and augmentation. Cervical assessment estimates whether the cervix is favorable
for induction. The Bishop scoring system is used to estimate cervical readiness for labor with
five factors: cervical dilation effacement, consistency, position, and fetal station. Vagina birth is
more likely to result if a Bishop score is higher than (ACOG, 2015a).
Risks
Induction and augmentation of labor, like spontaneous labor, are associated with the following
risks (ACOG, 2015a; Cunningham et al., 2014; Simpson & O'Brien-Abel, 2014):
Excessive UA (increased frequency, duration, or insufficient relaxation time or resting tone) can
reduce placental perfusion and fetal oxygenation. Uterine tachysystole may or may not be
accompanied by an indeterminate or abnormal FHR pattern.
Uterine rupture may occur, which is more likely with overdistention of the uterus with excess
amniotic fluid or a multifetal pregnancy or in cases of excessive UA.
Maternal water intoxication can occur, which is more likely if a hypotonic IV solution is used to
dilute the oxytocin and with rates greater than 20 milliunits/min.
Chorioamnionitis and cesarean birth.
Postpartum hemorrhage.
Elective labor induction at term is associated with increased risk for cesarean birth and newborn
respiratory problems. Studies have demonstrated that nulliparous women who have their labor
induced are two to three times more likely to have a surgical birth. A Bishop score of 7 or less is
associated with an increased risk for cesarean birth compared with spontaneously laboring
patients (Cunningham et.al., 2014). The risk for cesarean after failed induction was similar
whether women had medical or elective inductions. Risk for chorioamnionitis increases as the
duration of ruptured membranes increases (Cunningham et.al., 2014).
Technique

Pharmacologic and mechanical methods may be used for labor induction and
augmentation. Cervical assessment estimates whether the cervix is favorable for induction. The
Bishop scoring system is used to estimate cervical readiness for labor with five factors:
 • Cervical dilatation,
• effacement,
• consistency,
• position and
• fetal station.

Vaginal birth is more likely to result if a Bishop score is higher than 8 (ACOG, 2015a).

Bishop Scoring System to Evaluate the Cervix

Bishop score:
1. The Bishop score is used to determine maternal readiness for labor and evaluates cervical
status and fetal position.
2. The Bishop score is indicated before the induction of labor.
3. The 5 factors are assigned a score of 0 to 3, and the total score is calculated.
4. A score of 8 or more indicates a readiness for labor induction.
Cervical Ripening
Cervical Ripening is a process used to ripen (soften) the cervix and make it more likely to
dilate with the force of labor. Typically, this procedure is performed before the scheduled
induction.
Pharmacologic Methods
Actions For
Hypertonic
Contractions, When Oxytocin
Precautions and
Drugs Dosage Induction May
With Or Without Comments
Begin
Nonreassuring
FHT Pattern
Prostaglandin • 0.5 mg • Place the • Safe interval • Limit
Gel applied in woman in side- has not been dinoprostone gel
(Dinoprostone the cervix; lying position. established to maximum of
[Prepidil]) maybe • Provide O2 by • Delaying 1.5 mg in the
• Prostaglan repeated 6- face mask or oxytocin cervix in 24 hr.
din E2 12 hr later. nonrebreather administration woman should
(PGE2) Maximum face mask at 10 for 6-12 hours remain
cause recommend L/min. after total recumbent with
cervical ed dose is administer intracervical lateral uterine
ripening 1.5 mg tocolytic drug dose of 1.5 displacement for
• Given via applied in such as mg or 2.5 mg 15-30 min after
intravagina the cervix terbutaline. vaginal dose application. Has
l or in a 24-hr • Typically recommended increased effect
intracervic period. begins 1 hr if combined with
al • 2.5 mg after gel other oxytocics
applied in application. such as oxytocin
the vagina. Higher (Pitocin).
incidence with Increases
vaginal hypersensitive
application. effect of the herb
ephedra. Use
caution in
women with
asthma,
hypertension,
glaucoma, severe
renal or hepatic
dysfunction, or
ischemic heart
disease.
Vaginal Insert • 10 mg in a • Same as for • 30-60 min • Remove after 12
(Dinoprostone time- dinoprostone after removal hrs or when
[Cervidil]) release gel. Remove of insert active labor
vaginal insert begins.
insert left • Hypertonic • Adverse effects
in place for uterine activity can be reduced
may occur up with 15 min of
 up to 12 to 9.5 hr after removal. Most
hour insert expensive of
• Remove placement. prostaglandin
with onset Greater options.
of active incidence than
labor, with lower dose
membrane intracervical
rupture, or dinoprostone
uterine gel.
tachysystol
e.
Misoprostol • 1 quarter to • Same as for At least 4 hour • Misoprostol is
(Cytotec) ½ of 100 dinoprostone after last dose currently FDA
• Prostaglan mcg tablet gel. Higher approved only
din E1 vaginally dose or more for treatment of
(PGE1) (25-50 frequent peptic ulcers but
analog mcg; see administration is widely used
usually following is more likely for cervical
given for precautions to cause ripening and
gastric ). Also excessive induction of
ulcers. used for contractions, labor.
• Also use labor which may or Manufacture
for both induction may not be does not intend
cervical by accompanied to seek approval,
ripening repeating by a but the ACOG
and 25 mcg nonreassuring supports its use
induction dose every FHR pattern. for these
of labor. 3-6 hour. purposes.
• Not given • A 50 mcg • 100 mcg tablet is
to previous dose has nor scored. The
CS or been hospital
major associated pharmacy should
uterine with prepare the 25 or
surgery excessive 50 mcg dose for
uterine greater accuracy.
• Patient
activity Cost is 1%-2%
remain
that other
recumbent
prostaglandin
for 30
preparations.
mins. And
Contraindicated
FHR and
in woman with
UA should
previous
be
cesarean or other
monitored
uterine surgery.
continuousl
y for
period of
 30 minutes
to 2 hours

Prostaglandins
A. Description
1. Stimulate uterine contractions
2. Help to ripen or soften cervix
3. Enhance postpartum uterine contraction
4. Available in oral, rectal, or vaginal preparations

B. Examples: misoprostol (Cytotec), dinoprostone (Cervidil), carboprost (Hemabate)

C. Major adverse side effects: maternal

1. Hypertonic uterus, uterine rupture
2. Nausea, vomiting, diarrhea, vasoconstriction; more common with carboprost (should
never be administered IV)

D. Nursing care associated with prostaglandins

1. Monitor continuously, particularly uterine contractions
2. Have oxygen and resuscitative equipment available

Oxytocics
A. Description
1. Stimulate uterus to contract
2. Induce labor; infused slowly
3. Augment contractions that have already begun
4. Induce contraction of lacteal glands, which promotes let-down reflex for breastfeeding
5. Exert vasopressor and antidiuretic effects
6. Enhance postpartum uterine contraction; infused rapidly
7. Available in IM, IV, oral, and nasal preparations

B. Example: oxytocin (Pitocin, Syntocinon)

C. Adverse side effects

1. Maternal
a. Hypertension (contracts smooth muscles of blood vessels)
b. Dysrhythmias; tachycardia (vasoconstriction)
c. Hypertonic uterus; uterine rupture
d. Water intoxication (antidiuretic effect) may precipitate seizures and coma
2. Fetal: caused by tetanic uterine contractions
a. Anoxia; asphyxia (vasoconstriction)
 b. Dysrhythmias (premature ventricular complexes [PVCs], bradycardia)
c. Hyperbilirubinemia (hepatic dysfunction)

D. Nursing care associated with oxytocics

1. Monitor vital signs every 30 to 60 minutes and with each dose increase
2. Have oxygen and emergency resuscitative equipment available
3. Maintain continuous fetal monitoring; assess uterine contractions and tone, and FHR
every 15 minutes
4. Use infusion-control device for IV administration; always given by secondary line (IV
piggy back [IVPB])
5. Discontinue infusion for prolonged uterine contractions, inadequate uterine resting tone,
or nonreassuring fetal response to contractions.
Oxytocin Administration
Oxytocin is the most common drug given for induction and augmentation of labor.
Oxytocin is a powerful drug and predicting a woman response to its impossible. Several
precautions reduce the chance of adverse reactions in the mother and fetus.
• Oxytocin is diluted in an isotonic solution and given as a secondary (piggyback) infusion
so it can be stopped quickly if complications develop.
• The oxytocin line is inserted into the primary (nonadditive or maintenance) IV line as
close as possible to the venipuncture site (the proximal port) to limit the amount of drug
infused if discontinued.
• Oxytocin is started slowly, increased gradually, and regulated with an infusion pump.
The primary line is also regulated with an infusion pump.
• UA, FHR, and fetal heart patterns are monitored before induction for baseline, when
oxytocin is started and throughout labor.

Nursing Considerations
When providing care during cervical ripening and labor induction or augmentation, the
nurse observes the woman and fetus for complications and takes corrective actions if
abnormalities are noted. The nurse has a great responsibility when administering uterine
stimulants to a pregnant woman. The nurse decides when to start, change and stop an oxytocin
infusion using the facility’s protocols and medical orders. Facility policies related to oxytocin
must clearly support correct nursing and medical actions.

Observe the Fetal Response

Oxytocin stimulates uterine contractions, and they may become too
frequent(tachysystole). Tachysystole may reduce placental blood flow (uteroplacental
insufficiency), which decreases exchange of fetal oxygen and waste products. Before induction
and augmentation of labor, the nurse assesses the FHR and contraction pattern to ensure fetal
well-being is present. ACOG and AWHONN set forth standards for FHR assessment based on
risk-stratification of the patient (Simpson, 2013). Individual facilities set documentation
guidelines incorporating recommendations.
 The nurse remains alert for FHR patterns that suggest reduced placental exchange
secondary to excessive UA. Examples are fetal bradycardia, tachycardia, pathologic
decelerations, and decreased FHR variability. The nurse should assess the woman and fetus
carefully to identify the most likely cause of the problem and institute corrective actions.
If indeterminate or abnormal patterns occur with tachysystole, the nurse takes the
following steps to reduce UA and increase fetal oxygenation (ACOG, 2015c; Simpson &
O'Brien-Abel, 2014):
• Stop the oxytocin infusion and administer a bolus of at least 500 mL of the primary
nonadditive infusion.
• Keep the woman in a side-lying position to prevent aorto-caval compression and
increase placental blood flow.
• Consider oxygen administration at 10 L/min via nonrebreather facemask until FHR
pattern improves.
• Notify the provider; anticipate order for terbutaline (Brethine), a smooth muscle
relaxant, 0.25 mg subcutaneously, if no improvement with other interventions.
• Oxytocin may be restarted when the tachysystole resolves and the FHR pattern
returns to normal. The oxytocin should be restarted at no more than half the previous
rate if it has been turned off for less than 20 to 30 minutes. If more than 30 to 40
minutes have elapsed, it should be restarted at the initial dose.

SAFETY CHECK

Signs of Excessive Uterine Activity

• Contraction duration longer than 120 seconds

• Less than 60 seconds relaxation time between contractions in first stage labor and 45 to
50 seconds in second stage labor
• Uterine resting tone firm by palpation or higher than 20 to 25 mm Hg (with intrauterine
pressure catheter) Montevideo units
• More than 5 contractions in a 10-minute window, averaged over 30 minutes

Nursing Actions for Excessive Uterine Activity (ACOG, 2015c; Simpson & O'Brien-Able,
2014)

A. With Normal Fetal Heart Rate Patterns

• Position the woman on her side.

• Administer an IV fluid bolus of at least 500 mL.
• If the tachysystole does not resolve in 10 to 15 minutes, the oxytocin infusion rate
should be decreased by half.
• If tachysystole persists after another 10 to 15 minutes, the oxytocin infusion should be
stopped until the uterine activity is normal
 B. With Abnormal Fetal Heart Rate Patterns

• Stop the oxytocin infusion and administer bolus of at least 500 mL of the primary
nonadditive infusion.
• Keep the woman in a side-lying position to prevent aortocaval compression
(Venacaval syndrome) and increase placental blood flow.
• Consider oxygen administration at 10 L/min via nonrebreather face mask until FHR
pattern improves.

In both cases, oxytocin may be restarted when the any systole resolves, and the FHR pattern
returns to normal. The oxytocin should be restarted at no more than half the previous rate if it has
been turned off for less than 20 to 30 minutes. If more than 30 to 40 minutes has elapsed, it should
be restarted at the initial dose.

Observe the Mother’s Response

The uterus must be assessed for excessive UA that may reduce fetal oxygenation and
contribute to uterine rupture. Contractions are for frequency duration and intensity, uterine resting
tone of at least 60 seconds between contractions in first stage labor and 45 to 50 to so seconds in
second stage labor (Miller et al. 2017). UA observations are charted at the same intervals as the
FHR Corrective actions for excessive UA with normal FHR patterns include positioning the
woman on her side and administering an IV fluid bolus of at least 500 ml. If the tachysystole does
net resolve in 10 to 15 min. the oxytocin infusion rate should be decreased by half. If tachysystole
persists after another 10 to 15 minutes, the oxytocin infusion should be stopped until the UA is
normal. Provided that the FHR pattern has remained normal, the oxytocin infusion may be
restarted as described previously in the discussion of the fetal response (ACOG. 2015: Simpson &
O'Brien Able 2014).

If the oxytocin must be discontinued, the medical decision about resuming is

individualized. The oxytocin infusion may be restarted at the same or a lower dose if the
contractions are no longer too frequent and the FHR is reassuring. If the oxytocin has been
discontinued for 40 minutes or longer, the drug that was in the woman's system has been
metabolized. Therefore, it should be restarted at the beginning dose ordered and advanced more
slowly to prevent a recurrence of uterine tachysystole and indeterminate or abnormal FHR
patterns.

The woman's blood pressure and pulse rate are taken every 30 minutes or with each
oxytocin dose increase to identify changes from her baseline. Her temperature is assessed every
2 hours, unless ruptured, and then it is assessed hourly to identify infection (Simpson & O'Brien-
Abel, 2014).

The woman may need to use pharmacologic and nonpharmacologic pain management
techniques sooner than in a spontaneous labor. Although the goal of induced and augmented
labor is to mimic natural labor, stimulated contractions often increase in intensity more quickly.
Cervical ripening may increase the discomfort felt by the woman.
 Recording intake and output identifies fluid retention. which may precede water
intoxication. Signs and symptoms of water intoxication include headache, blurred vision,
behavioral changes, increased blood pressure and respirations, decreased pulse rate, auscultatory
crackles and wheezing, and coughing,

After birth, the mother is observed for postpartum hemorrhage caused by uterine
relaxation. Postpartum uterine atony is more likely if she had prolonged use of oxytocin. The
uterine muscle becomes fatigued and does not contract effectively to compress vessels at the
placental site, and the oxytocin receptor sites may be saturated and less responsive. Atony is
manifested by a soft uterine fundus and excess amounts of lochia, usually with large clots.
Hypovolemic shock may occur with hemorrhage.
References:

1. Pilliteri, Adele, (2010). Maternal and Child Health Nursing: Care of the Childbearing and
Child Rearing Family (6th ed). Philadelphia: Lippincott Williams and Wilkins.
2. Murray, S.S., and McKinney E.M., (2020). Foundations of Maternal-Newborn and
Women’s Health Nursing (8th ed). Singapore: Elsivier Pte. Ltd.
3. https://nursing.com/blog/oxytocin-pitocin-nursing-pharmacology-considerations/
4. https://www.thewomens.org.au/health-information/pregnancy-and-birth/labour-
birth/induction-of-labour
5. https://www.healthunit.com/induction-and-augmentation
6. https://www.news-medical.net/health/Speeding-up-Labor.aspx

RLE Learning Process

This module has 4 parts:

1. Desired Learning Outcome
2. Learning Activities
3. Explore and Apply
4. Feedback

Desired Learning Outcome: at the end of 16-hour virtual learning exposure, you are expected to:

1. Assess the fetal heart rate and the uterine activity.

2. Administration of uterine drugs.
3. Making of NCP

How will you be graded? Check what’s in the Box

Papers not turned in on or before the due date will lose one-half
grade per day late--no exceptions.

Need to fill-in the box with pertinent information.

 Ms. Girlie

Meanwhile, you may write down some of your questions, comments in

the box provided. Before we proceed with Module 3, I want you to rest
for 30 minutes and have some stretching after.

Learning Task 1: Applying Knowledge

Essay

1. What precautions are taken to enhance the safety of oxytocin

administration for the woman and fetus?
2. How may oxytocin administration differ if labor is being
augmented rather than induced?
3. What signs may indicate a nonreassuring fetal response to
oxytocin stimulation?
4. What are the signs of excessive uterine activity?
5. How can induction of labor with oxytocin contribute to
postpartum hemorrhage?
Learning Task 2: Critical Thinking

Case Scenario

Sharry is a primigravida at 43 weeks of gestation. Her labor is being

stimulated with oxytocin administered IV. Her contractions have been
increasing in intensity with a frequency of every 2 to 2 ½ minutes and
a duration of 80 to 85 seconds. She is currently in supine position with
a 30-degree elevation of her head. On observation of the monitor
tracing, you note that during the last 2 contractions the FHR decreased
after the contraction peaked and did not return to baseline until about
10 seconds into the rest period. A slight decrease in variability and
baseline rate was observed.

a. Identify the pattern described and the possible factors

responsible for it.
b. Describe the actions you would take. State the rationale for
each action.
c. Make a nursing care plan. (Identify at least 2 nursing
diagnoses)

Nursing Care Plan:

Fill in the appropriate elements of the care plan for this client.
PLANNING
ASSESSMENT NURSING GOAL / EVALUATION
NURSING
DIAGNOSIS EXPECTED RATIONALE
INTERVENTIONS
OUTCOME
Feedback: Before we moved on to the next module. I would gladly want
to listen to your feedback. Kindly rate each area with a scale of 1-5
as 1 as the lowest and 5 as the highest.

Item 1 2 3 4 5
Comprehensive content
Relevance of the content
Clarity of test and message
Alignment of the assessment
activities to learning outcomes

3 Points Exit

Three things I’ve learned:

1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________

Two real-life realizations after finishing the module.

1. ________________________________________________________________________
2. ________________________________________________________________________

One most favorite part of the lesson

1. ________________________________________________________________________

Note: Please submit your work in Google Classroom 16 hours after

duty. You may use this document to insert your answers under each
learning task.

You just finished Module 5.