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Cervical Ripening

Section II

Topics to be covered

•Definition of Cervical Ripening

•Review the pharmacological properties of prostaglandins

•Compare/contrast methods used for cervical ripening

•Explain the procedures for administration of prostaglandins

•Describe nursing role assessments and interventions with cervical ripening/prostaglandins

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Process of affecting physical softening, thinning and dilating of the cervix in

preparation for labor and birth

Indications for Prostaglandins

• Ripening an unfavorable cervix

• Has been used for induction

• IUFD

• Will not be covered in this class

• Treatment of postpartum hemorrhage

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• Score of 6 or less

• Unfavorable cervix

• Score over 8

• Favorable cervix, Induction likely to be successful

• Approaches success rate of spontaneous labor

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Cervical Ripening Agents

Mechanical and Other

Methods of Ripening

• Membrane Stripping

• Amniotomy

• Transcervical Balloon Catheters

• Hygroscopic/Osmotic Dilators

• Laminaria (seaweed)

• Lamicel and Dilapan

• Nipple Stimulation

• Sexual Intercourse

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Let’s review handout:Mechanical methods and other methodsof Ripening andLabor induction

Demonstration on inserting Ripening balloon catheter

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•PGE1 (misoprostol) Cytotec

Prostaglandin Cervical Ripening Agents

PGE2 (Dinoprostone)

Cervidil (insert) FDA approved

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How Do Prostaglandins

Work?

•Soften the cervix and relax cervical smooth muscle

•May also produce uterine contractions• Increase Inflammatory mediators in the cervix

•Remodel the cervical extracellular matrix through a decrease in collagen and cervical glycosaminoglycans

Chiossi et al (2012)

Misoprostol

• Routes of administration

• Oral Is starting to be used more for cervical ripening/induction

• Sublingual

• Buccal

• Intravaginal

• Currently being used for cervical ripening/induction

• Rectal

• Currently being used to treat postpartum hemorrhage

• 800-1000mcg

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Administration, Monitoring, And Risks

Let’s refer to the table entitled Comparison of Prostaglandin Cervical Ripening Agents…

Where is the Posterior Fornix?

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Misoprostol: Oral Versus Intravaginal

Route Onset Peak Half-Life Duration

Oral 8 to 11 minutes 30 minutes 90 minutes 2 hours

Intravaginal 20 minutes 1 to 2 hours 4 hours; 4 to 6 hours in some women

Simpson, K. R. (2020)

•Misoprostol should not be used for cervical ripening or labor induction in patients at term who have had a cesarean delivery or major uterine surgery.

•ACOG, 2019

•Contraindication

ACOG, 2019

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Prostaglandin Ripening:

Nursing Care*

• Monitor for Maternal/Fetal response

• Fetal Heart Rate

• Maternal comfort/discomfort

• Monitor for Contraction Activity

• Main side effect is tachysystole with or without fetal heart rate changes

• Monitor for Labor Progress

Contraction Activity

• In addition to contraction frequency, don’t forget

• Duration

• Intensity

• Resting tone

• Relaxation time

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AWHONN Staffing Recommendations

• Women receiving pharmacologic agents for cervical ripening such as Cervidil or Cytotec require continuous electronic fetal monitoring and a minimum of 1 nurse to 2 women with assessment of maternal-fetal status at least every 30 minutes

AWHONN (2010, p.18); Simpson (2020, p.s8)

Nursing Care: Fetal Response

• Assess fetal heart rate using continuous electronic fetal monitoring

• Observe for evolving patterns over time

• FHR Patterns Associated With Acidemia

• Be on the watch for these patterns

• Absent variability with recurrent late decelerations

• Absent variability with recurrent variable decelerations

• Absent variability with fetal bradycardia

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Interventions for Uterine

Tachysystole and/or Fetal

Heart Rate Concerns

Related to Prostaglandins

•Reposition

•Assess hydration status and consider IV fluid bolus

•Consider Terbutaline (Brethine) based on fetal response

• 0.25 mg SQ

• If cervidil is in place, remove it

•Notify provider based upon maternal/fetal response

Oxygen for Intrauterine

Resuscitation????

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ACOG

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ARRIVE Trial

• Multicenter unmasked trial

• Randomly assigned low-risk nulliparous women who were at 38 weeks 0 days to 38 weeks 6 days of gestation to either

• Labor induction at 39 0/7 weeks to 39 4/7 weeks, or to

• Expectant management

• Women were asked to fore go elective delivery before 40 weeks 5 days and to have delivery initiated no later than

42 2/7 weeks

Arrive Trial

• Primary outcome

• Perinatal death or severe neonatal complications

• Secondary outcome

• Cesarean delivery

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Arrive Trial Conclusions

• Compared to expectant management, induction of labor at 39 weeks in low-risk nulliparous women

• Did NOT result in a significantly lower frequency of composite adverse perinatal outcomes

• It DID result in a significantly lower frequency of cesarean delivery

Society for Maternal Fetal MedicineSMFM

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Society for Maternal Fetal MedicineSMFM: ARRIVE Trial

CMQCC Response to Arrive Trial

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Questions?

Case Study

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References

• Abrão, K. C., Francisco, R. P. V., Miyadahira, S., Cicarelli, D. D., & Zugaib, M. (2009). Elevation of uterine basal tone and fetal heart rate abnormalities after labor analgesia: A randomized controlled trial. Obstetrics & Gynecology, 113(1), 41-47.

• American Academy of Pediatrics & American College of Obstetricians and Gynecologists (2017). Guidelines for Perinatal Care, 8th edition. Elk Grove, IL: American Academy of Pediatrics.

• American College of Obstetricians and Gynecologists (2019). Medically indicated late-preterm and early-term deliveries. ACOG Committee Opinion Number 764, January 24, 2019. Washington, DC: ACOG.

• American College of Obstetricians and Gynecologists (2019). Avoidance of nonmedically indicated early-term deliveries and associated neonatal morbidities. ACOG Committee Opinion Number 765, January 24, 2019. Washington, DC: ACOG

• American College of Obstetricians and Gynecologists (2019). Vaginal birth after cesarean delivery. ACOG Practice Bulletin Number 205. Washington, DC: ACO

• American College of Obstetricians and Gynecologists (2013a; reaffirmed 2019). Definition of Term Pregnancy. ACOG Committee Opinion Number 579. November 2013.

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ACOG & SMFM Consensus Statement

• http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery

• American College of Obstetricians and Gynecologists & Society for Maternal-Fetal Medicine (2014; reaffirmed 2016). Obstetric Care Consensus Safe Prevention of the Primary Cesarean Delivery. Number 1. March 2014.

References

• American College of Obstetricians and Gynecologists (2014). revitalize: Obstetric data definitions (version 1.0). Retrieved from https://www.acog.org/-/media/project/acog/acogorg/files/pdfs/publications/revitalize-ob.pdf?la=en&hash=D9ECE1577C2A0B535F42C1B8DC492070

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• American College of Obstetricians and Gynecologists (2009; reaffirmed 2019). Induction of labor. ACOG Practice Bulletin Number 107. Washington, DC: ACOG.

• American College of Obstetricians and Gynecologists (2009; reaffirmed 2019). Intrapartum fetal heart rate monitoring: Nomenclature, interpretation, and general management principles. ACOG Practice Bulletin Number 106, Washington, DC: ACOG.

• Association of Women’s Health, Obstetric and Neonatal Nurses (2019). Position Statement: Elective Induction of Labor. Washington, DC: AWHONN.

• Association of Women’s Health, Obstetric and Neonatal Nurses (2018). Fetal heart monitoring. Washington, DC: AWHONN.

• Association of Women’s Health, Obstetric and Neonatal Nurses (2015). Fetal Heart Monitoring Principles and Practices, 5th ed. Washington, DC: AWHONN

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• Association of Women’s Health, Obstetric and Neonatal Nurses (2010). Guidelines for Professional Registered Nurse Staffing for Perinatal Units. Washington, DC: AWHONN.

• Caldeyro-Barcia, & Poseiro, J. J. (1960). Physiology of the uterine contraction. Clinic Obstetr Gynecology, 3: 386-408.

• Chiossi, G., Costantine, M. M., Bytautiene, E., Kechichian, T., Hankins, G. D. V. et al. (2012). The effects of prostaglandin E1 and Prostaglandin E2 on in vitro myometrial contractility and uterine structure. American Journal of Perinatology, 29, 615-622

• Clark, S., Belfort, M., Saade, G., Hankins, G., Miller, D., & Frye, D. (2007). Implementation of a conservative oxytocin-based protocol for oxytocin administration: maternal and newborn outcomes. American Journal of Obstetrics & Gynecology, 197: 480.e1-480.e5.

• Clark, S. L., Simpson, K. R., Knox, E., & Garite, T. J. (2009). Oxytocin: new perspectives on an old drug. American Journal of Obstetrics & Gynecology, 200: 35.e1-35.e6.

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• Dudley, D. J. (1997). Oxytocin: Use and abuse, science and art. Clinical Obstetrics and Gynecology, 40(3), 516-524.

• Freeman, R. K., Garite, T. J., Nageotte, M. P., & Miller, L. A. (2012). Fetal Heart Rate Monitoring, 4th edition. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

• Gard, J. W., Alexander, J. M., Bawdon, R. E., & Albrect, J. T. (2002). Oxytocin preparation stability in several common obstetric intravenous solutions. American Journal of Obstetrics & Gynecology, 186, 496-498.

• Garite, T. J., & Simpson, K. R. (2011). Intrauterine resuscitation. Clinical Obstetrics and Gynecology, 54(1), 28-39.

• Grobman, W. A., et al (2018). Defining failed induction of labor, American Journal of Obstetrics & Gynecology, 218(1), 122e1-122e8.

• Grobman, W. A., et al (2018). Labor induction compared with expectant management of low-risk nulliparous women. The New England Journal of Medicine, 379(6), pp. 513-523.

• Harper, L. M., Caughey, A. B., Odibo, A. O., Roehl, K. A., Zhao, Q., & Cahill, A. G. (2012). Normal progress of induced labor. Obstetrics & Gynecology, 119(6), 1113-1118.

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• Institute for Safe Medication Practices. https://www.ismp.org/recommendations/high-alert-medications-acute-list.

• Miller, L. A., & Miller, D. A., & Cypher, R. L. (2017). Fetal Monitoring A Multidisciplinary Approach, 8th ed. St. Louis: Elsevier/Mosby.

• Robinson, C., Schumann, R., Zhang, P., & Young, R. C. (2003). Oxytocin-induced desensitization of the oxytocin receptor. American Journal of Obstetrics & Gynecology, 188, 497-502.

• Society of Maternal-Fetal (SMFM) Publications Committee (2019). SMFM statement on elective induction of labor in low-risk nulliparous women at term: the ARRIVE trial. www.smfm.org

• Society for Maternal-Fetal Medicine; Bernstein, P. S., Combs, C. A., Shields, L. E., Clark, S. L., Eppes, C. S.; and the SMFM Patient Safety and Quality Committee (2017). The development and implementation of checklists in obstetrics. www.smfm.org

• Simpson, K. R. (2020). Cervical ripening and labor induction and augmentation, 5th edition. Washington, D.C.: AWHONN.

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• Spong, C. Y, (2013). Defining “Term” Pregnancy: Recommendations From the Defining “Term” Pregnancy Workgroup. JAMA 309(23), 2445-2446.

• Wen, T., Beceiro, A., Conway, D., & Piper, J. (2001). Is there a maximum effective dose of pitocin? American Journal of Obstetrics & Gynecology, 185(6), Supplement December, page S212.

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