Care of the Woman During Labor induction

Before each increase of the Pitocin infusion rate, assess the

I FHR baseline, variability, and reactivity, noting the

presence of accelerations, any decelerations, or

following:
Maternal blood pressure, pulse, respirations, temperature, and pain level
E Contraction statusincluding frequency, duration, intensity,

bradycardia
For additional information about nursing interventions during use of Pitocin, see Drug Guide: Oxytocin (Pitocin) and Nursing Care Plan: The Induction of Labor.

and resting tone

Q

Drug Guide

text/rind:

intrinsic
is 1milliunit/min = 3 miJhr. If 10units Pitocin are added to 250 mL IVsolution, the concentration is 1 milliunit/min = 1.5 mL/hr.

Overview of Obstetric Action Oxytocin (Pitocin) exerts a selective stimulatory effect on the smooth muscle of the uterus and blood vessels. Oxytocin affects the myome! trial cells of the uterus by increasing the excitability of the muscle cell, increasing the strength of the muscle contraction. and supporting prop! agation of the contraction (movement of the contraction from one myo! metrial cell to the next). Its effect onthe uterine contraction depends on the dosage used and on the excitability of the myometrial cells. During the rst half of gestation, there is little excitability of the myometrium, and the uterus is fairly resistant to the effects of oxytocin. However, from midgestation on, the uterus responds increasingly to exogenous intravenous oxytocin. Cautious use of diluted oxytocin administeredin! travenously at term results in a slow rise of uterine activity. The circulatory half-life of oxytocin is 3 to 5 minutes. It takes approximately 40 minutes for a particular dose of oxytocin to reach a steady-state plasma concentration (Wilson et al., 2013). The effects of oxytocin on the cardiovascular system can be pro! nounced. Blood pressure initially may decrease, but after prolonged administration may increase by 30% above the baseline. Cardiac output and stroke volume increase. With doses of 20 milliunits/min or above, oxytocin exerts anantidluretic effect, decreasing free water exchange in the kidney and markedly decreasing urine output. Oxytocin is used to induce labor at term and to augment uterine contractions in the rst and second stages of labor. Oxytocin may also be used immediately after birth to stimulate uterine contraction and thereby control uterine atony.

SAFETYALERT!
It is imperative for the nurse to know the concentration of Pitocin in milliunits per minute to prevent accidental overdos! age, which can result in tachysystolic labor patterns, nonre! assuring fetal status. and fetal bradycardia. For Administration After Expulsion of Placenta I One dose of 10 units of Pitocin (1 mL) is given intramuscularly or added to IVuids for continuous infusion. ll Assess maternal blood pressure, pulse. and uterine resting tone before each increase in oxytocin infusion rate. I Record all assessments and IV rate on patient's chart. Record oxytocin infusion rate in miliiunits per minute and milliliters per hour (e.g., 0.5 milliunits/min [3 mL/hrl). I Record all patient activities and procedures. I Apply nursing comfort measures. I if bleeding is well controlled, often oxytocin is discontinued afterthe initial postpartum infusion.

Route, Dosage, Frequency For induction of Labor or Augmentation of Labor 3 Start with primary IV tubing and piggyback secondary IV with 10 units of Pitocin (1 mL) to 1000 mL of intravenous solution. (i he resulting concentration is 10 milliunits oxytocin per 1 mL of intravenousuid.) Oxytocin is infused using an infusion pump. I Using an infusion pump, administer IV, starting at 0.5"1 milliunit/ min and increase by 1"2 milliunits/min every 40"60 minutes. Alternatively, start at 1"2 milliunits/min and increase by 1 milliunit/ min every 15 minutes until an adequate contraction pattern (every 2"3 minutes and lasting 40"60 seconds) is achieved. I Provide continuous monitoring of the fetus and uterine contrac! tions, and ensure that vital signs, including maternal blood pres! sure, heart rate, and oxygen saturation, are being assessed every 15 minutes. of in some settings or inasituation when limited uids may beadmin! istered, a more concentrated solution may be used. When 10 units Pitocin are added to 500 mLIVsolution, the resulting concentration

Maternal Contraindications I Severe preeciampsialeclampsia I Predisposition to uterine rupture (in nullipara over 35 years of age, multigravida 4 or more, overdistention of the uterus, previous major surgery of the cervix or uterus) Cephalopelvic disproportion Malpresentation or malposition of the fetus, cord prolapse More than one previous cesarean birth Preterm infant Rigid, unripe cervix; total placenta previa I Presenceof nonreassuring fetal status Maternal Side Effects Hyperstimulation of the uterus results in hypercontractiiity, which in turn may cause the following: I Abruptio placentae I Impaired uterine blood ow, leading to fetal hypoxia E Rapid labor and birth, leading to lacerations of cervix, vagina, or perineum; uterine atony; fetal trauma Uterine rupture I Water intoxication (nausea, vomiting, hypotension. tachycardia, cardiac arrhythmia) if oxytocin is given in electrolyte-free solution or at a rate exceeding 20milliunits/min; hypotension with rapid IV bolus administration postpartum
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Drug Guide .liiatilill lfiiilll):

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a Maternal vital signs, including blood pressure, heart rate, and oxygen saturation, are monitored every 15 minutes. [a Assess FHR; frequency, duration. and intensity of uterine contrac! tions; and presence of decelerations, accelerations, and uterine resting tone every 15 minutes and before each increase in the oxytocin infusion rate. Record patient activities (such as change of position, vomiting), procedures done (amniotomy, sterile vaginal examination), and administration of analgesic agents to allow for interpretation and evaluation of tracing. I! Assess cervical dilatation as needed. I Discontinue IVoxytocin infusion and infuse primary solution when (1) nonreassuring fetal status is noted (bradycardia, late or vari! able decelerations); (2) uterine contractions are more frequent than every 2 minutes; (3) duration of contractions exceeds more

Effect on Fetus/Newborn ti Fetal effects are primarily associated with the presence of hyper! contractility oi the maternal uterus. Hypercontractility decreases the oxygen supply to the fetus, which is reected by irregularities or decrease in fetal heart rate (FHR), as well as hypoxia E Hyperbilirubinemia(Wilson et al., 2013) 3 Trauma from rapid birth Hypoxia asan effect of maternal hypotension
Nursing Considerations I Explain induction or augmentation procedure to patient. E Apply fetal monitor, and obtain 15- to 20-minute tracing and non! stress test (N31) to assess FHR before starting lVoxytocin. a For induction or augmentation of labor, start with primary Ill, and piggyback secondary IV with 0xytocln and infusion pump. Pitocin can never be run without aninfusion pump and must always be run

using a secondary line. a Ensure continuous fetal and contraction monitoring.Telemetry units can beworn for ambulationor use of bath tubs. I The maximum rate is 40milliunitslmin (A000, 2009). Not all proto! cols recommend a maximum dose. When indicated, the maximum dose is generally between 16 and 40 milliunitslmin. Decrease oxy! tocin by similar increments once labor has progressed to 5"6 cm dilatation. Protocols may vary from one agency to another. 0.5 milliunit/min = 3 mUhr 8 milliunitslmin = 48 mL/hr 1.0 mllllunit/min = 6 mUhr 10milliunitslmin = 60 mUhr 1.5 milliunitslmin = 9 mUhr 12 milliunitslmin = 72 mUhr 2 milliunitslmin = 12 mL/hr 15 milliunitslmin = 90 mUhr 4 milliunitslmin = 24 mL/hr 18milliunitslmin = 108 mUhr 6 milliunitslmin = 36 mUhr 20 milliunits/min = 120 mUhr

than 60 seconds; or (4) insufcient relaxation of the uterus be! tween contractions or a steady increase in resting tone is noted (ACOG, 2009). In addition to discontinuing IV oxytocin infusion, turn patient to side, and if nonreassuring fetal status is pres! ent, administer oxygen by tight face mask at 7"10 Umin; notify physician/CNM. I Maintain intake and output record.

SAFETY ALERT!
Women receiving Pitocin warrant ongoing assessment eV cry 15 minutes and need closer ongoing observation when Pitocin levels are increased. If the nurse cannot adequately monitor the woman immediately following a dosage increase, it is advisable to wait to increase the medication until careful monitoring capabilities are available.

Expected Outcome Intervention Rationale 1. Nursing Diagnosis: Injury, Risk for, related to hypersystole of uterus caused by induction of labor (NANDA-l 2012)
N10 Priority Intervention: Health education

N08 Suggested Outcome: Maternal status: lntrapartum; patient will remain free from injury

Goal: The woman will experience progression of labor without difculty or complications.
Obtain a baseline for maternal blood pressure,pulse,respirations, temperature, and pain level.

E Pitocin induction can affect the cardiovascular system. Blood pressure may initially be de! creased. lithe induction is prolonged, the blood pressure may increase by 30%. Respirations can become elevated because of pain sensation, anxiety, or physiologic causes.Temperature is obtained to monitor for infection.The pain level is assessed continuously to determine if pain medicationis warranted or changes in vital signs are caused by maternal discomfort.
a Assesses for fetal well-being. Normal FHR ranges from 110 to 160 beats/min.Variability measuring three to ve uctuations in 1 minute is documentedas average.Continuous elec! tronic fetal monitoring (EFM) is performed during a Pitocin induction.

a Place patient on external fetal monitor for 20 minutes to obtain a baselinefor fetal heart rate (FHR) and variability.

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