Cervical Ripening

Cecilia Gambala MD, MSPH

Sarah Kilpatrick MD, PhD
Basics
Description
Cervical maturation or cervical ripening re!ers to the use o! either pharmacologic or
nonpharmacologic metho"s to pro"uce a more !avorable cervi# that is so!ter an" more
e!!ace"$ %his e!!ect &ill subse'uentl( increase the likelihoo" o! a success!ul in"uction
o! labor$ %he goal o! prein"uction cervical ripening is to "ecrease time to "eliver( an"
possibl( lo&er the rate o! cesarean "eliver($
Pharmacologic metho"s)
o Hormonal metho"s)
Prostaglan"ins
o *#(tocin
+onpharmacologic metho"s)
o Membrane stripping
o Mechanical "ilators
o H(groscopic "ilators
o Balloon catheter ,alone, &ith traction, &ith in!usion-
o .mniotom(
/pi"emiolog(
Bet&een 0112 an" 3224, the rate o! labor in"uction in the 5S increase" !rom 1$67 to
30$37 o! all births nation&i"e$
Pathoph(siolog(
Pharmacologic metho"s)
o PG/s)
32 carbon bioactive lipi" important !or cervical maturation
/3) Dinoprostones ,Cervi"il, Prepi"il-
/0) Misoprostol ,C(totec-
o *#(tocin ,Pitocin-)
Potent en"ogenous uterotonic agent
M(ometrial o#(tocin receptor concentrations increase on
average 02283229!ol" "uring pregnanc(, reaching a ma#imum
"uring earl( labor$
+onpharmacologic metho"s)
o Mechanical release o! en"ogenous prostaglan"ins !rom the membranes
an" a":acent "eci"ua, &hich ma( be involve" in stimulating
m(ometrial contractions an" in the onset o! labor
o Ma( trigger an autonomic neural re!le# that promotes the release o!
o#(tocin !rom the maternal posterior pituitar(
Diagnosis
Signs an" S(mptoms
Histor(
Patients &ho re'uire cervical ripening are those &hose management plans
inclu"e an in"uction o! labor !or either maternal or !etal in"ications$
;n"uction re!ers to the initiation o! uterine contractions be!ore the spontaneous
onset o! labor !or the purpose o! "eliver($
Cervical ripening ma( be the 0st step to in"uction$
;mportant obstetric histor()
o Histor( o! prior cesarean "eliveries)
Histor( o! prior classical uterine incision contrain"icate"
*ther contrain"ications to in"uction o! labor inclu"e but are not limite" to)
o Placenta or vasa previa
o %ransverse !etal lie
o .ctive genital herpes in!ection
o .llergies or a"verse reactions to me"ications ,i$e$, prostaglan"ins,
o#(tocin, misoprostol-
.lert
PG/0 use is contrain"icate" in patients &ith histor( o! prior cesarean section or ma:or
uterine surger($
Ph(sical /#am
Cervical e#am &ith assessment o! "ilation, e!!acement, station, consistenc(,
an" cervical position
Bishop score) ;! <=, then cervical ripening recommen"e" !or an increase"
likelihoo" !or a success!ul in"uction o! labor$ /ach parameter can score up to
> points)
o Dilation in centimeters
o Close", 2 points)
083 cm, 0 point
>84 cm, 3 points
?6 cm, > points
o /!!acement 7)
28>27, 2 points
428627, 0 point
=28@27, 3 points
?A27, > points
o Station)
9>, 2 points
93, 0 point
90 or 2, 3 points
B0 or B3, > points
o Consistenc()
Cirm, 2 points
Me"ium, 0 point
So!t, 3 points
o Cervical position)
Posterior, 2 points
Mi"position, 0 point
.nterior, 3 points
.ssess shape an" a"e'uac( o! bon( pelvis) Clinical pelvimetr(
.ssess estimate" !etal &eight an" presentation b( Deopol" maneuvers$
%ests
Routine labor an" "eliver( a"mission testing
+S% to assess !etal &ell being
.mniotic !lui" assessment i! in"icate"
;maging
5S to con!irm verte# presentation i! nee"e"
%reatment
General Measures
Document in"ications o! in"uction o! labor$
Revie& histor( o! an( contrain"ications to labor an"Eor vaginal "eliver($
Con!irm G.$
Determine !etal position$
Con!irm !etal &ell being$
Continuous !etal monitoring is necessar( in appropriate situations$
Pregnanc(9Speci!ic ;ssues
B( %rimester
Doses o! pharmacologic agents changes !rom >r" trimester in"uctions to 3n" trimester
in"uctions !or termination$ *#(tocin ,Pitocin- is not as e!!ective !or in"uction o! labor
compare" to other options available !or 3n" trimester in"ications$ /#act "osing
consi"erations are liste" in Me"ications section belo&$
Risks !or Mother
Caile" in"uction
+ee" !or cesarean section
%ime
Discom!ort
P$>=1
Risks !or Cetus
;ntolerance to uterine contractions
Special %herap(
Complementar( an" .lternative %herapies
Mechanical "ilation using an intracervical catheter can be augmente" &ith lo&9"ose
;F Pitocin$
Me"ication ,Drugs-
;! a pharmacologic metho" is pre!erre" !or cervical ripening, the !ollo&ing
"rugs can be use"$ Consi"er changing in"uction metho" a!ter 34 hours i! no
progress$
Prostaglan"in /3)
o >r" trimester)
Prepi"il) 2$6 mg in 3$69mD gel intracervical preparation '48=h
Cervi"il) 02 mg in time"9release intravaginal preparation '03h
PG gel) Dinoprostone in various concentrations ,386 mg- in 02
mD gel
o 3n" trimester)
Dinoprostone) 32 mg suppositor( '=h
Prostaglan"in /0, Misoprostol ,C(totec-)
o >r" trimester)
36862 Gg '4h intravaginall( at e#ternal cervical os or posterior
!orni#
62 Gg P* '4h
o 3n" trimester cervical ripening an" in"uction !or termination)
0228322 Gg intravaginall( '>84h
4228A22 Gg intravaginall( '=803h
o %ablets come in 02283229Gg !orms
*#(tocin 084 m;5Emin, lo&9"ose, continuous in!usion
.lert
PG/0 use is contrain"icate" in patients &ith histor( o! prior cesarean
"eliveries or ma:or uterine surger($
Si"e e!!ects) %ach(s(stole ,more !re'uent &ith 62 Gg- or h(perstimulationH
nausea, "iarrhea, an" !ever
Surger(
;! a nonpharmacologic metho" is pre!erre", the !ollo&ing metho"s can be
use"$ Keep in min" relative contrain"ications) Mucopurulent cervical
"ischarge, rupture" membranes$
Membrane stripping)
o Digital separation o! chorioamnionic membrane !rom the &all o! the
cervi# an" lo&er uterine segment
Mechanical "ilators, balloon catheters)
o ;ntracervical Cole( balloon catheter place" in the cervical canal at the
lo&er uterine segment, late# or nonlate# in siIes 0A83= gauge$
o %he catheter balloon is then !ille" &ith >2 mD o! sterile normal saline$
o %raction is then applie" b( taping the catheter taut onto the patientJs
thigh$
o +ormal saline solution can also be in!use" through the catheter port at
>2 mDEh ,/.S;H e#tra amniotic saline in"uction-$
o Can also use concomitantl( &ith o#(tocin
o ;! not e#pelle" spontaneousl( a!ter 03 hours, remove an" continue &ith
another metho"$
H(groscopic "ilators)
o .bsorbs &ater to s&ell an" !orcibl( "ilate the cervi#
o Daminaria) Desiccate" sea&ee"
o Dilapan pol(acr(lonitrile
o Damicel) Magnesium sul!ate in pol(vin(l alcohol
o Place" into cervical canal at internal os a!ter cleansing cervi# &ith
Beta"ine
o Place gauIe into vagina to keep "ilators in place$
o Remove 03834 hours a!ter placement an" procee" &ith !urther
ripening or in"uction$
.lert
;! late# allerg(, balloon catheter is contrain"icate"$
Collo&up
Complications
Potential complications o! PG/ analogues)
o Complications are "ose relate"
o 5terine h(perstimulation)
;ntracervical PG/3 get ,2$6 mg-) 07
;ntravaginal PG/3 gel or vaginal insert) 67
Subse'uent CHR "eceleration
Rarel(, uterine rupture
Rarel(, placental abruption
*#(tocin)
o 5terine rupture rare
o 5terine h(perstimulation
o Kater into#ication &ith high concentration an" h(potonic solutions
.mniotom()
o 5mbilical cor" prolapse ,rare-
o Chorioamnionitis
o 5mbilical cor" compression
o Rupture o! vasa previa
Stripping the membranes)
o Blee"ing !rom un"iagnose" placenta previa or lo&9l(ing placenta
o .cci"ental amniotom(
Mechanical "ilators)
o Risk o! maternal or neonatal in!ection
Patient Monitoring
Mother
Kith PG preparation)
o Patient shoul" remain recumbent !or at least >2 minutes$
o Recor" vital signs$
o 5terine activit( is monitore" continuousl( !or >2 minutes to 3 hours
a!ter a"ministration o! PG/3 gel$
o ;! no increase in uterine activit( an" CHR unchange", ma( trans!er
else&here
Kith Misoprostol)
o 5terine activit( monitoring in hospital setting
Cetus
Kith PG/3 vaginal insert)
o /lectronic !etal heart rate monitoring !rom placement o! vaginal PG/3
until at least 06 min a!ter removal$
Kith misoprostol)
o CHR monitoring in hospital setting
Bibliograph(
.C*G Committee *pinion +o$ >43$ ;n"uction o! Dabor a!ter Faginal Birth a!ter
Cesarean Deliver($ Kashington, DC) .C*GH 322=$
Gabbe$ *bstetrics) +ormal an" problem pregnancies, 4th e"$ +e& Lork) Churchill
DivingstoneH 3223$
Miscellaneous
.bbreviations
M CHRNCetal heart rate
M G.NGestational age
M +S%N+onstress test
M PGNProstaglan"in