HEALTH SERVICES CODE I.12
NURSING PROCEDURE TITLE: Intrauterine Pressure Catheter (IUPC) Assisting with Insertion and Amnioinfusion in Labour & Birth A. IUPC B. Amnioinfusion
CATEGORY: RN – Special Nursing Procedure
A. INTRAUTERINE PRESSURE CATHETER (IUPC) - ASSISTING WITH INSERTION
PURPOSE Intrauterine Pressure Catheter provides the most accurate means of assessing the intensity of uterine contractions when external monitoring is limited and/or high doses of oxytocin are being infused. To infuse saline solution into intrauterine amniotic space when indicated.
NOTE:
ADVANTAGES:
Provides the most accurate assessment of contraction frequency, intensity and duration in mmHg. May be beneficial when there is difficulty palpating contractions.
DISADVANTAGES:
Placement requires cervical dilation and for membranes to be ruptured which may increase the risk for infection. Rare but possible risks include uterine perforation, placental trauma and fetal trauma. These are lessened with proper placement and aseptic technique. Invasive procedure that restricts patient’s ability to ambulate and reposition comfortably.
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NURSING ALERT: The use of an IUPC is contraindicated in undiagnosed vaginal bleeding, vaginal or intrauterine infection.
EQUIPMENT
1. IUPC: Intrauterine pressure catheter kit 2. Sterile gloves and lubricant 3. Transducer cables 4. Appendix A: Calculating Montevideo Units 5. Appendix B: Oxytocin Induction and Augmentation
PROCEDURE
1. Ensure verbal consent should be obtained by the physician prior to insertion. Explain the procedure, advantages and disadvantages to the patient and her supports.
2. Assess maternal vital signs and document accordingly.
3. Continue monitoring, assessment, interpretation, evaluation and documentation of the Electronic Fetal Monitoring (EFM) as per current classification system.
4. Ensure that membranes are ruptured and cervical dilation is adequate for insertion.
5. Assist the patient into modified lithotomy position and provide pericare.
6. Open the appropriate intrauterine pressure catheter set maintaining sterility.
7. Plug the reusable cable part into the uterine activity outlet on the monitor.
8. Connect the catheter to the reusable cable by locking in place with a click.
Figure A: Connect Catheter to Cable
9. Adjust EFM monitor to zero mmHg.
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NOTE: Depending upon the monitor, zeroing may be done by pressing a > < ‘ re-zero button or UA Reference button on either the connecting cable or the monitor.
10. Assist the physician as needed while s/he is inserting the IUPC. Reassure the patient while the procedure is being done.
11. Place the attachment pads on patient's upper thighs and attach transducer cable to pad.
Figure B: Secure Adhesive Pad to Mother
12. Palpate uterus for contraction.
13. Press and hold the blue button on the reusable cable when there is no contraction and
with the catheter connected to the cable. In conjunction, press the uterine adjustment (UA) reference button on the front of the monitor to “zero”. Remove your finger from the button once it has zeroed. Resume monitoring.
Figure C: Secure Adhesive Pad to Mother NOTE: Re-zeroing the System: The System must be re-zeroed in the following circumstances: If the patient is disconnected from the monitor for any reason If the mother’s position has changed so that the height of the maternal xyphoid has changed, they system may be to be re-zeroed to get accurate readings. If you see the message CHECK IUP in the UA display area on monitor screen, there is insufficient compensation to provide 100 mmHg above the reference level. If a negative value (< 0 mmHg) is displayed.
NOTE: To check cable function if cable performance is in question: Disconnect the intrauterine catheter from the cable. Plug catheter end of the cable into the inline cable test port. The inline cable test port is located in the Re-zero box on the blue cable. Press and hold the blue re-zero button on the cable. In conjunction, press and hold the uterine adjustment (UA) reference button on the front of the monitor to zero. Remove your hand from monitor. Release blue button. In the presence of amnioinfusion the resting tone may be elevated and the physician should be notified. Replace the cable if this reading is not obtained.
14. Ask patient to cough. A spike on tracing indicates proper positioning and functioning of the IUPC. If there is no peak, re-zero the system.
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Figure C: Rezeroing the system
Figure D: Pressing Zero Button
Figure E: Cable Check
15. Document the time of insertion, baseline resting tone pressures with the mother in semi- flower’s, left lateral and right lateral positions and if the system was re-zeroed.
16. Assess contractions remains every 15 minutes by palpation, IUPC reading, or if changes are observed. Assessing Montevideo units to assess adequacy may be helpful. See Appendix A.
NOTE: Assessment parameters with IUPC typically are an intensity >25 mmHg and <75 mmHg above the resting tone (except in the second stage). Normal resting tone is <7-25mmHg. Refer to physician’s orders for addition.
17. Document the patient’s tolerance to the procedure.
NURSING ALERT:
Uterine resting tone may be elevated with: oxytocin administration, hypertonus, amnioinfusion, chorioamnionitis, oligohydramnios, polyhydramnios, and multiple fetuses. If hypertonus is observed, discontinue oxytocin and notify physician.
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B. AMNIOINFUSION USING AN IUPC
PURPOSE
Amnioinfusion is the process of infusing a warmed isotonic solution through the cervix into the amnion to increase the total fluid volume to alleviate persistent complicated variable decelerations associated with cord compression.
NOTE:
ADVANTAGES:
Amnioinfusion has been shown to improve fetal response to labour and is associated with lower cesarean section rates.
DISADVANTAGES:
Risks associated with amnioinfusion are cord prolapse, uterine over-distention and infection. In the event that the amnioinfusion is unsuccessful in improving fetal status, the patient should be readied for a cesarean section. The patient is unable to leave the bed.
NURSING ALERT:
In order to implement the amnioinfusion, cord prolapse must be ruled out. Membranes must be ruptured and cervix dilated.
EQUIPMENT
1. 1,000 mL sterile normal saline, pre-warmed to 37ºC 2. IV tubing 3. Infusion pump 4. Intravenous fluid warmer 5. IUPC kit (if not already in place) 6. Additional peripads
PROCEDURE
1. Ensure informed consent is obtained by physician. Explain the advantages and disadvantages to the patient and her supports.
2. Assess maternal vital signs and document accordingly.
3. Continue monitoring, assessment, interpretation, evaluation and documentation as per current classification system.
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4. Assist physician to preform IUPC placement if not already insitu. Secure the IUPC to the adhesive leg pad.
NOTE: While patient is in a recumbent position, be sure to have a lateral wedge placed to decrease the risk of supine hypotension syndrome and optimize uteroplacental blood flow.
5. Remove cap from the amnioline on the IUPC.
6. Observe for presence of amniotic fluid in line. Note characteristics of the amniotic fluid.
NOTE: In most cases, amniotic fluid will spontaneously fill the amnioline once the cap is removed. If not, attach a 3 cc syringe and draw back until amnioline is filled. Remove syringe. DO NOT INFUSE AIR INTO THE UTERINE CAVITY.
7. Attach amnioinfusion apparatus to amnioinfusion line.
8. Re-zero IUPC and begin amnioinfusion as per orders.
9. Assist patient to a comfortable position and provide pericare as needed.
10. Document time of infusion, rate of infusion, fetal heart rate response to infusion and temperature settings of the infusion warmer.
11. Assess, interpret, and provide interventions every 15 minutes for EFM. Assessment including palpation of contractions should be done every 15 minutes or as needed. Amnioinfusion may elevate the resting tone and the physician should be notified if the resting tone is above 25 mmHg.
12. Monitor maternal vital signs as per protocol. Monitor temperature every 2 hours or when other signs and symptoms of infection are present.
13. Monitor intake and output every hour on the labour record.
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REFERENCES:
Caple, C., & Pravikoff, D,. (November 4, 2016) Amnioinfusions: Assisting with. CINAHL Nursing Guide. EBSCO Publishing. Retrieved January 3, 2017 at: http://web.a.ebscohost.com/nup/detail/detail?vid=2&sid=b5337769-ac94-47ef-b2e2- f7fc2f101a2e%40sessionmgr4008&hid=4207&bdata=JnNpdGU9bnVwLWxpdmUmc2 NvcGU9c2l0ZQ%3d%3d#AN=T707024&db=nup
Champlain Maternal Newborn Regional Program. (2014). Intrauterine Pressure Catheter- Assisting with Insertion and Monitoring. Ottawa, Ontario. Adapted with permission. Retrieved February 13, 2017 at: http://www.cmnrp.ca/site/cmnrp/Obstetrical_p737.html
Cunningham F, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS. eds. (2014) Chapter 23. Abnormal Labour. Williams Obstetrics.(24th Edition). New York, NY: McGraw-Hill. Retrieved March 13, 2017 at: http://accessmedicine.mhmedical.com/content.aspx?bookid=1057§ionid=59789163
Evans, R.J., Evans, M.K., Brown, Y.M.R., & Orshan, S.A., (2010) Canadian Maternity, Newborn, & Women’s Health Nursing. Chapter 16 High-Risk Labour and Childbirth. (pp. 650-651). Philadelphia, PA: Lippincott Williams & Wilkins.
Fundamentals of Fetal Health Surveillance: A Self-Learning Manual. (2014) FHS-408 Module. Chapter 6 Electronic Fetal Surveillance. (4th Edition). Vancouver, BC: The British Columbia Perinatal Health Program. Retrieved February 2, 2017 at: http://www.cesei.org/education/courses/content.php?cid=6646
Gabbe, S.G., Neibyl, J.R., Simpson, J.L., Landon, M.B., Galan, H.L., Janiaux, E.R.M., Grobman, W.A., (2017). Obstetrics Normal and Problem Pregnancies. Chapter 12 Normal Labour and Delivery. (pp. 249). (7th Edition). Philadelphia, PA: Elsevier
Hofmeyr, F.J., & Lawrie, T.A. (2012). Amnioinfusion for potential suspected umbilical cord compression in labour. Cochrane Database of Systemic Reviews 2012, Issue 1. Art. No.:CD000013.
Maggio, L., Forbes, J., Carey, L.L., Sangi-Haghpeykar, H., & Davidson, C. (2014). Association of Montevideo units with uterine rupture in women undergoing a trial of labor. Journal of Reproductive Medicine. Vol.50. No 9-10. (pp.464-469).
Medtronic (2017) Kendal Intrauterine Pressure Catheter. Reference #2076CAO.
Mol, B.W.J., Logtenberg, S.L.M., Verhoeven, C.J.M., Bloemenkamp, K.W.M., Papatsonis, D.N.M., Bakker, J.J.H., & Van der Post, J.A.M. (2016). Does measurement of intrauterine pressure have predictive value during oxytocin-augmented labour. Journal of Maternal- Fetal & Neonatal Medicine. Vol. 29(20). (pp.3239-3242). DOI: 10.3109/1476705.2015.1123243.
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REFERENCES (Continued):
Vazquez, V.G., Ruiz, R.S., Badillo, M.P.C., Fuentes, M.N., Vallejo, J.L.G., & Prieto, A.P.(2013). Intrapartum transcervical amnioinfusion. Current Women’s Health Reviews, Vol. 9 (pp245- 251). Bentham Science Publishers.
Written By: A. Dornstauder, RN, Labour & Birth Unit; F. CarteriBitz, CDE Labour & Birth Unit; J. Hanowski, CDE Labour & Birth Unit; L. Thorp, RN Coordinator Perinatal Outreach Education Program Date: May 2017
Approved by: Date:
18 Jan 18
Regina Qu’Appelle Health Region Health Services Keyword(s): IUPC Nursing Procedure Committee
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APPENDIX A
Calculating Montevideo Units
Montevideo Units (MVU’s) Using MVU’s as a measure to quantify adequate contractions can be associated with determining the likelihood for a successful vaginal delivery. MVU’s ranging >200 mmHg are typically associated with adequate contraction patterns for successful vaginal delivery in active labour. There is no correlation between higher MVU’s and potential for determining risk for uterine rupture. Lower MVU’s can be correlated with increased likelihood for cesarean section. Calculating MVU’s is done by subtracting the baseline intrauterine pressure from the peak contraction pressure for each contraction over a 10 minute period. Each pressure is then added together to obtain MVU’s.
(52+50+47+44=49=242 MVU)
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APPENDIX B
Oxytocin Induction and Augmentation
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