INTRAPARTUM AMNIOINFUSION

POLICY Definition

Amnioinfusion refers to the instillation of fluid into the amniotic cavity. This procedure is typically performed during labour through an intrauterine pressure catheter introduced transcervically after rupture of the fetal membranes. Obstetricians order intrapartum amnioinfusion in the presence of oligohydramnios and repetitive fetal heart rate (FHR) variable decelerations, as this procedure has been shown to reduce the occurrence of the decelerations, improve short-term measures of neonatal outcome and lower the use of Cesarean section. There is no evidence that intrapartum amnioinfusion effectively reduces the risk of meconium aspiration syndrome. It is therefore not recommended for use only in the presence of thick meconium-stained .

Applicability: Intrauterine amnioinfusions occur in the Birthing area of the Acute Perinatal Program.

PROCEDURE 1.1 The following conditions should be met for placement of an IUPC:

 Fetal membranes must be ruptured  The cervix must be sufficiently dilated (at least 2-3 cm) to allow passage of the IUPC

1.2 Assemble Materials  Electronic Fetal Monitor  Alaris Infusion pump  Intrauterine Pressure Catheter (IUPC) Covidien™  Intravenous Infusion tubing for main line  Normal saline at room temperature – 1 litre, labelled Note: There is no evidence that warming the fluid above the ambient room temperature before administration confers any advantage.

1.3 Preparation  Attach the intravenous (IV) tubing to the litre of normal saline and prime the IV tubing. Clamp the line.

1.4 IUPC Insertion Obstetrician Performs a cervical exam to confirm adequate , ruptured membranes, and presenting part, and to determine optimal for catheter placement. Inserts the tip of the introducer (with the catheter inside) just inside the cervical os, avoiding placement between the decidua and membranes. Advance catheter to the cervical os. Note: Do not advance introducer through the cervix. Connect the purple cable to the white connector. 1) Feed catheter until the 45 centimetre mark (cm) is at the introitus. 2) Slide the introducer out of the vagina along the catheter. Separate the introducer from the catheter. Anchor the catheter in place and pull the introducer off the catheter. NOTE: In this position, the tip is usually just beyond the fetal head. 3) The catheter should go in easily and never be forced. If any resistance is met, the obstetrician should change the angle or position of insertion of the catheter. 4) Flow of amniotic fluid through the catheter at this point indicates appropriate placement

WW 05.03A Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 26-APR-2016 Page 1 of 3 Refer to online version – Print copy may not be current – Discard after use

INTRAPARTUM AMNIOINFUSION

Connect the purple cable to the white connector Remove the cap from the amnio port on the IUPC. Attach the primed IV tubing to the amnio port.

1.5 Intrauterine Infusion Place the amnioinfusion on the Alaris pump.  Infuse the initial bolus of 300 millilitres (mL) normal saline in approximately 20 minutes (15 mL/ minute) or as the physician's order.  After the initial bolus has infused, adjust and regulate the infusion rate (usually 100-200 mL/hr) according to the physician's orders.  Document the total volume of normal saline infused.

1.5 Monitoring Continuous electronic fetal monitoring

Observe and document every 15 minutes for the first hour after the IUPC insertion and start of amnioinfusion:  Colour and amount of fluid return  Fetal heart rate and pattern  Intrauterine pressure catheter placement  Uterine pressure - in Montevideo units, Note: The resting tone recording will be higher (by approximately 15 mm Hg) than normal, caused by the positive pressure flow from the fluid at the end of the catheter. Discontinue the amnioinfusion after the physician’s assessment and written orders. Discuss the ongoing need for the IUPC to monitor uterine contractions versus external uterine monitoring

DOCUMENTATION  Electronic Fetal Monitor Tracing (EFM)  Fetal Monitoring Label  Labour Partogram – record the total volume of normal saline infused and amount returned  Physician’s History and Progress Notes  Physician’s Orders

REFERENCES WW 05.03A Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 26-APR-2016 Page 2 of 3 Refer to online version – Print copy may not be current – Discard after use

INTRAPARTUM AMNIOINFUSION

Diogo Ayres-de-Campos, D. Spong Y. Chandraharan E for the FIGO Intrapartum Fetal Monitoring Expert Consensus Panel 1 (2013) FIGO consensus guidelines on intrapartum fetal monitoring: , Hofmeyr GJ, et al. Cochrane Database Syst Rev. 2012; (1):CD000013 [LOE 1a] ). Amnioinfusion for potential or suspected umbilical cord compression in labour. Roque, H. (2015). Amnioinfusion: Technique In UpToDate. Topic last updated on November 11, 2015. Xu, H., Hofmeyr, J., Roy, C., Fraser, W. (2007). Intrapartum amnioinfusion for meconium-stained amniotic fluid: a systematic review of randomised controlled trials. BJOG 114:383-390.

WW 05.03A Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 26-APR-2016 Page 3 of 3 Refer to online version – Print copy may not be current – Discard after use