Week 11 High Risk Birth

Discuss VBAC (vaginal birth after cesarean) contraindications and risk.

After an alarming trend in escalating cesarean birth rates, there was a movement for women to be counseled regarding options for a trial of labor after cesarean (TOLAC) and attempt vaginal birth after cesarean (VBAC). TOLAC is a desirable option for women with nonrecurring indications for a cesarean (such as umbilical cord prolapse, breech, placenta previa, or nonreassuring fetal status). Women who have previously had a vaginal birth, have had one previous cesarean (and in some cases two), and have no medical, obstetric, or fetal contraindications for vaginal birth are excellent candidates for a TOLAC. While women with a previous vaginal birth and women who present in spontaneous labor have the highest success rates, women should be counseled on all birthing options. The average VBAC success rate is 60% to 80% (ACOG, 2015b). The ACOG (2015b) guidelines state that the following aspects are encouraging when considering a TOLAC: No contraindications for vaginal birth A woman with one or two previous cesarean births and a low transverse uterine incision A clinically adequate pelvis based on clinical pelvimetry or prior vaginal birth A woman with one previous cesarean birth with an undocumented uterine scar unless there is a high suspicion there was a classic incision performed previously Absence of other uterine scars or history of previous uterine rupture Risks associated with failed VBAC births are hemorrhage, need for blood products, ICU admission, uterine scar separation or uterine rupture, hysterectomy, surgical injuries, neonatal death, neurologic complications, and maternal death. Note that these complications occur as a result of a uterine rupture. The incidence of uterine rupture is 0.9% of all TOLACs (ACOG, 2015b). Women who go into spontaneous labor have a much lower incidence of uterine rupture than those who are given oxytocin (Pitocin) for induction or augmentation (ACOG, 2015b). Prostaglandin agents should not be used in women attempting a VBAC because of the increased risk of uterine rupture. The incidence of uterine rupture in women who receive a prostaglandin agent is as high as 2.25%, which is a 15.6-fold increase when prostaglandins are administered (ACOG, 2015b). Conservative policies, such as awaiting spontaneous labor, prohibiting the use of prostaglandin agents, and avoiding elective inductions, can assist in reducing the incidence of uterine rupture. See the Concept Map: TOLAC. Women who have a successful VBAC have lower incidences of infection, less blood loss, fewer blood transfusions, and shorter hospital stays. Healthcare costs are considerably lower for women who have a VBAC than for those who have a repeat cesarean birth (ACOG, 2015b). After a woman has had one successful VBAC, the risks of neonatal and maternal complications are low in subsequent attempts. An increasing number of VBACs are associated with greater VBAC success (ACOG, 2015b). Avoidance of repeat cesarean births is advocated for women who wish to have subsequent pregnancies because this reduces maternal and fetal morbidity and mortality in women desiring more children. Research shows that there are some factors that decrease the odds of a successful VBAC. These include recurrent indication for the initial cesarean, advanced maternal age, non-White ethnicity, gestational age greater than 40 weeks, maternal obesity, preeclampsia, shortened interval between pregnancies, and macrosomia (ACOG, 2015b). Nursing Management The nursing care of a woman undergoing VBAC varies according to institutional protocols. Generally, an intravenous infusion of fluids is started, continuous electronic fetal monitoring (EFM) is used, and clear fluids may be taken. A woman at higher risk may require additional precautionary measures, such as internal monitoring after the membranes have ruptured. Care must be taken to ensure that the woman and her partner feel safe but not unduly restricted by the VBAC status. Supportive and comfort measures are very important. The woman may be excited about this opportunity to experience labor and vaginal birth, or she may be hesitant and frightened about the possibility of complications. Your presence is important in providing information and encouragement for the laboring woman and her partner. (Ladewig 466-467)

Define "dystocia," and identify its contributing factors

Dystocia is difficult labor Dystocia may be caused by a wide variety of problems, the most common of which is dysfunctional (or uncoordinated) uterine contractions. These uncoordinated contractions result in a prolonged labor. Contractions that result in a more normal progression of labor tend to be moderate to strong when palpated and occur regularly (two to four contractions in 10 minutes in early labor and four to five per 10 minutes in later phases). Dysfunctional contractions are typically irregular in strength, timing, or both. These irregular uterine contractions are not effective in producing dilatation or effacement. Figure 21-1 depicts normal, tachysystolic, and hypotonic uterine contraction patterns. (Ladewig 425) Tachysystolic labor usually indicates more frequent contractions occur with less intensity.....contractions are painful but they don't produce effacement or dilation of the cervix.....these produces a prolonged latent phase.....prolonged contractions put baby at risk for hypoxia TS labor contributing factors: Maternal risks of tachysystolic labor include: Increased discomfort caused by uterine muscle cell anoxia Fatigue as the pattern continues and no labor progress results Frustration and stress on coping abilities Dehydration and increased incidence of infection if labor is prolonged Fetal/neonatal risks include: Nonreassuring fetal status caused by contractions and increased resting tone interfering with the uteroplacental exchange of gases and nutrients Prolonged pressure on the fetal head, which may result in cephalohematoma, caput succedaneum, or excessive molding (Figure 21-2) (Ladewig 425-426) Side note: To determine if the fetal heart rate (FHR) is reassuring, the following components should be present: a baseline FHR of 110 to 160 beats/min, presence of variability, spontaneous accelerations, and absence of decelerations. (Ladewig 425) Hypotonic labor Usually occurs in the active phase of labor..... characterized by fewer than two to three contractions in a 10-minute period (see Figure 21-1C). The contractions may be of low intensity and are characterized as causing minimal discomfort. Contributing factors: Hypotonic labor may occur when the uterus is overstretched from a twin gestation, or in the presence of a large fetus, hydramnios, fetal malposition, prematurity, or grand multiparity. Bladder or bowel distention and CPD may also be associated with this pattern. (Ladewig 427) MGMT Mgmt of tachysystolic labor: Management of tachysystolic labor may include bedrest and sedation to promote relaxation and reduce pain. Often pharmacologic intervention to promote sedation will stop these contractions. If the tachysystolic pattern continues and develops into a prolonged latent phase, oxytocin (Pitocin) infusion or amniotomy may be considered. An amniotomy can help a normal labor progress because of pressure on the cervix. Oxytocin can be used to strengthen existing contractions and lead to a more productive pattern (see Chapter 22). These methods are instituted only after cephalopelvic disproportion (CPD) and fetal malpresentation have been ruled out. (Ladewig 426) Mgmt of hypotonic The goals of therapy are to improve the quality of the uterine contractions while ensuring a safe outcome for the woman and her baby. Uterine contractions can be stimulated in several ways including the use of oxytocin (Pitocin), amniotomy, or stimulation of the nipples, which causes the release of endogenous oxytocin. Before initiating treatment for hypotonic labor, the physician/CNM validates the adequacy of pelvic measurements and establishes gestational age to ensure the fetus has reached maturity. After CPD, fetal malpresentation, and fetal immaturity have been ruled out, oxytocin (Pitocin) may be given intravenously via an infusion pump to improve the quality of uterine contractions. Intravenous fluid is useful to maintain adequate hydration and prevent maternal exhaustion. Amniotomy may be used to stimulate the labor process. An amniotomy is used to allow the presenting part to directly apply pressure on the cervix and promote effacement and dilatation. The application of an electric breast pump or manual stimulation of the nipples may help strengthen uterine contractions, and is an excellent starting point for women who want an unmedicated birth. (Ladewig 427)

Compare and contrast mechanical versus pharmacologic cervical ripening techniques in terms of mechanism of action, potential risks and specifics of management

For cervix's that need induction prostaglandin agents aids Oxytocin.....Vaginal births are more successful when prostaglandin agents are used prior to oxytocin Prostaglandin E1 ....is misoprostol Prostaglandin E2 is Prepidil or Cervidil Mechanical dilation is another method that can be used. Above methods should be used when preg woman is at term, or late preterm in cases where there is a medical, obstetric, or fetal indication for immediate birth including fetal demise Prepidil is .5mg of dinoprostone....it's placed intracervically or intravaginally....both have similar outcomes.... Prep can be administered every 6 hrs...max dose is 3 doses in 24 period Cervidil....packaged as a square vaginal mesh releasing 10mg of dinoprostone at .3mg/hr over 12 hrs. Cervidil insert has more vaginal births within 24 hours of administration, shorter hospitalizations and a lower incidence of postpartum hemorrhage compared to those that received the prepidil gel If you receive prostaglandin agents for induction of labor you have less or lower requirements for the oxytocin You would use these agents whenever induction is needed but not emergent And example would be the woman at 42 weeks gestation with an unfavorable cervix....she could be given prosta gel to ripen her cervix before oxytocin prostas are good for Maternal gestational diabetes preeclampsia and a large for gestational age fetuses.....Or for births that are late-term and warrant birth occurring in the near future MGMT of Prep: Gel is admin in hospital and then woman is monitored for 2 hours....adverse effects typically occur during this time.....after this woman is sent home and induction scheduled in near future Risks include: hypersystole and nonreassuring fetal status......typically these occur in the first 4 hrs... If FHR is unchanged after 2 hrs and uterine activity hasn't become regular, then discharge woman with instructions for follow up and warning signs. MGMT of Cervidil: While vaginal insert is in place continuous fetal monitoring should happen....woman should remain in a recumbent position for 2 hrs after admin risks include hypersystole, NRFS, and hyperstimulation If hypersystole or NRFS occurs then remove the insert immediately Administer a beta-adrenergic agent if hyperstimulation occurs Misoprostol is the synthetic PGE1 and it's typically administered vaginally...in the past oral and sublingual had been used According to book....miso is more effective than the above two agents as well as oxytocin Adv's over the others are: birth within 24 hrs of admin, and lower ces rates.......adverse outcomes are the same as the above....so all three are equal in that regard....also most of the adverse outcomes result from doses beyond the rec 25mcg Guidelines for induction: -initial does 25 mcg -dosing intervals shouldn't exceed intervals of 3 to 6 hrs -only administer when uterine activity and FHR can be continuously monitored for an initial observation period...(like the above 2hrs etc) -contraindicated in women with previous c-section and previous uterine surgery due to risk of uterine rupture Mechanical method.....Transcervical Balloon Catheter Transcervical balloon catheter insertion is a mechanical method that uses a Foley catheter balloon placed in the uterus to induce cervical ripening and dilatation. The Foley catheter is inserted through the cervix into the lower uterine segment and is then filled with 30 mL to 50 mL of sterile water resulting in direct pressure, which causes stress in the lower uterine segment and probably the local production of prostaglandins. Advantages of the balloon catheter include higher vaginal birth rates and lower rates of hypersystolic labor when combined with PGE 2 PGE 2 gel (Goldberg, 2015). Balloon catheter placement is often combined with other methods, including saline infusion, which has not been associated with any increased risk of chorioamnioitis (Goldberg, 2015). (Ladewig 454) Can also use low dose oxytocin The dosage is typically increased by 1 to 4 mu/min and may be more appropriate for fetuses with risk factors for labor intolerance, although this approach is less common than the prostaglandin agents (Ladewig 454) Laminaria is another form of mechanical dilation The use of laminaria in contemporary practice is mainly reserved for women with fetal demise. Laminaria sticks or tents are made from dried seaweed under the brand names of Dilapan and Lamicel. The agent works by water absorption and is a form of mechanical dilatation. Laminaria work in the same manner as the transcervical balloon catheter in that it results in mechanical dilatation (Goldberg, 2015). (Ladewig 454) Nursing Management Physicians/CNMs and birthing room nurses who have had special education and training may administer agents for cervical ripening. Provide the woman and her support person(s) information about the procedure and answer any questions. Assess baseline maternal vital signs and apply an electronic fetal monitor. The electronic fetal monitoring (EFM) tracing should indicate minimal or absent uterine activity, a reassuring fetal heart rate (FHR) pattern, and a reactive non-stress test (NST). If uterine contractions are not occurring regularly, the ripening agent is inserted into the vagina. Prepidil can be administered every 6 hours. If prescribed, Misoprostol (Cytotec) is administered every 3 to 6 hours until adequate cervical change occurs (ACOG, 2015a). Instruct the woman to empty her bladder prior to insertion. After insertion she should lie supine with a right hip wedge for a specified time (usually at least 1 hour). The woman can then assume any comfortable position. As discussed previously, monitor the woman for uterine hypersystole and FHR abnormalities (changes in baseline rate, variability, presence of decelerations) for at least 2 hours following insertion. During administration of PGE 2 PGE 2 , if nausea and vomiting are present or contractions occur more frequently than every 2 minutes (and/or last longer than 75 seconds), the gel is removed. (Ladewig 454) Signs of labor vs signs of common reaction to prosta's Prostas....cramping, uterine irritability, and gel leakage) true signs of labor (strong regular contractions, rupture of membranes (Ladewig 453)

Discuss maternal/fetal indications, contraindications, and potential risks of forceps-assisted delivery and vacuum-assisted delivery

Forceps-assisted delivery: Forceps are surgical instruments designed to assist in the birth of a fetus by providing either traction or the means to rotate the fetal head to an occiput-anterior position. In medical literature and practice, forceps-assisted birth is also known as instrumental delivery or operative vaginal delivery. The use of forceps is rare in modern obstetrics, with only 1% of deliveries being accomplished with forceps. This significant reduction has led to a reduction in trained obstetricians that are able to teach or perform the procedures; therefore, its use is likely to continue to decline (Ladewig 459) Indications for Forceps-Assisted Birth Forceps may be indicated in the presence of any condition that threatens the mother or the fetus and when immediate birth is indicated. Maternal conditions include cardiac or pulmonary disease, infection, inability of the mother to maintain effective pushing efforts, and history of spontaneous pneumothorax. Fetal conditions include premature placental separation, prolapsed umbilical cord when complete dilatation has been reached and fetal head is engaged, and nonreassuring fetal status (Ross, 2015). Forceps may be used to shorten the second stage of labor and assist the woman's pushing effort. Table 22-2 lists the conditions that must be met before forceps are used. (Ladewig 459) See table as well Neonatal and Maternal Risks Newborn complications may include ecchymosis or facial edema, facial lacerations, and brachial plexus (Ross, 2015). Caput succedaneum or cephalohematoma (entrapped hemorrhage) with subsequent hyperbilirubinemia may occur, as may transient facial paralysis. Although rare, cerebral hemorrhages, fractures, brain damage, and fetal death have also been reported (Ross, 2015). Maternal risks include possible lacerations of the birth canal; extensions of a midline episiotomy into the anus; vulvar or perineal edema, hematoma, bleeding, bruising, and anal incontinence (Ross, 2015). (Ladewig 459-460) Can see ch for nursing mgmt if needed Vacuum Assisted delivery: obstetric procedure used to facilitate the birth of a fetus by applying suction to the fetal head. The vacuum extractor is composed of a soft suction cup attached to a suction bottle (pump) by tubing. The suction cup, which comes in various sizes, is placed against the fetal occiput, and the pump is used to create negative pressure (suction) inside the cup. Traction is applied in coordination with uterine contractions and maternal pushing, descent occurs, and the fetal head is born (Figure 22-4). Progressive descent with the first two pulls should be assessed. Continuation of the procedure without noted descent should be limited to prevent cephalohematomas, brain injury, and fetal death (O'Grady, 2015). (Ladewig 460) Provide ongoing communication with the woman and her partner regarding the procedure, assess pain level, and advise the woman that if more than pressure is felt, pain medication can be provided. Assess FHR by continuous electronic fetal monitoring (EFM). Reassure the parents that the caput (chignon) on the baby's head will disappear within 2 to 3 days. Assessment of the newborn should include inspection and continued observation for cephalohematomas, intracerebral hemorrhage, and retinal hemorrhage (O'Grady, 2015). Because babies born via vacuum are at increased risk for jaundice, careful assessment of the newborn's skin color is also needed. (Ladewig 460) Thus risks of this include: Cephalohematomas intra-cerebral hemorrhage and retinal hemorrhage also at increased risk for Jaundice

List 5 indications for cesarean delivery

Indications Commonly accepted indications for cesarean birth include complete placenta previa, cephalopelvic disproportion, placental abruption, active genital herpes, umbilical cord prolapse, failure to progress in labor, nonreassuring fetal status, previous classical incision on the uterus (either previous cesarean birth or myomectomy), more than one previous cesarean birth, benign and malignant tumors that obstruct the birth canal, and cervical cerclage. Certain maternal medical conditions including cardiac disorders; severe maternal respiratory disease; central nervous system disorders that increase intracranial pressure; mechanical vaginal obstruction, such as an ovarian mass or lower uterine segment fibroids; and severe mental illness that results in an altered state of consciousness are all contraindications to a vaginal birth and warrant a cesarean birth (Cunningham et al., 2014). Other indications that are now commonly associated with cesarean birth, although in some circumstances the babies may be able to be delivered vaginally, include breech presentation, two or more previous cesarean births, major congenital anomalies, and severe Rh alloimmunization (ACOG, 2015b). (Ladewig 461-462)

Identify indications and contraindications for labor induction

Labor induction is considered inducing labor before spontaneous labor with or without membranes ruptured in order to birth the baby Indications for labor: Diabetes mellitus Renal disease Preeclampsia-eclampsia Chronic pulmonary disease Premature rupture of membranes (PROM) Chorioamnionitis Postterm gestation greater than 42 weeks Mild abruptio placentae without evidence of nonreassuring fetal status Intrauterine fetal demise (IUFD) Intrauterine fetal growth restriction (IUGR) Alloimmunization Oligohydramnios Nonreassuring fetal status Nonreassuring antepartum testing Fetal macrosomia (Ladewig 454) Relative indications include chronic hypertension, systemic lupus erythematosus, gestational diabetes, hypercoagulation disorders, cholestasis of pregnancy, polyhydramnios, fetal anomalies requiring specialized neonatal care, previous stillbirth, and late-term gestation (Ladewig 454) Contraindications: Client refusal Placenta previa or vasa previa Transverse fetal lie Prior classic uterine incision (or any vertical incision in the upper portion of the uterus) Active genital herpes infection Umbilical cord prolapse Absolute cephalopelvic disproportion Previous ruptured uterus (Ladewig 454) All contraindications to vaginal birth or spontaneous labor are contraindicated to induction. Relative contraindications include cervical carcinoma; malpresentation, such as breech; and funic presentation. A funic presentation is when the umbilical cord is interposed between the cervix and the presenting part. It can be located by clinical evaluation or by ultrasound (Ladewig 454)

Discuss the pharmacologic action and medication management of Pitocin

Pitocin stimulates uterine smooth muscle to contract Administration of oxytocin (Pitocin) is an effective method of initiating uterine contractions to induce labor and may also be used to enhance ineffective contractions (labor augmentation). A primary line of 1000 mL of electrolyte solution (e.g., lactated Ringer solution) is started intravenously. Ten units of oxytocin (Pitocin) are added to a secondary line of intravenous (IV) fluid so the resulting mixture will contain 10 milliunits/mL of oxytocin (Pitocin) (1 milliunit/min, or 6 mL/hr), and the prescribed dose can be calculated easily. After the primary infusion is started, the oxytocin (Pitocin) solution is piggybacked into the primary tubing port closest to the catheter insertion. The infusion is then administered using an infusion pump to control the flow rate precisely. The rate of infusion is based on physician/CNM orders and hospital protocol. Changes to the infusion rate are determined by assessment of the contraction pattern and fetal response. The goal for induction is to achieve stable contractions every 2 to 3 minutes that last 40 to 60 seconds. The uterus should relax to full baseline resting tone between each contraction. Progress is determined by changes in the effacement and dilatation of the cervix and station of the presenting part. Oxytocin (Pitocin) induction is not without some associated risks, including hyperstimulation of the uterus, resulting in uterine contractions that are too frequent or too intense, with an increased resting tone. Hypersystole may lead to a reduction in placental perfusion and may increase the risk of nonreassuring fetal status. Other risks include uterine rupture, water intoxication, fetal hypoxia, and in rare circumstances, fetal death (Ladewig 455)

Compare and contrast the risks and anticipated management of a patient with findings of premature rupture of membranes vs. preterm premature rupture of membranes

Risks for PPROM & PROM: Abruptio placentae Amniocentesis Bleeding during pregnancy Cervical insufficiency History of laser conization or loop electrosurgical excision procedure (LEEP) Hydramnios Infection Low body mass index Low socioeconomic status Maternal genital tract anomalies Multiple pregnancy Placenta previa Previous history of PPROM Tobacco use Trauma Urinary tract infection (UTI) (Ladewig 405) Maternal risk for this is especially associated with chorioamnionitis and endometriosis....abruptly placenta occurs frequently in P/PROM as well Retained placenta, hemorrhage maternal death and maternal sepsis are also complications associated with PROM Fetal/Newborn complications: Compression of the umbilical cord Fetal sepsis Increased perinatal morbidity and mortality Malpresentation Nonreassuring fetal heart rate tracings Premature birth Prolapse of the umbilical cord Respiratory distress syndrome (with PPROM) (Ladewig 405) Favorable outcomes for babies at term Faley favorable outcomes for babies at 32 to 37 weeks The earlier the baby is born two more likely do you have already RDS and NEC And intraventricular hemorrhage PROM that occurs at term is associated with favorable outcomes. Gestations from 32 to 37 weeks generally have favorable outcomes although there may be some complications. In general, babies born before 30 weeks have an increased risk of more serious complications, including respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), sepsis, and fetal/neonatal death (Guillet et al., 2015). The earlier the gestational age, the greater the likelihood of newborn complications (Guillet et al., 2015). (Ladewig 405) Mgmt for woman at 37 weeks without infection is conservative: CBC C-Reactive Protein Urinalysis....a culture for Group B strep, Chlamydia, and Gonorhea Ultrasound for gestational age, Amniotic fluid volume, and fetal well being NST's & BPP's Maternal heart rate blood pressure and temperature will be assessed every four hours along with fetal heart rate Antibiotics will be given in PPROM For both : Prophylaxis group B strep will be given and for babies born preterm corticosteroids and magnesium sulfate Babies In nursery will be monitored for sepsis and given antibiotics See table on down for this one....just shows antibiotics and week breakdown and then there's the nursing mgmt section

Compare and contrast classical vs. lower-segment (low transverse) cesarean delivery techniques and potential risks with each.

The skin incision for a cesarean birth is either transverse (Pfannenstiel) or vertical and is not indicative of the type of incision made into the uterus. The transverse incision (Figure 22-5) is made across the lowest and narrowest part of the abdomen. Because the incision is made just below the pubic hairline, it is almost invisible after healing. The limitation of this type of skin incision is that it does not allow for extension of the incision if needed. This incision is used when there is not an emergent need for birth, such as failure to progress, unknown breech presentation, or cephalopelvic disproportion (CPD) with no maternal or fetal stress. This type of incision is typically preferred by women for cosmetic reasons but does require more time to make and repair. (Ladewig 462-463) The vertical incision is made between the navel and the symphysis pubis and is typically reserved for emergent situations, such as nonreassuring fetal status when rapid birth is indicated. It is also used in preterm or macrosomic neonates, or when the woman is significantly obese (Cunningham et al., 2014). Time factors, client preference, previous vertical skin incision, or physician preference determines the type of skin incision. (Ladewig 463) The type of uterine incision depends on the need for the cesarean. The choice of incision affects the woman's opportunity for a subsequent vaginal birth and her risks of a ruptured uterine scar with a subsequent pregnancy. The two major locations of uterine incisions are in the lower uterine segment and in the upper segment of the uterine corpus. The lower uterine segment incision most commonly used is a transverse incision (Figure 22-6). The classic incision is a vertical incision made into the upper uterine segment and is no longer used. (Ladewig 463-464) See the table for adv's and disadvantages of each

Define external cephaloversion (ECV) and discuss indications, contraindications, and the nurse's role during the procedure

Version, or turning of the fetus, is a procedure used to change the fetal presentation by abdominal or intrauterine manipulation. The most common type of version is external cephalic version (ECV), in which the fetus is changed from a breech to a cephalic presentation by external manipulation of the maternal abdomen (Ladewig 451) This is decreasing as 90% of breech babies are born Caesarian Before the external version is begun, an ultrasound is used to locate the placenta and to confirm fetal presentation. The following criteria should be met before performing external version: The pregnancy is at 36 or more weeks of gestation. A version may result in complications that require immediate birth by cesarean. A non-stress test (NST), obtained immediately before performing the version, is reactive. A reactive NST indicates fetal well-being. The fetal breech is not engaged. Once the presenting part is engaged it is difficult, if not impossible, to do a version. (Ladewig 451) Contraindications include: Evidenced-based contraindications include the following (Berhan & Haileamlak, 2016): History of placental abruption or suspected placental abruption Severe preeclampsia Nonreassuring fetal status Complications based on expert opinion include the following (Berhan & Haileamlak, 2016): Amniotic fluid alterations, including rupture of membranes, oligohydramnios, or hydramnios Placenta previa or vasa previa Previous cesarean birth or other significant uterine surgery Multiple gestations Fetal abnormalities, such as intrauterine growth restriction (IUGR) or nuchal cord Before the ECV begins, an intravenous line may be established to administer medications in case of difficulty. The woman may receive tocolytics to relax the uterus. Some physicians may also order regional anesthesia for the procedure. Both tocolytics and regional anesthesia have been associated with higher success rates and fewer cesarean births (Berhan & Haileamlak, 2016). Ultrasound is frequently used to provide information about the fetal position and placental location. The version is discontinued in the presence of severe maternal pain or significant fetal bradycardia or decelerations. CLINICAL TIP Because the ECV procedure can be uncomfortable, encourage the woman to take slow, deep breaths. Using distraction and speaking in a calm, reassuring voice can help decrease fear and anxiety. Nursing Management On admission begin a thorough assessment by verifying that there are no contraindications to the version procedure. Maternal vital signs and a reactive non-stress test (NST) are obtained. This initial assessment period provides an ideal time for educating the woman and her partner and for addressing their concerns. They can be encouraged to express their understanding and expectations of the procedure. At the same time, the possibility of failure of the ECV; the slight risk of vaginal bleeding or spontaneous rupture of membranes; or the need for a cesarean birth if the FHR becomes nonreassuring should also be discussed. Explaining what will occur in any of these circumstances will better prepare the woman and her partner if intervention becomes necessary. Although the physician is ultimately responsible for obtaining informed consent, it is also your role to ensure that the woman understands the procedure and has the opportunity to ask questions and voice her concerns or fears. Place an intravenous (IV) line before beginning the procedure to maintain IV access in case of a complication. Throughout the procedure, continue to monitor maternal blood pressure, pulse, and comfort level frequently (because the mother may experience pain during the procedure). Fetal well-being is ascertained before, intermittently during, and for (at least) 30 minutes following the procedure, using electronic fetal monitoring (EFM), ultrasound, or both. Also assess maternal-fetal response to the tocolytic. If an epidural catheter was placed for anesthesia purposes, remove the catheter prior to discharge. Provide aftercare instructions, which should include maternal monitoring for contractions, fetal movement (fetal kick counts), and signs of complications from the procedure. (Ladewig 451-452)