CH 19 Nursing care during obstetric procedures.

If nonreassuring FHR patterns occur or if contractions are hypertonic, the nurse takes steps. These steps include: 1. Reducing or stopping the oxytocin infusion and increasing the rate of the primary nonadditive infusion.

2. Keeping the woman on her side to prevent aortocaval compression and increase placental blood flow. 3. Giving 100% oxygen by snug facemask at a rate of 8 to 10 L/min in addition a tocolytic drug such as terbutaline may be given.

• As term nears, the fetus may spontaneously turn to a cephalic presentation. •The fetus is more likely to return to an abnormal presentation if version is attempted before 37 weeks because of smaller size. • If fetal compromise or onset of labor occurs, the fetus will be at or near term at birth.

3. woman is given tocolytic drug to relax uterus. An epidural block or other analgesic may be given to increase maternal comfort and relaxation. Ultrasonography guides fetal manipulations. If indicated, Rho(D) immune globulin (RhoGAM) is given to the Rh-negative woman after external version to prevent Rhsensitization. lastly labor induction can be done.

2. Infection: With interruption of the membrane barrier, vaginal organisms have free access to the uterine cavity and may cause chorioamnionitis, or infection of the amniotic sac. Birth within 24 hours of amniotomy is desirable.

3.Abruptio Placentae (premature separation of a normally implanted placenta) may occur if the uterus is distended when the membranes rupture. The risk is greater if there is excessive amniotic fluid in the uterus (hydramnios), because of greater uterine distention.

The pulse, respirations, and blood pressure provide important clues to the woman's circulatory and respiratory status. If oxygen saturation falls below 95%, having her take several deep breaths usually raises it.

A respiratory rate of less than 12 breaths per minute suggests respiratory depression. Deep breathing and coughing move secretions out of the lungs and promote full expansion. A small pillow to support her incision reduces pain when she coughs. Position changes every 2 hours improve ventilation and decrease discomfort from constant pressure.

Risks Maternal risks include laceration or hematoma of the vagina, perineum, or periurethral area and a very large episiotomy. The infant may have ecchymoses, facial and scalp lacerations or abrasions, facial nerve injury, cephalhematoma, subgaleal hemorrhage, and other intracranial hemorrhage.

A vacuum extractor creates circular scalp edema and redness or bruising called a chignon at the application area.

OPERATIVE VAGINAL BIRTH An operative vaginal birth is one in which the physician applies traction to the fetal head during birth with a vacuum extractor or forceps, to aid the woman's expulsive efforts.

A vacuum extractor uses suction to grasp the fetal head as traction is applied .It is not used to deliver the fetus in a converted presentation, such as breech or face; otherwise, its use is similar to that for forceps.

c SEC TECHNIQUE Epidural or combined spinal-epidural (CSE) block is typical for cesarean birth. drug such as famotidine (Pepcid) or sodium citrate with citric acid (Bicitra) is given to reduce gastric acidity before surgery.

A wedge placed under one hip prevents aortocaval compression and promotes placental blood flow. An indwelling catheter inserted after the regional block is established but before the surgery keeps the bladder away from the operative area, reducing the risk for injury

The woman's blood pressure and pulse are taken every 30 minutes or with each oxytocin dose change to identify changes from her baseline. Her temperature is checked every 4 hours (every 2 hours after membrane rupture) to identify infection.

After birth, observe for postpartum hemorrhage caused by uterine relaxation. Postpartum uterine atony is more likely if the woman has received oxytocin for a long time, because the uterine muscle becomes fatigued

•Hypertension associated with pregnancy or chronic hypertension, both of which are associated with reduced placental blood flow • Abruptio placentae (large abruptions require immediate delivery) •Maternal medical conditions that are worsening with continuation of the pregnancy (such as diabetes, renal disease, pulmonary disease, chronic hypertension) • Fetal death

Augmentation of labor with oxytocin is considered when labor has begun spontaneously but progress has slowed or stopped because of poor contractions.

cesarean birth and VBAC VBCA associated with a small but significant risk of uterine rupture.

Besides risks common to any surgery, multiple cesarean births have risks such as greater risk for placental abnormalities such as placenta previa (low-lying placenta) or placenta accreta (abnormal adherence of the placenta to the uterine wall, often along the previous incision area)

Techniques Amniotomy and Medical methods for induction or augmentation use drugs such as prostaglandins or intravenous (IV) oxytocin (Pitocin), or both, to stimulate contractions.

CERVICAL RIPENING Procedures to ripen (soften) the cervix and make it more likely to dilate with the forces of labor are a common adjunct to induction. Cervical ripening may be done the morning of induction or possibly the day before.

B) internal version: Malpresentation in twin gestations is usually managed by cesarean birth, but internal version may be used for vaginal birth of the second twin.

CONTRAINDICATION OF VERSION Maternal conditions that may contraindicate external version or reduce its success include: • Uterine malformations that limit the room available to perform the version and may contribute to the abnormal fetal presentation. • Previous cesarean birth, although some facilities offer version on an individualized basis. • Disproportion between fetal size and maternal pelvic size. •Fetal size 4000 g or larger.

• Active genital herpes at the time of birth •Some previous uterine surgical procedures, such as a classic cesarean incision • Persistent nonreassuring FHR patterns •A prolapsed umbilical cord •Fetal malpresentations, such as breech or transverse lie •Hemorrhagic conditions, such as abruptio placentae or placenta previa

CONTRAINDICATIONS TO C SEC. These conditions include fetal death, a fetus that is too immature to survive, and maternal coagulation defects.

RSK OF C SEC Many maternal risks are associated with any major abdominal surgery: • Infection •Hemorrhage and possibly transfusion •Urinary tract trauma or infection •Thrombophlebitis, thromboembolism •Paralytic ileus •Atelectasis •Anesthesia complications

Cesarean delivery poses added risks for the infant, which may include: • Inadvertent preterm birth •Transient tachypnea of the newborn caused by delayed absorption of lung fluid • Persistent pulmonary hypertension of the newborn • Injury, such as laceration, bruising, fractures, or other trauma Validation of fetal maturity is essential when a cesarean birth is planned.

IDENTIFYING COMPICATIONS: Cord compression is suspected if deep or prolonged variable decelerations occur during contractions or persistent bradycardia is present after contractions.

Chart the quantity, color, and odor of the amniotic fluid. Assess mom's tem every 2 hrs report elevations greater than 38C (100.4° F). Fetal tachycardia (sustained rate above 160 beats per minute [bpm]) often precedes maternal fever. Change the underpads regularly for comfort and to reduce the moist environment that favors bacterial growth.

NURSING CONSIDERATIONS : PROVIDING INFO. Providing Information The physician explains the indications and risks for external version to the woman before she signs an informed consent form. The nurse verifies the woman's understanding of the purposes, risks, and limitations of version.

Consent for cesarean birth is obtained. Also obtain consents if epidural or spinal anesthesia is planned.The purposes and side effects of any tocolytic drug are reviewed. Tachycardia, flushing, headache, and tremors are common side effects of tocolytics such as terbutaline.

INDICATIONS: Maternal indications may include exhaustion, inability to push effectively, cardiac or pulmonary disease, and intrapartum infection. Fetal indications may include cord compression, premature separation of the placenta, or nonreassuring FHR patterns.

Contraindications A cesarean birth is preferable if the maternal or fetal condition mandates a more rapid birth than can be accomplished with forceps or a vacuum extractor or if the procedure would be too traumatic.

Determining Whether Induction Is Indicated The Bishop scoring system (Table 19-1) uses five factors to estimate cervical readiness for labor: cervical dilation, effacement, consistency, position, and fetal station.

Contraindications • Placenta previa (implantation in lower uterus), which may result in hemorrhage during labor • Vasa previa, in which fetal umbilical cord vessels branch over the amniotic sac rather than inserting into the placenta; fetal hemorrhage is a possibility if the membranes rupture • Abnormal presentation for which vaginal birth is often hazardous •Umbilical cord prolapse, because immediate birth by cesarean is indicated

Facial asymmetry, most obvious when the infant cries, suggests facial nerve injury that is usually temporary. Neurologic abnormalities such as seizures suggest that the newborn has had an intracranial hemorrhage. Seizures also may occur with neonatal hypoglycemia or sepsis, however. Scalp edema in the area of vacuum extractor cap is common.

EPISIOTOMY Examples of situations when the birth attendant may do an episiotomy include: • Fetal shoulder dystocia, in which the shoulder of a fetus becomes lodged under the mother's symphysis during birth • Forceps- or vacuum extractor-assisted births •Birth with the fetus in an occiput posterior (face up) position

INDUCTION AND AUGMENTATION OF LABOR Indications:Induction of labor, or artificial initiation of labor, is considered when ending the pregnancy benefits the woman or fetus and when labor and vaginal birth are considered safe.

Examples of specific conditions that are indications for induction include: • Fetal compromise • Spontaneous rupture of the membranes at or near term without onset of labor (premature rupture of the membranes or PROM) • Postterm pregnancy •Chorioamnionitis (inflammation of the amniotic sac)

tachysystole:to contractions that are too strong, too long, or do not relax at least 30 seconds

FHR patters when inc. uterine contraction w/ dec relaxation : fetal bradycardia (<110 bpm at term), tachycardia (persistent rate >160 bpm at term), late decelerations (slowing after the peak of the contraction), and decreased FHR variability (reduced rate fluctuations) that is not explained by medications or fetal sleep.

VERSION --> methods to change fetal presentation

Indications A) External Cephalic Version: The fetus may be changed from a breech, shoulder (transverse lie), or oblique presentation to a cephalic presentation using external cephalic version (ECV) during late pregnancy

PROMOTING SAFETY The catheter bag is placed near the head of the table so that the anesthesia clinician can monitor urine output..

Leads for the cardiac monitor and pulse oximeter are placed to observe heart and respiratory functions. A grounding pad permits safe use of the electrocautery. Infant care equipment should be readied for immediate use.

median or midline and mediolateral

NURSING CONSIDERATIONS: An upright position while pushing promotes gradual stretching of the woman's perineum. Laboring down, or delaying pushing until the urge is felt, also gradually distends the soft tissues of the pelvic floor. .

Amniotomy is deferred if the fetal presenting part is high in the pelvis or if the presentation is not cephalic. The risk for a prolapsed cord is greater in these situations because more room is available for the cord to slip down. In addition, a cesarean, or surgical, birth is usually performed for a noncephalic presentation.

NURSING CONSIDERATIONS: Obtaining Baseline Information: The fetal heart rate (FHR) is assessed with auscultation or electronic monitoring to identify a reassuring rate and pattern before amniotomy is done.

hand pump is used to create suction to hold the vacuum cup on the fetal head in the midline of the occiput. a maximum of 3 pulls

Nursing Considerations The woman's bladder should be empty, usually by catheterization, before attempting an operative vaginal birth. The physician specifies the type of forceps or vacuum cup. The FHR should be assessed, and any rate less than 100 bpm should be reported.

Amniotomy (artificial rupture of the amniotic sac) is often done in conjunction with induction or stimulation of labor or to permit internal electronic fetal monitoring

Observe for 3 major risks: 1. prolapse of the umbilical cord:umbilical cord will slip down in the gush of fluid. The cord can be compressed between the fetal presenting part and the woman's pelvis, obstructing blood flow to and from the placenta and reducing fetal gas exchange.

Oxytocin administration is therefore titrated to uterine and fetal response. The rate of oxytocin infusion may be gradually reduced when the woman is in the active phase of labor, about 5 to 6 cm of cervical dilation. it is stooped if tachysystole occurs

Observing the Fetal Response: Oxytocin stimulates uterine contractions, and they may become too strong (hypertonic). Hypertonic contractions can reduce placental blood flow and therefore reduce exchange of fetal oxygen and waste products. Before induction or augmentation of labor, the nurse determines whether the FHR and patterns are reassuring.

After the surgery, the incision area is cleansed with sterile water and a sterile dressing is applied. Blood and amniotic fluid are cleaned from the woman's abdomen, buttocks, and back before she is transferred to a bed. Smooth transfers done by an adequate number of personnel reduce pain and hypotension.

PROVIDING POSTOP CARE In addition to temperature, routine postoperative assessments include:• Vital signs and character of respirations; oxygen saturation; ECG pattern (usually normal sinus rhythm)• Return of motion and sensation (if a regional block was given)•Level of consciousness (particularly if general anesthetic or sedating drugs were given)

When the woman pushes, use of an open-glottis technique promotes gradual perineal stretching. Daily perineal massage and stretching by the woman from 36 weeks of gestation until birth has been shown to reduce the risk for perineal trauma during birth

Perineal cold applications are done for the first 12 hours, followed by intermittent perineal heat applications after at least 12 hours if needed.

If the woman chooses VBAC, the nurse should reinforce the appropriateness of attempting VBAC and advantages of a vaginal birth, such as fewer overall complications individually.

Possible indications for cesarean birth include but are not limited to: • Dystocia •Cephalopelvic (fetopelvic) disproportion cephalopelvic disproportion: Fetal head size that is too large to fit through the maternal pelvis at birth. Also called fetopelvic disproportion. •Hypertension, if prompt delivery is necessary •Maternal diseases such as diabetes, heart disease, or cervical cancer, if labor is not advisable

Medical Methods: Preparations containing prostaglandin E2 (PGE2, or dinoprostone) may be used to facilitate cervical ripening. Prostaglandin may be given as an intravaginal or intracervical gel or a timed-release vaginal insert

Prostaglandin should be given cautiously to women who have asthma; glaucoma; ischemic heart disease; or pulmonary, hepatic, or renal disease. The major adverse reaction to prostaglandin for induction is tachysystole. (It's use for cervical ripening or labor induction remains an offlabel use for misoprostol)

RISKS: FHR changes are common during the procedure, The fetus may become entangled in or compress the umbilical cord, can cause abruption placentae if the manipulation disrupt placental site.Mixing of fetal and maternal blood within small breaks in placental vessels.

Technique External Version: 1. A nonstress test or biophysical profile to evaluate feta health. An ultrasound examination confirms fetal gestational age and fetal presentation and demonstrates adequacy of amniotic fluid. 2. it is done at 37 wks or + but bf labor bc:

the dressing check for drainage w/ each fundal check. The nurse assesses the lochia and urine output with other assessments. Lochia may pool under the mother's buttocks and lower back. Urine may be bloody temporarily if the cesarean birth occurred after a long labor or an attempted forceps or vacuum delivery.

The nurse must remember that a falling urine output is an early sign of hypovolemia, occurring well before the fall in blood pressure. oral analgesics the day after surgery.

•Abdominal dressing •Uterine firmness and position (midline or deviated) •Lochia (color, quantity, presence and size of any clots) •Urine output (quantity, color, other characteristics) •IV infusion •Pain-relief needs

The nurse observes for return of motion and sensation if the woman had epidural or subarachnoid block anesthesia. The level of consciousness and respiratory status (skin or mucous membrane color; rate and quality of respirations; oxygen saturation) are important observations if she had general anesthesia.

Technique The woman's bladder should be empty to limit bladder trauma. Membranes must be ruptured and the cervix completely dilated for forceps or vacuum-extraction birth. .

The woman needs adequate anesthesia, usually with a regional block such as an epidural block.Forceps- and vacuum extractor-assisted births are classified according to how far the fetal head has descended into the pelvis when these instruments are applied

Incisions Two incisions are made: one in the abdominal wall (skin incision) and the other in the uterine wall.

Three types of uterine incisions are possible (1) low transverse; (2) low vertical; and (3) classic, a vertical incision into the upper uterus.

TEACHING The nurse explains preoperative procedures and their purposes, such as labs, the abdominal skin prep, indwelling catheter, IV lines, medications, and dressings. The catheter and IV lines usually remain in place no longer than 24 hours after birth.

Use of serial compression devices to reduce risks of venous thrombosis should be explained. The nurse may need to reinforce anesthetic information provided by the anesthesia clinician.

Women who have regional anesthesia, such as an epidural or subarachnoid block, often fear that they will feel pain during surgery. They do feel pressure and pulling, but these sensations do not mean that the anesthesia is wearing off.

if she is having general anesthesia-->The nurse describes the OR and everyone who will be present to make it less intimidating to the woman. Staff she encounters in the OR before surgery should introduce themselves if possible. The support person should be told when he or she can expect to come into the OR. If it is not already in place, an epidural block is often established after the woman goes to OR

The three classifications are outlet, low, and midpelvis (or mid-forceps): • Outlet operative vaginal delivery: The fetal head is on the perineum, with the scalp visible at the vaginal opening without separating the labia.

• Low operative vaginal delivery: The leading edge of the fetal skull is at station +2 cm (about 4 cm below the level of the mother's ischial spines) or lower. • Midpelvis operative vaginal delivery: The station is above +2 cm, but fetal head is engaged.

Fetal conditions that may contraindicate version: •Placenta previa. is an indication for C sec. itself. • Multifetal gestation, which reduces available room to turn the fetus or fetuses. • Uteroplacental insufficiency. • Engagement of the fetal presenting part into the pelvis.

• Oligohydramnios (abnormally small amount of amniotic fluid), ruptured membranes, or a cord around the fetal body or neck (nuchal cord). These conditions limit the room in which to turn the fetus and may lead to cord compression and fetal hypoxia.

Mechanical Methods: Any of several techniques use mechanical means to ripen and begin dilation of the cervix: • Transcervical catheter: Placement of a balloon-tipped Foley catheter in the cervix with possible saline infusion through the catheter into the space between the internal os and intact membranes (extra-amniotic saline infusion, or EASI).

• Placement of hydrophilic (moisture-attracting) inserts into the cervical canal, where they absorb water and expand, gradually dilating the cervix. Examples are: • Dilapan-S and Lamicel •Laminaria tents: sterile, cone-shaped preparations of dried seaweed; more than one can be placed in the vagina to absorb water and expand

Oxytocin administration: precautions reduce the chance of adverse reactions in the mother and fetus: • Oxytocin is diluted in an isotonic solution and given as a secondary (piggyback) infusion so that it can be stopped quickly if complications develop.

• The oxytocin line is inserted into the primary IV line as close as possible to the venipuncture site to limit the amount of drug infused after changing to the nonadditive fluid. • Primary nonadditive IV fluid is started first. Oxytocin is then started slowly, increased gradually. • Uterine activity and FHR and patterns are monitored before induction, when oxytocin is started, and throughout labor.

RISKS: • Uterine tachysystole (hyperstimulation), which can reduce placental perfusion and fetal oxygenation caused by excessive frequency, duration, or intensity of contractions,

• Uterine rupture, more likely to occur with overdistention. •Maternal water intoxication caused by oxytocin's antidiuretic effects; more likely if hypotonic solutions are used to dilute the oxytocin. • Greater risk for chorioamnionitis and cesarean birth.

• Some uterine surgery, such as classic cesarean. • One or more previous low transverse cesarean births • Breech presentation • Maternal heart disease, which varies in severity •Severe maternal hypertension

•Uterine overdistention such as multifetal pregnancy, especially triplets or higher, and hydramnios • Fetal presenting part above the pelvic inlet, which may be associated with cephalopelvic disproportion or preterm • Nonreassuring FHR patterns that do not yet mandate emergency delivery