Chapter 19; Nursing Care During Obstetric Procedures: McKinney

Amniotomy Abruptio Placentae

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. As the uterus collapses with discharge of the amniotic fluid, the area of placental attachment shrinks. The placenta then no longer fits its implantation site and partially separates. A large area of placental disruption reduces fetal oxygenation, nutrition, and waste disposal.

Synopsis of chapter

Although labor is a normal process, special procedures are sometimes needed to help the mother or fetus. A physician or nurse-midwife performs these procedures while nurses provide supportive care. Descriptions of procedures and nursing considerations for each are addressed.

Version

Either of two methods may be used to change fetal presentation: external version or internal version. Each has different indications and a different technique. External version is much more common.

PROSTAGLANDIN PREPARATIONS FOR CERVICAL RIPENING AT TERM PROSTAGLANDIN GEL (DINOPROSTONE OR PREPIDIL) VAGINAL INSERT - DINOPROSTONE OR CERVIDIL - MISOPROSTOL (CYTOTEC)

--Dosage 0.5 mg applied to cervix. May be repeated 6-12 hr later to a maximum of 1.5 mg (three applications) applied to the cervix; 2.5 mg vaginally. 10 mg in a timed-release vaginal insert. Remove after 12 hr or at onset of active labor. One quarter of 100-mcg tablet vaginally (approximately 25 mcg; see cautions below). Also used for labor induction by repeating 25-mcg dose every 3-6 hr. A 50-mcg dose is associated with hypertonic contractions. --Actions for Uterine Tachysystole, with or without Nonreassuring Fetal Heart Rate Pattern Place woman in side-lying position. Provide oxygen by facemask at 8-10 L/min. Administer tocolytic drug such as terbutaline or magnesium sulfate. Typically begins 1 hr after gel application. Higher incidence with vaginal application. Same as for dinoprostone gel. Remove insert. Hypertonic uterine activity may occur up to 9½ hr after insert placement. Greater incidence than with lower-dose intracervical dinoprostone gel. Same as for dinoprostone gel. Higher doses or more frequent administration is more likely to cause excessive contractions, which may be accompanied by a nonreassuring FHR pattern. --When Oxytocin Induction May Begin Safe interval has not been established. Delaying oxytocin administration for 6-12 hr after total intracervical dose of 1.5- or 2.5-mg vaginal dose recommended. 30-60 min after removal of insert. At least 4 hr after last dose. --Precautions and Comments Limit dinoprostone gel to maximum of 1.5 mg dinoprostone gel in 24 hr. Woman should remain recumbent with lateral uterine displacement for 15-30 min after application. Has increased effect if combined with other oxytocics such as oxytocin (Pitocin). Increases hypertensive effect of the herb ephedra. Use caution in women with asthma, hypertension, glaucoma, or severe renal or hepatic dysfunction, ischemic heart disease. Remove after 12 hr or when active labor begins. Adverse effects can be reduced within 15 min of removal. Most expensive of the prostaglandin options. Misoprostol is currently FDA approved only for treatment of peptic ulcers but is widely used for cervical ripening and induction of labor. Manufacturer does not intend to seek approval, but American College of Obstetricians and Gynecologists supports its use for these purposes. 100-mcg tablet is not scored. Pharmacist should prepare the 25-mcg dose for best accuracy. Cost is about 1%-2% that of other prostaglandin preparations. Contraindicated in the woman with a previous cesarean or other uterine surgery.

Indications: 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. Successful version may allow the woman to avoid a cesarean birth. ECV to change the fetal presentation from breech to cephalic has shown a wide range of success given the many factors that impact the procedure. Some unsuccessful versions spontaneously change to cephalic before labor. Birth outcomes after ECV in current studies have shown mixed results. Some studies have found that the cesarean rate is still higher than average after successful ECV, whereas others have not demonstrated a difference

BOX 19-2 NURSING CARE FOR A WOMAN HAVING A CESAREAN BIRTH Before the Cesarean Birth

1. Assess the time of last oral intake and what was eaten. 2. Assess for allergies. Include drug, food, and substance (e.g., latex or skin prep) allergies. 3. Determine medications taken and last dose. Include over-the-counter and herbal preparations. 4. Have the woman sign informed consents for surgery, anesthesia, and usually blood transfusion. Newborn care is usually signed at this time if not earlier. 5. Obtain ordered laboratory work. 6. Do preoperative teaching: what the woman can expect in the operating and recovery rooms, infant care, and who will be present. 7. Start ordered intravenous infusion and begin bolus dose for regional anesthetic at appropriate time (see "Epidural Block" in Chapter 18). 8. Do abdominal hair clip with small scissors or an electric clipper. 9. Administer ordered medication to control gastric secretions if not done by anesthesiologist. 10. Insert a urinary indwelling catheter (or insert in operating room after regional block). 11. Assist woman to operating table, positioning her with a wedge under her hip to displace the uterus. Women having scheduled cesareans may walk to the operating room (OR). 12. Apply grounding pad for electrocautery. 13. Do sterile prep of abdomen. 14. Call infant care team if it is routine in the facility or for anticipated newborn complications.

BOX 19-2 NURSING CARE FOR A WOMAN HAVING A CESAREAN BIRTH During the Recovery Period

1. Begin anesthesia-related interventions: pulse oximeter, oxygen administration, cardiac monitor. a.Assess for return of sensation and movement if regional anesthesia was used. b.Assess level of consciousness if general anesthesia was used. 2. Do routine assessments every 15 min for the first hour, every 30 min during the second hour, and hourly thereafter until the woman is transferred to the postpartum unit. Assess: a.Vital signs; oxygen saturation. b.Electrocardiogram (ECG) pattern. c.Uterine fundus for firmness, height, and deviation (massage if poorly contracted). d.Lochia for color, quantity, and presence of large clots. e.Urine output for color, quantity, and patency of the catheter and tubing. f.Abdominal dressing for drainage. g.Return of lower body movement if regional block. 3. Assess need for analgesia, and administer as ordered. 4. Change position hourly if no contraindication exists. Have woman breathe deeply and cough at each routine assessment time. Provide a small pillow to support her incision when coughing or turning if sensation is present.

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. Examples of these conditions are severe fetal compromise or a high fetal station and acute maternal conditions such as pulmonary edema.

Amniotomy Technique

A disposable plastic hook (Amnihook) is commonly used to perforate the amniotic sac (Figure 19-1). The physician or nurse-midwife does a vaginal examination to determine cervical dilation and effacement, fetal station, and fetal presenting part. 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. The hook is passed through the cervix, and the membranes are snagged. The hole is enlarged with the finger, allowing fluid to drain.

Technique external version

A nonstress test or biophysical profile (see Chapter 15) is done before external version to evaluate fetal health and placental function. If the test is nonreactive or other nonreassuring signs are present, the procedure is not done. Version adds stress to the fetus already functioning with reduced physiologic reserve. An ultrasound examination confirms fetal gestational age and fetal presentation and demonstrates adequacy of amniotic fluid External version is usually attempted at 37 or more weeks of gestation but before the woman is in labor, for the following reasons: •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. The woman may be given a tocolytic drug, such as terbutaline 0.25 mg subcutaneously, to relax the uterus while the version is performed. An epidural block or other analgesic may be given to increase maternal comfort and relaxation. Ultrasonography guides fetal manipulations during external version and helps monitor the FHR. The physician gently pushes the breech out of the pelvis in a forward or backward roll (Figure 19-3). If indicated, Rho(D) immune globulin (RhoGAM) is given to the Rh-negative woman after external version to prevent Rh sensitization (Branch, Silver, & Aagaard-Tillery, 2008). Labor induction may be done immediately after a successful version, or the woman may be discharged to await spontaneous labor or a later induction. FIG 19-3 External version. Intravenous (IV) access is established in case of emergency or for some tocolytic drugs. If terbutaline is the tocolytic drug, it is given by subcutaneous injection.

CRITICAL THINKING EXERCISE 19-1

A physician performs an amniotomy on a laboring woman whose cervix is dilated to 5 cm. The amniotic fluid is pale yellow and moderate in amount and has a strong odor. The fetal heart rate (FHR) averages 160 to170 beats per minute (bpm) and accelerates when the fetus moves. Maternal vital signs are temperature, 37.6° C (99.7° F); pulse, 92 bpm; respirations, 22 breaths per minute; and blood pressure, 116/80 mm Hg. Contractions are moderate to firm in intensity and occur every 3 to 4 minutes with a duration of 50 to 60 seconds and complete uterine relaxation between contractions. 1.Which of these observations should the nurse regard as normal? Which observations are abnormal? 2.Should the nurse modify routine labor care based on the postamniotomy assessments?

CRITICAL THINKING EXERCISE 19-2

A woman is having term labor induced with oxytocin. Her cervix is 4 cm dilated and fully effaced, and the fetal head is at station 0. The nurse notes that the fetal heart rate (external monitor) is near its baseline of 120 to 130 beats per minute (bpm), with a variability of 10 bpm. Contractions are firm, occur every 2 minutes (every 120 sec), and the duration is usually 100 seconds. The nurse must palpate contractions because the woman has thick abdominal fat. With palpation the nurse notes that the woman's uterus does not fully relax before another contraction begins. 1. What is the correct interpretation of these assessments? 2. What are appropriate nursing actions in this situation, and why are they done?

Promoting Safety

Although the need for general anesthesia during pregnancy occurs infrequently, the nurse must assume that it may be needed. The woman's food intake is assessed for type and time on admission. Oral intake and emesis during labor are recorded and reported to the anesthesia clinician. Usually the woman is on nothing per mouth (NPO) status, or only ice or clear liquids is given if a cesarean birth is expected. Anesthesia-related drugs to control gastric and respiratory secretions are administered as ordered. The woman is transferred and positioned carefully to prevent injury, especially if she has received regional anesthesia that reduces motor control and sensation. Her bony prominences are well padded. A safety strap placed across her thighs secures her on the narrow operating table. A wedge placed under one hip or tilting the operating table avoids aortocaval compression and reduced placental blood flow. During positioning, the drain tube of the indwelling catheter should be routed under her leg to promote drainage and keep the tube away from the operative area. The catheter bag is placed near the head of the table so that the anesthesia clinician can monitor urine output. The nurse verifies proper function of machines such as suction devices, monitors, and electrocautery. 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. 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.

Promoting Comfort

Amniotic fluid leaks from the woman's vagina after membranes rupture. Change the underpads regularly for comfort and to reduce the moist environment that favors bacterial growth.

Amniotomy Indications

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 (see Chapter 17). Although it is a common procedure, amniotomy implies a commitment to delivery.

Amniotomy Risks

Amniotomy is seen by many professionals and expectant mothers as harmless, and it usually is, but the nurse must observe for three major associated risks, and assist in any emergency procedures needed.

Episiotomy technique

An episiotomy is done when the fetal presenting part has crowned to a diameter of about 3 to 4 cm. The two types of episiotomies have different advantages and disadvantages: median or midline; and mediolateral (Figure 19-7).

Amniotomy: Prolapse of the Umbilical Cord

An immediate and continuing risk is that the 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.

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. The use of forceps has decreased while use of vacuum extractors has increased. The number of births assisted by vacuum extraction is more than four times the number of forceps-assisted births. However, as the rate of cesarean births has risen, vaginal births assisted by either vacuum extractor or forceps have decreased since 1990 (Bofill & Martin, 2008; Martin, Hamilton, & Ventura, 2011). Forceps are metal instruments having two curved blades with rounded edges that can be locked in the center. Many styles are available for different needs (Figure 19-4). Disposable foam pads are available to cushion the fetal head. Forceps or a vacuum extractor also may be used during a cesarean birth to help pull the baby through the incision. A vacuum extractor uses suction to grasp the fetal head as traction is applied (Figures 19-5, p. 422 and 19-6, p. 422). 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. Three applications is the usual limit allowed by policy.

Contraindications

Any contraindication to labor and vaginal birth is a contraindication to induction or augmentation of labor. These conditions may include: •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 note: This system is used to estimate how easily a woman's labor can be induced. Higher scores are associated with a greater likelihood of successful induction because her cervix has undergone prelabor changes, often called ripening. A woman who has given birth before usually has a successful induction when her Bishop score is 5 or higher. Delivery in a woman who is having her first baby is most successfully induced if her score is 7 or higher. •Some uterine surgery, such as classic cesarean (see p. 427 and Figure 19-9) or extensive surgery for uterine fibroids Other maternal or fetal conditions are not contraindications to induction but require individual evaluation, such as the following: •One or more previous low transverse cesarean births (see Figure 19-9) •Breech presentation (vaginal birth may be more hazardous; also the fetus may turn to a normal position by the time spontaneous labor occurs) •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 (fetal head size that is too large to fit through maternal pelvis) or a preterm fetus •Nonreassuring FHR patterns that do not yet mandate emergency delivery.

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

BOX 19-1 VAGINAL BIRTH AFTER CESAREAN BIRTH

Approximately 60% to 80% of women with one low transverse uterine incision from a previous cesarean birth have successful vaginal births. Women who had their previous cesarean for a nonrecurring reason, such as breech presentation, are more likely to have a successful vaginal birth after cesarean (VBAC) birth than women who had their previous cesarean for dystocia. Women who have had a vaginal birth before or since the prior cesarean birth are more likely to have successful VBAC. Recommendations from the American College of Obstetricians and Gynecologists (ACOG) related to VBAC include: •No more than two previous low transverse uterine incisions •No other uterine scars (e.g., removal of fibroid tumors) or a previous uterine rupture •A pelvis that is clinically adequate for the estimated fetal size •Immediate availability of a physician during active labor if an emergency cesarean is needed •Availability of anesthesia and personnel to perform an emergency cesarean •Medical management of women who plan VBAC: •External cephalic version may be as successful for women having a previous cesarean as for women with an unscarred uterus. •Epidural analgesia and anesthesia may be used. •Induction and augmentation of labor with oxytocin may be done. Misoprostol should not be used for cervical ripening. •Most authorities recommend electronic fetal monitoring.

Identifying Complications

Assess the FHR for at least 1 full minute after membrane rupture, whether spontaneous or by amniotomy. Nonreassuring rate or other electronic fetal monitor patterns or significant changes from previous assessments are reported promptly to the birth attendant. Cord compression is suspected if deep or prolonged variable decelerations occur during contractions or persistent bradycardia is present after contractions. Other nonreassuring FHR patterns also may occur (see Chapter 17). Chart the quantity, color, and odor of the amniotic fluid. Refer to Chapter 16 for expected findings and signs of abnormality in the amniotic fluid. Assess the woman's temperature every 2 hours after the membranes rupture. Report elevations greater than 38° C (100.4° F). Fetal tachycardia (sustained rate above 160 beats per minute [bpm]) often precedes maternal fever.

Cesarean Birth

At one time, cesarean births made up only 5% of births, and then the number gradually rose to about 25% of births in the late 1980s. Efforts to reduce the number of cesarean births by use of vaginal birth after cesarean (VBAC) and reducing primary cesareans were successful until 1996, when the rates began to rise again. In 2009, the U.S. cesarean rate was 32.9% of deliveries (ACOG, 2010b; Martin et al., 2011). Several factors contribute to the increasing U.S. cesarean birth rate (Cunningham et al., 2010; Scott & Porter, 2008; Thorp, 2009): •Women are having fewer children, and those having their first baby are more likely to have a cesarean than those who have delivered vaginally in the past. •Both medically indicated and elective inductions continue to rise, increasing the risk for cesarean, particularly for the nullipara having an induction. •The high primary cesarean rate adds to the overall rate because more women will have repeat cesareans rather than attempting vaginal birth for their next children. •Women are having children later, and cesareans are more common in the older pregnant woman. •Obesity is prevalent, increasing the risk for pregnancy complications that result in cesarean. •Use of assistance such as forceps or vacuum extractor for vaginal birth has decreased. •Electronic fetal monitoring often prompts concerns about fetal oxygen and acid-base status or progress of labor. •Most breech presentations are delivered by cesarean. •There is fear of litigation if no tort reforms exist in the state of practice. Healthy People 2020 goals related to reducing cesarean birth rates show the increase since Healthy People 2010 was released. More recent targets are to reduce the primary (first) cesarean rate to 23.9% and the repeat cesarean rate to no more than 81.7% for women at low risk for complications (www.healthypeople.gov). Promotion of vaginal birth after cesarean in women for whom it is appropriate is a major way to accomplish the goal. Other possibilities include more careful evaluation of dystocia, or prolonged labor, as a reason for cesarean and careful selection of women who are appropriate candidates for vaginal breech birth. External cephalic version (p. 418) is an option to attempt changing the presentation of a term or near-term to a cephalic presentation. Experience with electronic fetal monitoring has improved knowledge of normal fetal responses to labor, promoting interventions for fetal benefit that may avoid cesarean delivery. Nurses and birth attendants increasingly recognize that simple interventions, such as upright positioning, often promote normal labor progress. Interventions, both nursing and medical, that reduce the primary cesarean birth rate also reduce the need for repeat (secondary) cesareans.

Nursing Considerations: Assisting with Amniotomy

Before amniotomy, place underpads under the woman's buttocks to absorb the fluid. One or more folded bath towels under the buttocks absorb amniotic fluid well. Other supplies needed are a disposable plastic hook, a sterile glove or pair of gloves, and a packet of sterile lubricant.

Risks of cesarean

Cesarean birth is one of the safest major surgical procedures although it poses greater risk for the mother than does vaginal birth. 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 (see Chapter 30) •Persistent pulmonary hypertension of the newborn (see Chapter 30) •Injury, such as laceration, bruising, fractures, or other trauma Validation of fetal maturity is essential when a cesarean birth is planned. Gestational age of at least 39 weeks can be confirmed by (AAP & ACOG, 2007): •Documentation of fetal heart sounds for 20 weeks by nonelectronic means or for 30 weeks by Doppler ultrasound •An interval of 36 weeks since positive results for a serum or urine pregnancy test performed by a reliable laboratory •An ultrasound examination between 6 and 11 weeks of pregnancy that supports a gestational age of 39 weeks or more •Clinical history and later ultrasound examinations support a gestational age of 39 weeks or more For women with questionable due dates, amniocentesis (see Chapter 15) may be done to establish fetal lung maturity if the cesarean is elective. Another alternative is to await spontaneous onset of labor to do the cesarean if VBAC is not planned.

Indications for cesarean birth

Cesarean birth is performed when awaiting a vaginal birth would compromise the mother, the fetus, or both. Possible indications for cesarean birth include but are not limited to: •Dystocia •Cephalopelvic (fetopelvic) disproportion •Hypertension, if prompt delivery is necessary •Maternal diseases such as diabetes, heart disease, or cervical cancer, if labor is not advisable •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 A prior cesarean birth alone is not an indication for another cesarean birth for most women. Many women will choose repeat cesarean rather than a trial of labor even if they are appropriate candidates for VBAC, because of the small, but real, added risk for uterine rupture. In other cases they choose elective (scheduled) repeat cesarean to avoid another unsuccessful experience or the pain of labor. For other women, trying to deliver their next baby vaginally—whether successful or not—is important.

DRUG GUIDE: Oxytocin (Pitocin)

Classification: Oxytocic Action: Synthetic compound identical to the natural hormone from the posterior pituitary. Stimulates uterine smooth muscle, resulting in increased strength, duration, and frequency of uterine contractions. Uterine sensitivity to oxytocin increases gradually during gestation. Oxytocin has vasoactive and antidiuretic properties. Indications: Induction or augmentation of labor at or near term. Maintenance of firm uterine contraction after birth to control postpartum bleeding. Management of inevitable or incomplete abortion. Dosage and Route: Induction or Augmentation of Labor 1. Intravenous infusion via a secondary (piggyback) line. Oxytocin infusion is controlled with a pump. Various dilutions of oxytocin and balanced electrolyte solution may be used. Mixtures having 60 mU/mL are convenient because the mL/hr setting on the infusion pump is the same number as the milliunits per minute infused, reducing the chance for errors. Common mixtures that provide 60 mU/mL of oxytocin include (1) 15 units of oxytocin (1.5 mL) plus 250 mL of solution; (2) 30 units (3 mL) of oxytocin plus 500 mL solution; (3) 60 units oxytocin plus 1000 mL solution. Lower concentrations, such as 10 to 20 units of oxytocin plus 1000 mL of solution also may be used. The drug may be given in 10-minute pulsed infusions rather than continuously. 2. Guidelines for oxytocin administration from the American College of Obstetricians and Gynecologists∗ provide examples of low- and high-dose oxytocin labor-induction protocols. Depending on the protocol followed, the following recommendations are provided: (1) starting dosages of 0.5 to 6 mU/min, and (2) increasing dosage by 1 to 2 mU/min-increments every 15 to 40 minutes. High-dose protocols may increase the dose in increments of up to 6 mU/min. The actual oxytocin dose is based on uterine response and absence of adverse effects. Higher starting doses, higher dose increases, and shorter intervals between dose increases are most likely to result in uterine hyperstimulation. A lower starting dose and lower rate-increase increments usually are required to augment labor. 3. After an adequate contraction pattern is established and the cervix is dilated 5 to 6 cm, the oxytocin may be reduced by similar increments. Control of Postpartum Bleeding: Intravenous infusion: Dilute 10 to 40 units in 1000 mL of intravenous solution. The rate of infusion must control uterine atony. Begin at a rate of 20 to 40 mU/min, increasing or decreasing the rate according to uterine response and the rate of postpartum bleeding. Correcting any identifiable cause of the hemorrhage should also be done. Intramuscular injection: Inject 10 units after delivery of the placenta. (See Chapter 28 for other medications used to treat postpartum hemorrhage.) Inevitable or Incomplete Abortion: Dilute 10 units in 500 mL of intravenous solution and infuse at a rate of 10 to 20 mU/min. Other dilutions are acceptable. Absorption: Intravenous, immediate; intramuscular, 3 to 5 minutes. Excretion: Liver and urine. Contraindications and Precautions: Include, but are not limited to, placenta previa, vasa previa, nonreassuring fetal heart rate (FHR) patterns, abnormal fetal presentation, prolapsed umbilical cord, presenting part above the pelvic inlet, previous classic or other fundal uterine incision, active genital herpes infection, pelvic structural deformities, invasive cervical carcinoma. Adverse Reactions: Most result from hypersensitivity to drug or excessive dosage. Adverse reactions include hypertonic uterine activity, impaired uterine blood flow, uterine rupture, and abruptio placentae. Uterine hypertonicity may result in fetal bradycardia, tachycardia, reduced FHR variability, and late decelerations. Fetal asphyxia may occur with diminished uterine blood flow. Fetal or maternal trauma, or both, may occur from rapid birth. Prolonged administration may cause maternal fluid retention, leading to water intoxication. Hypotension (seen with rapid intravenous injection), tachycardia, cardiac dysrhythmias, and subarachnoid hemorrhage are rare adverse reactions. Drug interactions include vasopressors and the herb ephedra, causing hypertension. Nursing Considerations: Intrapartum: Assess the FHR for at least 20 minutes before induction to identify reassuring or nonreassuring patterns. Perform Leopold's maneuvers, a vaginal examination, or both to verify a cephalic fetal presentation. If nonreassuring FHR patterns are identified or if fetal presentation is other than cephalic, notify the physician and do not begin induction until an ultrasound is done to ascertain fetal presentation. Observe uterine activity for establishment of effective labor pattern: contraction frequency every 2 to 3 minutes, duration of 40 to 90 seconds, intensity of 50 to 80 mm Hg (measured with an intrauterine pressure catheter). Observe for hypertonic uterine activity (also known as tachysystole): contractions less than 2 minutes apart or more than 5 contractions within 10 minutes; rest interval shorter than 30 seconds, duration longer than 90 to 120 seconds, or an elevated resting tone greater than 20 mm Hg (measured with an intrauterine pressure catheter). Observe FHR for nonreassuring patterns such as tachycardia, bradycardia, decreased variability, and late decelerations. If uterine hypertonicity (tachysystole) or a nonreassuring FHR pattern occurs, intervene to reduce uterine activity and increase fetal oxygenation: stop the oxytocin infusion; increase the rate of nonadditive solution; position the woman in a side-lying position; and administer oxygen by snug facemask at 8 to 10 L/min. Notify the physician of adverse reactions, nursing interventions, and response to interventions. Record the maternal blood pressure, pulse, and respirations every 30 to 60 minutes and with each dosage increase. Record intake and output. Postpartum: Observe uterus for firmness, height, and deviation. Massage until firm if uterus is soft ("boggy"). Observe lochia for color, quantity, and presence of clots. Notify birth attendant if uterus fails to remain contracted or if lochia is bright red or contains large clots. Assess for cramping. Assess vital signs every 15 minutes or according to protocol. Monitor intake and output and breath sounds to identify fluid retention or bladder distention. Inevitable or Incomplete Abortion: Observe for cramping, vaginal bleeding, clots, and passage of products of conception. Observe maternal vital signs, intake, and output as noted under postpartum nursing implications.

Providing Emotional Support

Emotional support begins well before the birth and extends well after it. A mother who has had a previous cesarean birth may harbor unresolved feelings of grief, guilt, or inadequacy because she perceives that she somehow failed in her expected birth experience. The nurse in the prenatal setting can open the subject of a woman's previous cesarean or vaginal birth with a broad lead, such as, "Tell me about when you had your other baby." Staff behavior can either reduce or increase the woman's anxiety. A calm and confident manner helps her feel that she is being cared for by competent professionals. A quiet, controlled voice is calming to the patient, her family, and the nurse and other staff. The nurse and the woman's significant others are important sources of emotional support. Therapeutic communication with a caring nurse helps clarify her concerns, so explanations to reduce her fear of the unknown can be most effective. The father or other support person should be encouraged to remain with her during surgery if she has regional anesthesia. In many hospitals the support person may come into the operating room (OR) after the woman is intubated for general anesthesia to foster attachment with the infant and help the mother integrate her birth experience. Nurses also support a woman's birth partner and significant others during the cesarean birth. The partner may be as anxious as the woman but may be afraid to express it because the woman needs so much support. The partner may be physically exhausted after hours of labor coaching. Encourage breaks and snacks when appropriate. The staff should not expect more support from the partner than he or she can provide. Talking with the mother and her family after birth allows the nurse to answer questions about the surgery and fill in any gaps in their understanding. This helps them understand the experience and promotes a positive perception of the birth.

Episiotomy

Episiotomy, or incision of the perineum just before birth, was once routine for vaginal births. The presumed maternal benefits of reducing pain, perineal tearing, and later pelvic relaxation with incontinence have not proven true. Data do not support liberal or routine episiotomy, and restrictive protocols are preferred. However, the birth attendant must decide if one is needed, and indications are not always clear (ACOG, 2008; Cunningham et al., 2010; Lund & McManaman, 2008). 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

Intravenous (IV) pump setup for infusion from two IV lines.

Fluid in the primary line (nonadditive, or maintenance line) contains no medication but is regulated by the infusion pump to maintain the correct rate. Oxytocin solution is regulated in the secondary line in the same pump, giving the nurse options to change or discontinue the oxytocin infusion rate while maintaining the primary line infusion at the same rate. A single IV line at the lower part of the pump connects to the woman's infusion site.

NURSING CARE PLAN: Cesarean Birth

Focused Assessment Christina is 22 years old and expecting her first baby. Her due date is 2 weeks from today, and a cesarean was scheduled 1 week from today. Her baby remains in a complete (full) breech. Because her membranes ruptured this afternoon and she is in early labor, she will have her cesarean today. Epidural anesthesia is planned for her surgery. Although her physician has discussed cesarean birth with her, Christina is anxious and has many questions about what will happen to her and her baby. She says she is very nervous about the upcoming surgery. She has never been a patient in a hospital. Christina's mother and husband Bruce are with her. Nursing Diagnosis Anxiety related to unfamiliarity with the setting and procedures for cesarean birth. Planning Expected Outcomes After interventions, Christina will: 1.State that she feels less apprehensive. 2.Verbalize understanding of preoperative and postoperative care. 3.Demonstrate postoperative techniques for coughing and deep breathing. Interventions and Rationales 1. Assess Christina's level of anxiety. Assessment enables the nurse to approach her preoperative care in the most appropriate manner. Mild to moderate anxiety facilitates learning and is expected, but high levels impair learning. 2. Remain with Christina as much as possible while completing preoperative procedures. Allow her to express her fears. Encourage her mother and Bruce to remain with her. The presence of significant others and a caring nurse provide support. Expression of her fears enables the nurse to answer Christina's concerns specifically. 3. Elicit Christina's feelings about surgery by using broad leads, such as, "What were your thoughts when you found out you might have your baby by cesarean?" Identification of expectations of the birth experience allows actions to be taken to make it a positive one. If a woman's expected and actual experience closely match, she is likely to be more satisfied with it. Misunderstandings and possible feelings of inadequacy or anger are identified. 4. Explain preoperative preparations using simple language, verifying Christina's understanding and giving her the opportunity to ask questions. Knowledge decreases anxiety and fear of the unknown. Simple language facilitates understanding when a woman's attention is narrowed from anxiety. Explanations and the chance to ask questions show respect and give the woman a greater sense of control. 5. Explain what to expect postoperatively, demonstrating as needed. Knowledge reduces anxiety and fear of the unknown. The explanation promotes understanding and acceptance of care that will be painful while providing reassurance of pain control. Return demonstration verifies learning and identifies the need for additional teaching. 6. Reduce unnecessary stimulation that can add to Christina's anxiety. Work efficiently, but calmly. Reducing anxiety emphasizes that Christina and Bruce are having a child and not just a surgical procedure. Evaluation Christina agrees that a cesarean birth is best for her baby. She asks a few other questions and then states that she understands preoperative and postoperative care but that she is still "a little nervous." She demonstrates effective coughing and deep-breathing techniques.

NURSING CARE PLAN: Cesarean Birth

Focused Assessment She will have epidural anesthesia for her birth. Her vital signs are temperature, 37.2° C (99° F); pulse, 90 beats per minute (bpm); respirations, 22 breaths per minute; and blood pressure, 122/70 mm Hg. The fetal heart rate (FHR) is 130 to 140 bpm and accelerates with fetal movement. She walks to the operating room, and epidural anesthesia is begun. Nursing Diagnosis Risk for Injury related to altered sensation from epidural anesthesia and the use of electrical equipment during surgery. Planning Expected Outcomes Christina will not have injury, such as pressure areas, muscle strains, and electrical injury, during the perioperative period. Interventions and Rationales 1. Pad bony prominences. Avoid obstructing her popliteal area. Place a wedge under her hip to tilt her uterus to one side. Padding reduces potential for tissue damage caused by pressure. An unobstructed popliteal area reduces venous stasis and possible thrombus formation. Padding includes a uterine displacement wedge to avoid aortocaval compression. 2. Transfer her from the operating table carefully after surgery, using enough staff members to keep her body in alignment. Brake the bed and operating table to keep them from separating. Be certain that the indwelling catheter tubing and intravenous (IV) line are free during the transfer. Having adequate staff reduces the risk for a fall or muscle strains in both the woman and the staff. 3. After anesthesia is in place, position her on the operating table and secure her legs with a safety strap. The safety strap prevents falls or displacement of the woman's legs, which have lost sensation. 4. Apply a grounding pad if electrocautery is to be used. A grounding pad prevents electrical shock or burn. Evaluation During surgery her body was secured in proper alignment, with proper padding of all her bony prominences. The grounding pad ensured electrical safety when electrocautery was used. She gave birth to an appropriate-for-gestational-age baby, 3318 g (7 lb, 5 oz). She was transferred to postanesthesia care without incident. During recovery and postpartum, she showed no signs of pressure, electrical, or musculoskeletal injury. Additional Nursing Diagnoses to Consider Risk for Aspiration (general anesthesia) Pain Risk for Impaired Spontaneous Ventilation Hypothermia Readiness for Enhanced Family Coping note: Only nursing diagnoses related to the preoperative and intraoperative care of the woman are discussed here. See Chapter 17 for nursing care related to fetal oxygenation. See Chapter 18 for care related to anesthesia. See Chapters 16 and 20 for nursing care of the mother during the recovery and postpartum periods. Although cesarean births are routine in the intrapartum unit, they are not routine to women who undergo them or to their families. Even a prior cesarean may have been unplanned. Avoid belittling their fears by telling women and their families not to worry or that everything will be all right, especially if an emergency occurs.

Indications: Maternal and Fetal

Forceps or vacuum extraction is considered if the second stage should be shortened for the well-being of the woman, fetus, or both and if a vaginal birth can be accomplished quickly without undue trauma. 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.

Nursing Considerations for episiotomy

Gradual stretching of the perineum is the key to reducing the need for episiotomy. 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. When the woman pushes, use of an open-glottis technique rather than prolonged breath-holding when pushing also 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. Women older than 30 years of age, having their first baby, and adhering to the daily 10-minute perineal massage showed greatest benefit (Albers & Borders, 2007). Nursing interventions during the recovery and postpartum periods are similar for all perineal trauma. Observe the perineum for hematoma and edema. Perineal cold applications are done for the first 12 hours, followed by intermittent perineal heat applications after at least 12 hours if needed.

Nursing Considerations

In addition to basic intrapartum care, the nurse observes the woman and fetus for complications and takes corrective actions if abnormalities are noted. Nursing care is similar for the woman who has cervical ripening. The nurse has a great responsibility when administering oxytocin or other uterine stimulants to a pregnant woman. The nurse must maintain safeguards to both mother and fetus when administering oxytocin and recognize when to start, change, or stop its infusion and when to notify the physician. Facility policies related to oxytocin must clearly support correct nursing and medical actions (Pearson, 2011).

Risks

Induction and augmentation of labor are associated with risks of spontaneous labor plus added risks of the procedure •Uterine tachysystole (hyperstimulation), which can reduce placental perfusion and fetal oxygenation caused by excessive frequency, duration, or intensity of contractions, or from poor uterine relaxation between contractions. Tachysystole may be accompanied by nonreassuring FHR patterns. •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.

Induction and Augmentation of Labor

Induction and augmentation of labor use artificial methods to stimulate uterine contractions. Techniques and nursing care are similar for both induction and augmentation. The U.S. prevalence of labor induction is more than 22% and has more than doubled since 1990. Late preterm births that were induced have more than doubled from 1990 to 2006 (iatrogenic, or the result of treatment) and the number of cesarean births have increased with the rise in labor inductions. A nullipara who has a cesarean after an unsuccessful induction usually has repeat cesareans for all other babies. Few women who have regular prenatal care expect to deliver more than a few days past their due date.

External version: Providing info

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

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. Labor induction is not done if the fetus must be delivered more quickly than the process permits; a cesarean birth would be performed instead. Examples of specific conditions that are indications for induction include (Simpson, 2008a): •Fetal compromise (such as intrauterine growth restriction, maternal-fetal blood incompatibility) •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) •Hypertension associated with pregnancy or chronic hypertension, both of which are associated with reduced placental blood flow •Abruptio placentae (large abruptions require immediate delivery) (see Chapter 27) •Maternal medical conditions that are worsening with continuation of the pregnancy (such as diabetes, renal disease, pulmonary disease, chronic hypertension) •Fetal death Elective induction for convenience of the woman or her physician is not recommended, although it has become common. Factors such as a history of rapid labors and living a long distance from the hospital may be valid reasons for elective induction because of the possibility of birth in uncontrolled circumstances. Prenatal testing may reveal a fetal anomaly for which specialized neonatal care at a distant facility will be needed. The mother may be transported to that facility for labor induction or cesarean birth, with the necessary equipment and specialists assembled to care for the newborn. Augmentation of labor with oxytocin is considered when labor has begun spontaneously but progress has slowed or stopped because of poor contractions. The medical provider may use augmentation if progress is slower than expected, even if contractions seem to be adequate (ACOG, 2011a). The rate of oxytocin may be lower than induction.

Technique: Internal Version

Internal version is an unexpected and urgent procedure. The physician reaches into the uterus with one hand and, with the other hand on the maternal abdomen, maneuvers the fetus into a longitudinal lie (cephalic or breech) to allow delivery.

Importance of Teaching

Knowledge helps reduce fear of the unknown and increases a woman's sense of control over her infant's birth. The nurse cannot assume that a woman who had a previous cesarean birth already knows what will happen and why. If her previous surgery was done after a long labor or in an emergency, she may recall only part of it and may not understand what she does remember. Teaching should be done in simple language and should include her partner. 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. The nurse reassures her that her anesthesia clinician will regularly assess her needs for pain management. If a woman is having general anesthesia, the nurse explains why operative preparations are completed before the woman is anesthetized. She should be reassured that her surgery will not begin until she is asleep and that she will not wake up during the procedure. 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. Explain that the room may seem cool, and the surgery table is narrow. Also explain that her room may be warm if a low-birth-weight or preterm infant is expected (see Chapter 29). Her labor nurse is often the circulating nurse during surgery, reassuring her with a familiar face and voice. Nursery staff is often the provider of newborn care in the OR. 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 the OR. Bringing the partner in may be delayed until the regional block and other preparations, such as placement of the indwelling catheter, are complete. These preparations may take up to 30 to 45 minutes for a scheduled cesarean birth, varying with facility and provider practices. Assure the support person that he or she will not be forgotten. Estimating wait time helps reassure the partner that no problem has occurred during the preparation phase. The nurse explains the postanesthesia care unit (PACU) and any equipment that will be used, such as a pulse oximeter, electrocardiogram (ECG) monitor, and automatic blood pressure cuff. Postoperative needs for routine assessments and interventions such as fundus and lochia checks, coughing, and deep breathing are explained. The woman is taught simple exercises to promote normal circulation in her legs when movement returns. The nurse reassures her that every effort will be made to promote her comfort with medication, positioning, and other interventions. She should be encouraged to ask for pain relief early, before it is severe, for best results. The healthy newborn will often remain with parents in the PACU. Basic care is the same as that following vaginal birth. See Chapter 22 for early newborn nursing care.

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.

Risks of operative vaginal birth

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 (see Figure 19-5), which resolves quickly after birth.

Providing Care after Amniotomy

Nursing care after amniotomy is the same as that after spontaneous membrane rupture.

Nursing Indications Cesarean

Nursing care for a woman who has a cesarean birth varies according to the situation (Box 19-2) (Nursing Care Plan: Cesarean Birth). She may be planning a cesarean birth, or a surgical birth may be unexpected. A planned cesarean may be her first, or she may have had a cesarean birth before. Her previous cesarean may have been planned or an emergency, and her feelings about the prior cesarean birth may be positive or negative. Nursing care for all women having cesarean childbirth is similar, but the approach in each situation is different. For example, although preoperative teaching is important, it must be abbreviated or even omitted in a true emergency.

Oxytocin Administration

Oxytocin is a powerful drug, and it is impossible to predict a woman's response to it. Several 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 (Figure 19-2). Oxytocin solutions are often premixed by the pharmacy. •The oxytocin line is inserted into the primary (nonadditive, or maintenance) IV line as close as possible to the venipuncture site (the proximal port) 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, and regulated as the secondary line in the infusion pump. •Uterine activity and FHR and patterns are monitored before induction, when oxytocin is started, and throughout labor. The woman's uterus becomes more sensitive to oxytocin as labor progresses. 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 may be stopped or reduced after her membranes rupture. If uterine tachysystole makes it necessary to stop oxytocin, the medical decision about restarting administration must be individualized. When labor is augmented with oxytocin, a lower total dose is usually needed to achieve adequate contractions.

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. The FHR is charted in the labor record at least every 15 minutes during first-stage labor and every 5 minutes during the second stage (Simpson, 2008b). The nurse remains alert for FHR patterns that suggest reduced placental exchange secondary to contractions that are too strong, too long, or do not relax at least 30 seconds (now termed tachysystole). Examples of these patterns are 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. Reduced placental exchange also may have causes other than excess uterine activity, such as maternal hypotension or maternal diabetes. The nurse must assess the woman and fetus carefully to identify the most likely cause of the problem and the indicated corrective actions. If nonreassuring FHR patterns occur or if contractions are hypertonic, the nurse takes steps to reduce uterine activity and increase fetal oxygenation. 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 to increase the woman's oxygen saturation, making more oxygen available for the fetus. The physician may order a drug to reduce uterine activity, such as terbutaline (Brethine) or magnesium sulfate. Terbutaline, 0.25 mg subcutaneously, can be given quickly to reduce uterine contractions.

Providing Postoperative Care

Postoperative care for the mother who has had a cesarean birth is similar to that for one who has had a vaginal birth, with added interventions. Her temperature is assessed on admission to the PACU and according to protocol thereafter. If her condition is stable, other assessments are done on admission and every 15 minutes during the first 1 to 2 hours, progressing to every 30 minutes to 1 hour until transfer to her postpartum room. 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) •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. Detailed respiratory observations are essential for a longer period if the woman received epidural opioid narcotics, which can cause delayed respiratory depression. Have naloxone (Narcan) available to reverse opioid-induced respiratory depression. (See Chapter 18 for more information about anesthesia and analgesia for cesarean birth.) 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. Supplemental oxygen by nasal cannula, face tent, or mask is occasionally needed. 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. As with a vaginal birth, the fundus is assessed for height, firmness, and position. To relax abdominal muscles, thus reducing pain from fundus checks if sensation has returned, she should flex her knees and take slow, deep breaths. The nurse gently "walks" his or her fingers toward the woman's fundus to determine uterine firmness. The woman who has a Pfannenstiel skin incision usually has less pain with fundus checks than the woman with a vertical skin incision. A firm fundus does not need massage. The dressing is checked for drainage with each fundus 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 urine drainage tube should be observed for gradual clearing of the blood. Urine should drain freely to prevent bladder distention, which worsens pain and increases the risk for postpartum hemorrhage. The nurse must remember that a falling urine output is an early sign of hypovolemia, occurring well before the fall in blood pressure. The woman's needs for pain relief should be assessed with her vital signs. The woman who received an epidural analgesic may not need other analgesia during the early postpartum period. If she needs added pain relief while the epidural analgesic is still in effect, an oral analgesic often suffices. A nonsteroidal antiinflammatory drug (NSAID) such as ibuprofen provides long-acting analgesia to supplement the epidural drug. Parenteral analgesic is usually given by a patient-controlled analgesia pump or occasionally intermittent injections. Oral analgesics usually replace parenteral ones the day after surgery.

Reducing Anxiety

The woman may be anxious before version because its success is not certain and complications may require rapid cesarean delivery. After successful version, she may still be anxious because the fetus can return to its previous position. Supporting her as she expresses her concerns and during the procedure helps reduce her anxiety somewhat. Pointing out reassuring fetal monitor patterns, such as a normal heart rate and rate accelerations, can help reduce her anxiety about her baby. If problems such as bradycardia develop, the nurse should explain what has happened, what steps are being done to relieve it, and the result of these interventions. Explanations of tocolytic-associated side effects and when they should disappear should be provided.

Technique of applying forceps or vacuum extraction

Preparation for forceps or vacuum extraction is the same as for any vaginal birth. 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. Fewer teachers experienced in the more complex forceps deliveries and medical-legal concerns have reduced the number of practitioners skilled in midpelvis forceps (American Academy of Pediatrics [AAP] & American College of Obstetricians and Gynecologists [ACOG], 2007; ACOG, 2009c). 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. The position is occiput anterior or either right or left occiput anterior (ROA, LOA) or posterior (ROP, LOP). •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. Low operative vaginal birth is subdivided according to the amount of rotation of the fetal head needed. Births requiring 45 degrees or less of fetal head rotation are simpler. •Midpelvis operative vaginal delivery: The station is above +2 cm, but fetal head is engaged. The physician determines the presentation, position, and station of the fetal head and the amount of cervical dilation. With correct application, the long axis of the forceps blades lies over the fetal cheeks and parietal bones. After checking for proper application, the physician locks the two blades in the center and pulls gently as the woman pushes, following the curve of the pelvis. The physician may keep the forceps on until the head is born or may remove the blades just before expulsion. The rest of the fetus is born in the usual way. A hand pump is used to create suction to hold the vacuum cup on the fetal head in the midline of the occiput. The physician applies traction intermittently with the woman's push, as in a forceps-assisted birth. A vacuum release allows removal of the cup. The vacuum should go no higher than the green zone, indicated on the vacuum pump. A maximum of three pulls is the recommended limit.

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 (Table 19-2). It is administered in a setting in which fetal monitoring and emergency care, including immediate cesarean birth, are readily available. 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 that can reduce placental blood flow and fetal oxygen exchange. The FHR and uterine activity should be monitored before prostaglandin insertion for a baseline and at least 30 minutes afterward for nonreassuring FHR patterns or excessive contractions. Misoprostol (Cytotec) is popular for preinduction cervical ripening and labor induction because of its low cost, stability, and ease of use (see Table 19-2). Misoprostol is a synthetic prostaglandin tablet that is used for prevention of gastric ulcers. It's use for cervical ripening or labor induction remains an off-label use for misoprostol. The woman's uterus becomes more sensitive to oxytocin as labor progresses. 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 may be stopped or reduced after her membranes rupture. If uterine tachysystole makes it necessary to stop oxytocin, the medical decision about restarting administration must be individualized. When labor is augmented with oxytocin, a lower total dose is usually needed to achieve adequate 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.

Technique: Preparation for cesarean

Routine laboratory studies vary with the mother's condition and type of anesthesia but may include a complete blood count, clotting studies such as prothrombin and partial thromboplastin times, and blood typing and screening. The physician may order one or more units of blood to be typed and screened or crossmatched to have available for transfusion if the woman's hemoglobin and hematocrit values are low or she has a high risk for hemorrhage, such as grand multiparity (five or more births) or abruptio placentae. Epidural or combined spinal-epidural (CSE) block is typical for cesarean birth. General anesthesia may be required for either known or unexpected reasons. For emergency cesarean with no epidural in place, a general anesthetic may be chosen because it can be established the most quickly. A drug such as famotidine (Pepcid) or sodium citrate with citric acid (Bicitra) is given to reduce gastric acidity before surgery. The woman does not have routine premedication other than drugs to control gastric and respiratory secretions. Additional preoperative care includes a "time-out" in which all members of the team validate the woman's identity, surgical site, and consents. Staff new to the woman identify themselves. Fetal surveillance continues until just before the sterile abdominal skin prep (intermittent auscultation or external monitor) or just after the prep (internal monitor) (AAP & ACOG, 2007). A wedge placed under one hip prevents aortocaval compression and promotes placental blood flow. A single IV dose of a prophylactic antibiotic such cephazolin is recommended preoperatively if she is not already on antibiotics. Additional antibiotic doses are ordered for added risks for infection (ACOG, 2011b). If a Pfannenstiel (transverse or "bikini") skin incision is planned, the woman's lower abdominal hair is clipped from about 3 inches above the pubic hairline to the mons pubis, about where her legs come together. The fronts of the upper thighs are also clipped. For a vertical skin incision, the upper border of the abdominal hair clipping is near the umbilicus. Cordless electric clippers with disposable heads reduce skin nicks that provide an entry point for microorganisms. 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 catheter may also be placed before the epidural. The catheter allows accurate observation of urine output during and after surgery, which helps evaluate circulatory status. The catheter also allows delay of ambulation to the restroom for urination until the woman can safely ambulate. A grounding pad for the electrocautery is applied to an area with no bony prominences, usually the thigh. After application of the pad, the woman's legs are secured to the operating table with a wide, padded strap. A sterile abdominal skin prep is done just before sterile draping and allowed to dry before sterile drapes are applied. As in other surgical skin preps, the direction of the scrub is generally circular, from the center of the operative area outward and from the pubic area downward on each upper thigh. It may be necessary to use wide tape to hold excess abdominal fat (the pannus, or "apron") upward, pulling it away from the skin incision area. If a general anesthetic is required, preoperative preps are completed before anesthesia is begun to reduce newborn exposure to anesthesia. The team scrubs, dons gowns and gloves, and drapes the woman before general anesthesia is induced.

Technique

Surgical, medical, or mechanical methods may be used for labor induction or augmentation. Amniotomy is the method of surgical induction and augmentation, because rupturing membranes stimulates uterine contractions if the cervix is favorable (soft, some dilation and/or effacement). Medical methods for induction or augmentation use drugs such as prostaglandins or intravenous (IV) oxytocin (Pitocin), or both, to stimulate contractions. Mechanical methods of induction use a variety of intracervical inserts to gradually stretch and soften the cervix.

Determining Whether Induction Is Indicated

The birth attendant evaluates whether labor and birth are safer for the woman or fetus than continuing the pregnancy. Labor is not induced if term gestation and/or fetal lung maturity are not established unless there is a compelling reason. Induction is more likely to be successful at term because prelabor cervical changes favor dilation. The Bishop scoring system (Table 19-1) uses five factors to estimate cervical readiness for labor: cervical dilation, effacement, consistency, position, and fetal station. The Bishop score remains popular because of its ability to predict probable success of induction. The likelihood of vaginal birth is similar to that of spontaneous labor if the score is greater than 8.

VBAC

The decision about whether to have a VBAC has never been more difficult than now. The dictum "once a cesarean always a cesarean" was accepted without question and the only women who had VBACs were those who entered the hospital in such advanced labor that there was no time for a repeat cesarean. As low transverse uterine incisions became the norm for most women having cesarean births, the safety of a trial of labor became established. VBAC gradually became an accepted way to lower the rise in cesarean births. Research continued on the safety of VBAC. AAP and ACOG (2007) have affirmed their support for VBAC but have urged caution when considering a trial of labor after cesarean (TOL or TOLAC) because VBAC is associated with a small but significant risk of uterine rupture. For this and other reasons many physicians are now conservative when discussing the option of VBAC with a woman. The risks and benefits of VBAC for each woman must be considered by her and her physician. For example, the risk of uterine rupture increases as the number of prior uterine incisions increases, and a woman who has had two cesarean deliveries might be reluctant to attempt VBAC for her third birth because of this added risk. In addition, the woman who tries VBAC and still needs a repeat cesarean birth incurs more costs because she has both labor and surgical expenses. She and her infant are more likely to have infections that further complicate their recovery and add to costs. The hospital also incurs greater costs for personnel and supplies. When making the decision about whether to attempt VBAC, women need to know that surgical birth has risks just as all surgeries have risks. 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) (ACOG, 2010b). So the woman and her physician must consider risks and benefits of both. Women may be anxious about attempting vaginal birth in a later pregnancy. A woman may know that she is a good candidate for VBAC but find it impossible to disregard even small risks. Scheduling a repeat cesarean may seem safer, simpler, and something on which she can count. The prospect of laboring and perhaps still needing a cesarean birth is worrisome as well. The physician discusses VBAC during prenatal care if it is a reasonable option. The nurse reinforces these explanations and identifies misunderstandings. 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. VBAC should be presented in a positive way if it is a real option, yet the possibility of cesarean delivery should be acknowledged because the surgery can be needed unexpectedly in any birth (Box 19-1).

Amniotomy Nursing Considerations: Obtaining baseline info

The fetal heart rate (FHR) is assessed with auscultation or electronic monitoring to identify a reassuring rate and pattern before amniotomy is done. A minimum of 20 to 30 minutes is needed for adequate fetal baseline evaluation and can be obtained with other admission information.

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. After birth, the mother and infant are observed for trauma. The mother may have vaginal wall lacerations or hematoma (see Chapter 28). Cold applications for the first 12 hours reduce pain by numbing the area and limit bruising and edema of the tissues. Intermittent applications after 12 hours aid resolution of the edema and bruising. The fundus is usually firm unless uterine atony is present. The infant often has reddening and mild bruising of the skin where the forceps were applied. Observe for skin breaks that allow entry of microorganisms; keep skin breaks clean. 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. After a forceps-assisted birth a parent may ask why the baby's cheeks are reddened or bruised. A response is to explain that the pressure of the forceps on the baby's delicate skin may cause minor bruising that usually resolves without treatment. Parents of an infant born with assistance of a vacuum extractor may likewise be concerned about the edema on their baby's head. Reassure them that this edema will soon resolve. Point out improvement in the baby's cheeks or scalp during the postpartum stay.

Contraindications of Cesarean

There are few absolute contraindications to cesarean birth, but there are conditions in which it is not desirable because the risks to the woman are too great when compared with the potential benefit to mother or fetus. These conditions include fetal death, a fetus that is too immature to survive, and maternal coagulation defects.

Risks

There are few risks to the woman, and serious adverse effects on the fetus are few. FHR changes are common during the procedure but usually return to normal after the procedure. The fetus may become entangled in or compress the umbilical cord, possibly resulting in transient or prolonged hypoxia. Abruptio placentae may occur if fetal manipulation disrupts the placental site. Mixing of fetal and maternal blood within small breaks in placental vessels may result in maternal sensitization to the fetal blood type. Cesarean birth may be needed for fetal compromise at the time of version or later if the fetus returns to an abnormal presentation.

Incisions: Technique: Cesarean

Two incisions are made: one in the abdominal wall (skin incision) and the other in the uterine wall. Either of two skin incisions is used: a midline vertical incision between the umbilicus and the symphysis or a Pfannenstiel incision just above the symphysis (Figure 19-8). Three types of uterine incisions are possible (Figure 19-9): (1) low transverse; (2) low vertical; and (3) classic, a vertical incision into the upper uterus. The low transverse uterine incision is preferred unless a complication such as a very large fetus or placenta previa in the lower anterior uterus prevents its use. The uterine incision does not always match the skin incision. For example, a woman may have a vertical skin incision and a low transverse uterine incision, particularly if she is obese.

Observing the Mother's Response

Uterine activity must be assessed for tachysystole that can reduce fetal oxygenation and contribute to uterine rupture. Contractions are assessed for frequency, duration, and intensity, and uterine resting tone is assessed for relaxation of at least 30 seconds between contractions. Uterine activity observations are charted at the same intervals as the FHR patterns. Corrective actions for tachysystole are the same as those listed in the discussion of the fetal response. In addition, a tocolytic drug such as terbutaline may be given. 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. Recording intake and output identifies fluid retention, which precedes water intoxication. Signs and symptoms of water intoxication include headache, blurred vision, behavioral changes, increased blood pressure and respirations, decreased pulse, rales, wheezing, and coughing. 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 and does not contract effectively to compress vessels at the placental site. It is manifested by a soft uterine fundus and excess amounts of lochia, usually with large clots. Hypovolemic shock may occur with hemorrhage.

Contraindications

Version is not done if a woman cannot or is unlikely to deliver vaginally. 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. Fetal conditions that may contraindicate version: •Placenta previa. Manipulation of the fetus within the uterus may cause hemorrhage, endangering both mother and fetus. Placenta previa other than marginal is an indication itself for cesarean birth (see Chapter 25). •Multifetal gestation, which reduces available room to turn the fetus or fetuses. Internal version may be done after the first twin is born. •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. •Uteroplacental insufficiency. Uterine contractions occurring during the version or during labor may worsen the insufficiency and cause fetal compromise. •Engagement of the fetal presenting part into the pelvis.

Nursing considerations: External Version

When caring for the woman having external version, the nurse provides information, assesses the woman and fetus, and helps reduce her anxiety.

Amniotomy 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. The risk is low at first but increases as the interval between membrane rupture and birth increases. Birth within 24 hours of amniotomy is desirable in the term pregnancy, although there is no absolute time when infection occurs.

Promoting Maternal and Fetal Health

• Admission information is collected as if the woman were in labor or having a cesarean birth, because the need for operative intervention may arise suddenly. • Maternal vital signs are assessed for baseline value, and the initial nonstress test is done. Abnormalities or nonreassuring FHR patterns should be reported promptly. • An IV line is established for possible drug administration or fluid resuscitation if the FHR is nonreassuring. • The nurse administers the tocolytic drug. Onset of action for terbutaline is 6 to 15 minutes after subcutaneous injection. • Real-time ultrasound is used to guide the version and check the FHR periodically. • After the version, the mother and fetus are observed for at least 1 hour. Reassuring fetal signs are a heart rate near the same range as baseline, resolution of bradycardia, and the presence of rate accelerations with fetal movement. • Maternal tachycardia, flushing, or headache may be present for up to 4 hours if terbutaline was given to relax the uterus. • Maternal vital signs are measured every 15 to 30 minutes until they return to near their baseline level. Maternal pulse should be no higher than 120 bpm. • The presence of regular contractions suggests the onset of labor. Spontaneous rupture of membranes sometimes occurs. • Rho(D) immune globulin is given to the Rh-negative woman. • The woman usually has some discomfort during the version, but it should diminish quickly afterward. Persistent or continuous pain suggests a complication such as abruptio placentae. • Because the woman undergoing external version is near term, the nurse should review the signs of true labor or membrane rupture with her and explain guidelines for returning to the hospital if she is not having induction immediately after the procedure (see Chapter 16).

SAFETY ALERT: Signs of Tachysystole

• Contraction duration longer than 90-120 sec. • Contractions occurring less than 2 min apart or relaxation of less than 30 sec between contractions. • Uterine resting tone above 20 mm Hg or peak pressure higher than 90 mm Hg during first-stage labor (with intrauterine pressure catheter). • Montevideo units greater than 400. • An FHR pattern of late decelerations accompanying hypertonic uterine activity. Nursing Actions for Tachysystole • Reduce or stop the oxytocin infusion. • Increase the rate of the primary nonadditive infusion. • Keep the laboring woman in a lateral position. • Give oxygen by snug facemask, 8 to 10 L/minute. • Notify the physician or nurse-midwife