12.2f Obstetric Procedures Flashcards
Version
- Turning fetus from 1 presentation to another
Extracephalic Version (ECV)
- Turn fetus from breech/shoulder presentation to vertex
- Done between 36-37 weeks
- Done with gentle constant pressure on abdomen
ECV
- First ultrasound is done to confirm position, multiple gestations, oligohydramnios, abnormalities, and measure fetal dimensions
- Next an NST is done to confirm fetal well-being
- Tocolytics are given to relax the uterus
NURSING JOBS
- Continuous FHR monitoring
- Maternal VS
- Assess comfort of mother
POST-PROCEDURE JOBS
- VS, Uterine Activity, Vaginal Bleeding, Rhogam For rH Negative Women Due to Risk of Bleeding
Contraindications of ECV
- Multiple Gestations
- Uterine Anomalies
- Multiple Gestations
- Oligohydramnios
- Uteroplacental Insufficiency
- Nuchal Cord (diagnosed via ultrasound)
- Previous c-section or other surgeries
- Obvious CPD (Cephalopelvic Disproportion)
Internal Version
- Internal movement of fetus
- Done with provider inserting hand into uterus to change positions
- Rarely used, mainly used with twin gestations to assist in birth of second infant
Induction of Labor
- Chemical/Mechanical initiation of uterine contractions before onset to stimulate birth
Most Common Methods
- Oxytocin
- Amniotomy (Artificial Rupture of Membranes)
DONE BECAUSE
- Risk of continuing pregnancy
- No contraindications for amniotomy or oxytocin
Elective Induction of Labor
- Labor is initiated without medical indication
- Should not be done until woman reaches 39 weeks
Induction of Labor Reasons
Maternal
- Hypertension, Preeclampsia, Eclampsia, Chorioamnionitis
Fetal
- Diabetes
- Post-Term Pregnancy (especially when oligohydramnios is present
- Hypertensive complications
- IUGR
- Isoimmunization
- Chorioamnionitis
- PROM with established fetal maturity
CONTRAINDICATIONS
- Severe fetal distress
- Shoulder presentation
- Floating fetal presenting part
- Uncontrolled Hemorrhage
- Placental Previa
- Previous uterine incision that prohibits trial of labor
RELATIVE CONTRAINDICATIONS
- Grand Multiparity (5+ pregnancies that ended after 20+ weeks)
- Multiple gestations
- Breech position
- Suspected cephalopelvic disproportion
- Inability to adequately monitor FHR
Bishop Score
- Success rate of induction of labor is higher depending on condition of cervix
- Bishop score rates favorable cervix
13 point scale
8+ is good marker for successful outcome
Bishop Score
Dilation 0 = 0 points 1 = 1-2cm 2 = 3-4cm 3 = >5cm
Effacement 0 = 0-30% 1 = 40-50% 2 = 60-70% 3 = >80%
Station 0 = -3 1 = -2 2 = -1, 0 3 = +1 +2
Cervical Consistency 0 = Firm 1 = Medium 2 = Soft 3 = Soft
Cervical Position 0 = Posterior 1 = Midposition 2 = Anterior 3 = Anterior
Prostaglandins
PGE1 and PGE2
- Effective to ripen cervix
Used to decrease oxytocin induction time and oxytocin dosage required
Mechanical Dilators
- Ripen cervix through release of endogenous prostaglandins
DONE BY
- Balloon Catheters (Foley Catheter)
- Inserted through cervical canal to ripen cervix
- This stretches lower uterine segment of cervix and releases endogenous prostaglandins
Hydroscopic Dilators
- Absorbs fluid from surrounding tissue and then enlarges it. Used for cervical ripening
Laminaria Tents (dilators made from seaweed) and synthetic dilators containing magnesium sulfate are inserted into cervix without rupture of membrane. When they absorb fluid, they expand causing cervical dilation and release of endogenous prostaglandins. They are left for 6-12 hours before removal.
NURSING CARE
- Document number of dilators/sponges inserted and removed
- Assess urinary retention, ROM, uterine tenderness, pain, contractions, vaginal bleeding, infection, fetal distress.
Amniotic Membrane Stripping (Sweeping)
- Separate membrane of wall of cervix and uterine segment by inserting finger into cervix and rotating it 360 degrees. It induces labor through release of oxytocin and prostaglandins
Methods
- Sex (prostaglandins in semen and stimulation of contractions through orgasm)
- Nipple stimulation to release oxytocin
- Walking - gravity and pressure on cervix stimulates release of oxytocin
Amniotomy (AROM)
- Used to induce labor when cervix is favorable (ripe)
- Labor usually begins 12 hours after AROM
Oxytocin
- Stimulates contractions and milk ejection
- Pitocin is synthetic oxytocin
RISKS
- Placental abruption
- Uterine rupture
- Unnecessary c-section due to abnormal FHR
- Postpartum hemorrhage
- Infection
- SEVERE HYPONATREMIA (water intoxication)
Fetal Risks
- Hypoxemia and Acidosis which leads to abnormal FHR
Nursing Assessment of Oxytocin
- FHR every 15 minutes and every change in dosage (1st stage of labor)
- FHR every 5 minutes during active pushing phase in second stage of labor
- Contraction monitoring every 15 minutes in 1st stage
- Contraction monitoring every 5 minutes in 2nd stage
- BP, Pulse, RR, Every 30-60 minutes or after dosage change
- I&O and limited IV intake to 1000 mL in 8 hours. Output should be 120+ mL/Hour
- Monitor side effects (n/v, headache, hypotension)
- Oxytocin should be titrated to lowest effective dosage. Can be discontinued after ROM and in active phase of labor
Uterine Tachysystole
Signs
- More than 5 contractions in 10 minutes or contractions lasting longer than 2 minutes
- Can also be normal contractions occurring within 1 minute of each other
Interventions (Category 1)
- Side-lying position
- IV bolus with 500mL lactated ringer
- Decrease oxytocin by half if uterine activity not normal after 10 minutes. Discontinue oxytocin if still not normalized after another 10 minutes
Interventions (Category 2 and 3)
- Discontinue oxytocin immediately
- Reposition to side-lying
- Administer IV bolus with 500mL lactated ringer
- Oxygen at 10 L/min via non-rebreather
- If there is still not a response administer terbutaline SubQ
RESUMPTION OF OXYTOCIN
- If discontinued for 20-30 minutes then resume at no more than 1/2 the rate that caused tachysystole
- If discontinued for 30-40 min, resume at initial starting dose
Augmentation of Labor
- Stimulation of contractions after labor has already started and progress is unsatisfactory
- Used for hypotonic uterine dysfunction slowing labor
METHODS
- Oxytocin Infusion
- Amniotomy (ROM)
- Emptying Bladder
- Ambulation
- Position Change
- Relaxation Measures
- Nourishment
- Hydration
- Hydrotherapy
AGGRESSIVE OXYTOCIN TO ALLOW BIRTH WITHIN 12 HOURS
- Starts with 6 milliunits then increases by 6 every 15 minutes
- Women need to be in active labor with 100% effacement
- Amniotomy should be done within 1 hour of admissions
Forceps Assisted Birth
- 2 Curved blades used to assist in birth of fetal head
- Used when there is prolonged second stage of labor that needs to be shortened for maternal reasons
CONDITIONS THAT MUSTT BE MET
- Cervix must be fully dilated
- Bladder should be empty
- Presenting part must be engaged (preferably vertex)
- Membrane must be ruptured so forceps can grasp head
- Size of maternal pelvis must be adequate for birth
INTERVENTIONS
- After birth assess mother for lacerations, urinary retention, and hematoma of pelvic soft tissue
- Assess infant for bruising, facial palsy, subdural hematoma
Terminology for Forceps/Vacuum Assisted Birth
Outlet - Scalp is visible without spreading labia
Low - At least +2 Station
Mid-Pelvis - Between 0-2 Station
Vacuum Assisted Birth
- Vacuum cup is attached to head to assist with birth
CONDITIONS
- Informed consent
- Complete cervical dilation
- Rupture of Membranes
- Engaged Head
- Vertex position
- No suspicion of CPD
- Adequate anesthesia
Maternal Risk
- Lacerations and Soft Tissue Hematoma
Fetal Risk
- Cephalohematoma, subdural hematoma, scalp lacerations
INTERVENTIONS
- Assess FHR throughout
- After birth assess trauma, infection, hyperbilirubinemia and jaundice while bruising resolves
C-Section
INDICATIONS FOR C-SETION
Maternal
- Cardiac Disease (Marfan Syndrome with Dilated Aortic Root)
- Hypertensive States that cause Poor Intrauterine Environment
Fetal
- Non-reassuring Fetal Status
- Breech/Transverse Position (Malpresentation)
- Active Maternal Herpes Lesions or HIV
Maternal/Fetal
- Cephalopelvic Disproportion
- Placental Previa/Abruption
Types of C-Sections
Elective - Chosen by mother with no medical indications
Scheduled - Planned c-section
Unplanned - Maybe caused by ineffective and difficult labor
Forced - Requires court order when woman refuses but is indicated for fetal reasons
Surgical Techniques C-Sections
- Incision can be either vertical or transverse
- Determined by urgency of the surgery, prior incision type
- Type of skin does not indicate the type of incision to be used
C-Section Complications
- Anesthesia Issues
- Hemorrhage
- Bowel/Bladder Injury
- Air Embolism
- Atelectasis
- Endomyometritis
- UTI
- Abdominal Wound Hematoma
- Dehiscence
- Infection
- Necrotizing Fasciitis
- Thromboembolic Disease
- Bowel Dysfunction
C-Section Dangers
- Fetus may be born prematurely
- Fetal asphyxia
- Fetal injury such as scalpel laceration
- More likely to have respiratory complications and require resuscitation
Anesthesia for C-section
- Spinal, Epidural, General Anesthesia
- Epidural Blocks are most common due to mothers wanting to be awake
CHOICE OF ANESTHESIA DEPENDS ON
- Mother Medical History
- Time (especially if there is an emergency)
Care Management
Preparation - Childbirth preparation classes
Intraoperative
- Family centered care is important
- Uterus should be displaced to prevent compression of inferior vena cava which causes decreased placental perfusion
- Foley catheter should be inserted
Postop
- Transfer to post-anesthesia recovery unit
- Maintain airways and prevent aspiration
- BP and pulse every 15 minutes for 2 hours
- Temp every 4 hours for the first 8 hours then every 8 hours
- Assess dressing, fundus, lochia
- IV I&O through foley catheter
- Oxytocin to prevent hemorrhage and ensure fundus is firm
- Cough/Deep breathing exercises as well as leg exercises
- Medications for pain relief
Post-Partum Care
- Pain is relieved through opioids, PCA’s, or IV/IM therapy
- Fundal massage after analgesics can also reduce pain
- Regular diet after woman passes flatus.
- IV fluids continued until woman can drink liquids
- Early ambulation is encouraged
Daily Care
- Woman can shower after original incision dressing has been removed
- Foley catheter can be removed after 1st post-op day
- Ambulation several times a day
- TED Hose or SCD Boots
Assessment
- VS, Incision, Fundus, Lochia, Breath/Bowel Sounds, Circulation in Lower Extremities, Urinary/Bowel Elimination Patterns, Emotional Status of Mother, Attachment of Mother to Baby
C-Section Complications to be Reported
- Temperature over 38C (100.4F)
- Painful/Cloudy Urine and Urgency
- Heavy Lochia and Odor
- Redness/Swelling/Foul Discharge/Wound Separation of Incision Site
- Severe Abdominal Pain
Trials of Labor (TOL)
- Observance of woman and her fetus for 6-8 hours of active labor to assess safety of vaginal birth
Vaginal Birth After Cesarean (VBAC)
- Low transverse uterine incisions have no contraindications to c-sections
CONTRAINDICATIONS
- High risk of uterine rupture
- Previous classical or T-shaped uterine incision
- Extensive trans-fundal surgery
- Previous uterine rupture
Less Likely To Have Successful VBAC
- Recurrent indications (such as dystocia) for initial c-section
- Increased age
- Non-Caucasian
- Gestation age beyond 40 weeks
- Obesity
- Fetal weight greater than 4000g
- Labor induction
