artificial management of labor Flashcards
induction - advantage
24 -48 hr
induction - disadvantages
less gradual contractions, dysfunctional (too freq), increase in bloody discharge
induction nc
data base (assess), VS, consent, NST (r), SVE, bishop score (likelihood to deliver vaginally with inductions -> 8, higher = more likely)
amniotomy
AROM: amnihook -> OB or nurse midwife
uses: induction, augmentation (speed up), access to fetus for monitoring (FSI, IUPC)
nc: FHR, date and time, fluid (clear, bloody, meconium), amount (scant, mod, copious), odor, tempt at least q2
cervical ripening
foley bulb: mechanical induction, puts P on cervix like fetal head -> prostaglandins ->soften cervix and cramp
advantages: effacement, shorter, decrease requirements for oxytocin, vaginal within 24hr, decrease c/s
r: uterine hyperstim (tachysystole), non reassuring FHR (P on cord), increase PPH, uterine rupture
prostaglandins
vaginally, stim C, thin cervix
cytotec (misoprostol): 25 mcg q6, dont start oxy within 4 hrs last dose (cant remove)
cervidil (dinoprostone): 10mg over 12 hr, bed rest 2 hr after, pat dry post void, pull string to remove
stripping of the membranes
OB, nurse midwife, NP
non pharm, separate amniotic membrane from lower uterine segment, release prostaglandins, uncomfy, may bleed
oxytocin
induction or augmentation
r: tachysystole, uterine rupture, water intox, non reassuring FHR
need NSTr, SVE with bishop, ok with foley bulb in place, CFM, titrated with increasing 1-2mu/min q30min, PPH (overuse)
need volutrol
water intoxication
hypoNa, cerebral edema, furosemide, stop oxy, NS
s/s: confused, lethargic, v, seizure -> coma, death
labor augmentation
stim labor naturally occurring
hypotonic c: no often or intense enough for cervical change, can happen after epidural
oxytocin
AROM
amnioinfusion
warmed sterile NS or LR into uterus via IUPC
replace lost or absent amniotic fluid, repetitive variable decel with increasing intensity, meconium dilution
fluid should be leaking out! if increase in tone -> stop infusion, head creates stopper, lift infant head and reposition pt
episiotomy
sx incision of perineum to enlarge vaginal outlet
midline mediolateral -> diagonal
cut v tear (1-4 degree)
forceps assisted birth
factors: heart disease, acute pulmonary edema or compromise, intrapartum infection, prolonged 2nd stage, exhaustion, non reassuring fetal strip
mid forceps: head engaged, low = +2
outlet: at perineum
only pull when pt is pushing, guider not a puller
nc: explain procedure, monitor c, inform physical/CNM of c, encourage push during c, reassure, document how long forceps used
vacuum
suction cup on occiput, pump creates suction, traction applied, fetal head should descend with each contraction, document length of use
forceps assisted birth: maternal r
vaginal/cervical lacerations, periutheral lacerations, extension of median episiostomy into anus, anal sphincter injury, perineal edema
forceps assisted birth: neonatal r
echymosis (bruises), edema, along sides of face; caput succedaneum or cephal hematoma, transient facial paralysis, brachial plexus, cerebral hemorrhage, fractures (clavicle), elevated billy
c/s: i
complete placental previa, CPD, placental abruption, active herpes, umbilical cord prolapse, failure to progress in labor, tumor obstructing birth canal, breech, previous c/s, major congenital anomalies, non rassuring
c/s: skin incisions
transverse (horizontal), pfannenstiel “bikini” -> common
vertical
c/s: uterine incisions
may not match skin
low transverse, classical vert, low vertical
vertical increases risk of uterine rupture with vaginal delivery -> repeat c/s
increase risk of previa or abn placental implant -> scar tissue
c/s: nc - before
assist with epidural or spinal -> bolus warmed LR 1500 if not previously in, pepcid 20 mg IV and reglan 10 mg IV -> if unscheduled, bicitra 30mL (w/n 30 min incision), monitor vs (anesthesia), FHR (doppler or internal FSE), indwelling cath, prep abd and perineum, make sure personnel and equipment present
c/s: nc - during
position on operating table, wedge to L tilt prior to delivery - R hip (supine hypoT and increase perfusion)
support, instrument count (when area closed), time out
doc: incision time, delivery, APGARS, AROM, placental extracted, EBL meds
c/s: nc - after
normal newborn care, VS q15, check dressing, palpate fundus and check lochia, i+o, iv oxytocin and pain manage
c/s: VBAC
TOLAC until successful
good candidates: 1 previous c/s with low transverse incision (uterus), adequate pelvis, no other uterine scars/rupture, physician that can do c/s, anesthesia present
r/o uterine rupture
comfort measures: pain
referred: c radiate to back
visceral: dull, slow and deep, ache, 1st stage
somatic: sharp and local, burn/tender, transition/pushing phase
comfort measures: systemic analgesia
max relief, minimize risk
all cross placental barrier, fetal liver and kidney inadequate to metabolize meds
admin: uncomfy, well established labor pattern, regular c, increase duration of c, mod-strong I, usually IV/IM
M assess: willingness, stable VS, no CI (allergies, hypoT, NSTnr), record med, dose, route, jeep upper side rails raised, assist to BR
F assess: 110-160, NSTr, mod variability, not immediate delivery
comfort measures: systemic analgesia - butorphanol tartrate (stadol)
IM/IV - rapid onset, peak = 30-60, duration = 3-4hr,
opioid analgesic, 1-2mg q2-4hr
SE-M: drowsy, dizzy, faint, hypoT
SE-F: resp depression
comfort measures: systemic analgesia - nalbuphine HCl (nubain)
IV, IM, SQ - opioid analgesi
10-20 mg (5-10mg - route)
OPD: 2-3, 15-20, 3-6
SE-M: resp dep, drowsy
SE-F: resp dep
Can precipitate NAS
comfort measures: systemic analgesia - merperidine (demerol)
IM (50-100mg), IV (25-50 mg q2-4hr)
SE-M: resp dep, c, dizzy, itch
SE-F: neurobehavioral dep, resp acidosis
comfort measures: systemic analgesia - fentanyl (sublimaze)
IM (7-15 min), IV (immediate)
PD: 30-60, 30-60
SE-M: hypoT, n/v, resp dep
SE-F: less neurobehavioral dep than Meperidine
short 1/2 life so more freq dosing
comfort measures: systemic analgesia - naloxone
withdrawal seizures w/ NAS babies
opiate ant, reverse mild resp dep
itchy after c/s -> anesthesia
M: 0.4-2mg IV, may be repeated
F: 0.1 mg/kg IM, may be repeated
comfort measures: regional anesthesia
temporary and reversible loss of sensation, prevent initiation and transmission of nerve impulses for pain control
epidural, spinal, combined spinal-epi, pudendal block, local anesthesia
comfort measures: regional anesthesia - epidural
L3 or L4
a: good analgesia, fully awake, continuous allows blocking for each stage, dose can be adjusted
d: hypoT, post delivery back pain, meningitis, cardio resp arrest, vertigo, onset may not occur for up to 30 min
comfort measures: regional anesthesia - spinal
a: immediate onset, relative ease of admin, decrease drug volume
d: increased incidence of hypoT, fetal hypoxia, short acting
comfort measures: regional anesthesia - combine spinal-epidural
a: faster onset, med can be added, low dose drugs
d: n, pruritus
comfort measures: regional anesthesia - nc before
assess M and F, labor progress, IV start and 1500mL warmed LR, help into position
comfort measures: regional anesthesia - nc after
M and F VS, assess for hypoT (fluid bolus, ephedrine 5-10mg IVP, O2 prn 10L NRB), admin antiemetics prn, RR, bladder and cath
comfort measures: regional anesthesia - pudendal block
perineal anesthesia
2ns stage and episiotomy repair
a: ease of admin, no hypoT
d: decreased urge to bear down
comfort measures: regional anesthesia - local analgesic
perineal anesthesia
1% lidocaine, decrease P in 2nd stage, repair episiotomy or laceration for pt without analgesia
comfort measures: general anesthesia
emergent deliveries, decrease plt needing c/s, schedules c/s and unable to place spinal
cricoid P: decrease change of aspiration during placement of endotracheal tube
problems: fetal resp dep (lower 1min APGAR), maternal intubation (sore throat), r/o aspiration (emesis, chm pneumonitis), increased risk of PPH (uterine atony, increase blood loss), less feeling of control, support person no present, amnesia
induction types
ambulation, amniotomy, cervical ripening, stripping of the membranes, oxytocin
bishop score components
cervical dilation
cervical effacement
fetal station
cervical consistency
cervical position
