Chapter 16: Nursing Care During Obstetric Procedures Flashcards
What are some indications for an amniotomy?
- To induce/augment labor
2. For placement of IUPC or fetal scalp electrode (which requires ruptured membranes)
Amniotomy
Artificial rupture of amniotic sac.
How is an amniotomy performed?
- Performed with amniohook of FSE.**
- Hook is passed through cervical opening, snagging membranes.
- Opening in membranes is enlarged with finger, allowing fluid to drain.
An amniotomy is deferred if
- If fetal presenting part is high or presentation is NOT cephalic.
- Head must be engaged at 0 station.**
What is the priority when an amniotomy is performed?**
Fetal heart tone which can come down quickly.
What are the risks associated with amniotomy?
- Prolapse of umbilical cord
- Infection
- Abruptio placentae
Risks of Amniotomy: Prolapse of umbilical cord
Primary risk is that the umbilical cord with slip down in gush of fluid -> reduce in fetal gas exchange.
Risks of Amniotomy: Infection
- When there is an interruption of the membrane barrier, vaginal organisms have access to the uterine cavity.
- Can cause chorioamnioitis.
- Risk is low but as interval between membrane rupture & birth increases, so does the risk for infection.
Chorioamnioitis
inflammation of amniotic sac; bacterial and viral.
Within what time frame would birth be desired after membrane is ruptured?
Within 24 hours of membrane rupture.
Risks of Amniotomy: Abruptio Placentae
- Occurs when uterus is distended w/ excessive amniotic fluid.
- As uterus collapses w/ discharge of amniotic fluid, area of placental attachment shrinks.
- This causes it to partially separate from uterus.
Why is abruptio placentae important?
It reduces fetal oxygenation, nutrition, and waste disposal.
What are some assessments that should be performed prior to amniotomy?
o FHR is assessed with electronic monitor or auscultation to verify reassuring rate and pattern.
o 20-30 min needed for adequate fetal baseline evaluation.
o NON-BALLOTABLE → if ballotable small for their size, rapid labor.
Safety and Nursing Considerations Prior to Amniotomy
- Place 2-3 underpads under buttocks; towel too
- Explain that amniotomy is no more painful that vaginal exam
- Gather disposable plastic hook, sterile gloves for birth and packet of sterile lubricant.
Nursing Care After Amniotomy
- FHR assessed at least 1 full minute after. **
- Chart quantity, odor and color of fluid.
- Assess temperature at least every 2-4 hours after membrane rupture.**
- Regularly change underpads to keep her dry and reduce moist environment (favors bacteria growth)
What FHR suggests possible cord compression after amniotomy?
< 100 bpm
What should the amniotic fluid look like after an amniotomy?
Should be clear (often with bits of vernix) and mild odor.
What are some abnormal characteristics of amniotic fluid to make note of?
- Large amt of vernix which suggests preterm fetus
- Greenish, meconium-stained fluid seen in posterm or placental insufficiency
- Foul strong odor, cloudy appearance, yellow which suggests chorioamnioitis
• Hydramnios → fetal abnormalities - Oligo → placental insufficiency/fetal renal tract abnormalities
What characteristics precede maternal fever?**
A rising FHR and fetal tachycardia precede maternal fever.
How often should vital signs be checked after an Amniotomy?
2-4 hours**
Induction and augmentation of labor
- Artificial method to stimulate contractions.
- Want to mimic natural labor as much as possible.
- Techniques/care are the same for both.
When is an induction performed?
Performed when a continued pregnancy may jeopardize the health of the woman or fetus and labor and vaginal birth are considered safe.
Augmentation of labor
is considered with oxytocin when labor begun spontaneously but progress
has slowed or stopped, even if contraction seem to be adequate.
Nonpharm augmentation
Nipple stimulation in shower, whirlpool.
Why is amniotomy considered a method of surgical induction and augmentation?
Because rupturing membranes stimulates uterine contraction.
What are drugs used for augmentation and induction of labor?
- Prostaglandins (augmentation)
- IV oxytocin (Pitocin)
Indications for induction and augmentation of labor
- IUFGR, blood incompatibility: intrauterine environment is hostile to fetal well being.
- Spontaneous rupture of membranes at or near term without onset of labor.
- Postterm pregnancy
- Chorioamnionitis
- HTN associated with pregnancy, chronic HTN: reduce placental blood flow.
- Abruptio placentae**
- Maternal medical conditions that worsen continuation of pregnancy (i.e diabetes, HTN, renal disease, etc.)
- Fetal death
Why is elective induction and augmentation not recommended?
o Unless factors as having rapid labor and living long distance from hospital.
o Make sure reassurance of fetal lung maturity.
What are contraindications to augmentation and induction of labor?
o If fetus has to be delivered more quickly → C/S instead.
o Placenta previa: results in hemorrhage during labor
o Vasa previa
o Umbilical cord prolapse, immediate c/s would be needed.
o Abnormal fetal presentation: vaginal birth is often more hazardous
o Fetal presenting part above pelvic inlet
o **Previous surgery in upper uterus, C/S history or extensive surgery for uterine fibroids.
Fetal presenting part above pelvic inlet may be associated with
cephalopelvic disproportion (fetal head TOO BIG) or preterm fetus
Vasa previa
fetal umbilical cord vessels branch over amniotic sac rather than inserting into placenta; fetal hemorrhage possible if membrane rupture.
What are the risks associated with induction and augmentation of labor?
- Hypertonic uterine activity
- Uterine rupture
- Maternal water intoxication
- Increased risk for chorioamnionitis and c-section.
- Newborn respiratory problems
- Tachysystole
Maternal water intoxication is likely during augmentation and induction of labor if
Hypertonic IV solution to dilute oxytocin has a rate greater than 20 milliunits/minute.
Steps for starting oxytocin for induction and augmentation of labor
- Placed in piggyback with isotonic solution
- Oxytocin line is inserted into primary IV line as close as possible to venipuncture site to limit amount of drug infused after changing to nonadditive fluid.
- Start slowly, increase gradually, regulate with infusion pump
Assessment before using oxytocin in augmentation and induction of labor
-Monitor uterine activity, FHR and fetal heart patterns.
When can the rate of oxytocin be reduced?
- Rate of oxytocin may be gradually reduced when she is in the active phase of labor (5 – 6 cm dilation) because the uterus is more sensitive to oxytocin.
- May be stopped or the rate reduced after her membrane rupture
How does the uterus react to oxytocin as labor progresses?
It becomes more sensitive to oxytocin as labor progresses.
Labor augmented with oxytocin
Lower total dose is needed to achieve adequate contractions.
Nursing responsibilities during oxytocin infusion for augmentation and labor
-Nurse must decide when to start, change, and stop an oxytocin infusion using the facility’s protocols and medical orders.
-Facility policies related to oxytocin must clearly support correct nursing and med action.
Assessing fetal response to augmentation or induction of labor using oxytocin
- Observe for tachysystole.
- Monitor for persistent bradycardia or tachycardia.
- Observe for late decelerations and decreased FHR variability.
Tachysystole Characteristics
- Contraction duration longer than 90 to 120 seconds
- Contractions occurring less than 2 minutes apart or relaxation of less than 30 seconds between contractions
- Uterine resting tone higher than 20 mm Hg (with intrauterine pressure catheter)
- Peak pressure higher than 90 mm Hg during first-stage labor (with intrauterine pressure catheter)
- Montevideo units (unit of measure for uterine contraction intensity) exceeding 400
- A fetal heart rate pattern of late decelerations accompanying hypertonic uterine activity
How often is FHR charted in labor record during the first and second stage while using oxytocin to induce labor?
At least every 15 minutes during 1st stage of labor and every 5 minutes during 2nd stage.**
Reduced placental exchange can be caused by
- Excess uterine activity
- Maternal hypotension
- Maternal DM
Interventions for non reassuring patterns OR tachysystole during augmentation or induction of labor using oxytocin.
- Reduce/stop oxytocin infusion and ↑ rate of primary nonadditive infusion**
- Keep woman in a NONSUPINE position (side-lying)
- Give 100% oxygen by facemask at 8-10 liters per minute to increase woman’s oxygen saturation, making more oxygen available for fetus.
- Terbutaline or magnesium sulfate may be ordered to reduce uterine activity