exam three: bleeding, IOL, birth variations Flashcards
bleeding during pregnancy is…
very common
bleeding in pregnancy is often..
- relatively benign
benign causes of bleeding in pregnancy
-Implantation bleeding when egg is implanted into uterus
-Spotting after intercourse or a pap smear
-Bloody “show” during labor
-Treatable infection (such as Chlamydia)
More serious causes of vaginal bleeding during pregnancy:
-Spontaneous abortion (aka miscarriage)
-Ectopic pregnancy
-Incompetent cervix
-Gestational trophoblastic disease (Molar pregnancy)
-Placenta previa
-Placenta abruptio (Abruption)
-Preterm labor*
-Uterine rupture*
1st trimester bleeding is common
-Up to 25% of women with known pregnancies will experience some type of bleeding in the first trimester.
-About half will result in pregnancy loss
high chance of loss with bleeding if…
Bleeding is accompanied by pain (i.e. cramping or back pain)
lower chance of loss with bleeding if
Once normal FHT are documented by doppler or ultrasound
Spontaneous Abortion (SAB)
Expulsion of fetus prior to 20 weeks gestation or weight less than 500 grams if age isn’t known
causes of SAB
-Chromosomal abnormalities- most common
-Uterine or cervical problems
-Inherited thrombophlebitis, endocrine disorders
-Teratogenic drugs
-Uncontrolled chronic disease (diabetes-high glucose is toxic to tissues, hypothyroidism)
-Infections
-Trauma especially abdomen
Pathophysiology of SAB
- Differs according to cause
- Embryonic death → loss of hCG → decreased progesterone & estrogen → uterine decidua sloughed off → uterus irritated and contracts → expels embryo or fetus
Classification of abortions
- threatened abortion
- imminent abortion
- incomplete abortion
- complete abortion
- missed abortion
- recurrent pregnancy loss
- Septic abortion-presence of infection
threatened abortion
- Bleeding for unexplained reasons prior to 20 weeks
- cervix is closed
- Threatened
Imminent Abortion
- Bleeding, cramping, os opens, membranes may rupture
- Will happen just a matter of time
- inevitable
Incomplete Abortion:
Expulsion of some products of conception, but some retained
Complete Abortion:
All of products of conception expelled
Missed Abortion:
- Fetus dies but has not bee expelled
- Diagnosis made by ultrasound
- Normally woman comes in for normal OB appt. and measures a size smaller than dates and don’t see fetal heart tones
Recurrent pregnancy loss:
- 3 or more pregnancies
Septic abortion-presence of infection
- Usually from prolonged rupture of membranes
- May be associated with IUD when get pregnant illegal abortion
Diagnosis of abortions
- physical exam
- US
- labs
physical exam to diagnose abortion
Speculum to see if cervix open and if anything is coming out of cervix
US to diagnose abortion
- Gestational sack in uterus with embryo?
- Size of embryo?
- Fetal heart tones?
labs to diagnose abortion
- HCG-should rise 50% Q 48-72 hours until 10 weeks when decreases.
- Repeat Q 48-72 Hours to see if rising appropriately.
- Blood type and Rh
- RhoGAM if Rh negative and antibody screen is negative
- CBC (to check for anemia following significant blood loss)
Treatment of SAB
- Lack of therapeutic interventions for threatened miscarriages or in the process of miscarrying to prevent from happening
- expectant
- medical
- surgical
expectant treatment of SAB
- Treatment for inevitable or with poor prognosis (missed or incomplete abortion) if clinically stable
- watch and wait
- 3-4 weeks to see if pass on own if in the 1st trimester
- Heavy bleeding, cramping or signs of infection and surgical intervention is recommended
medical treatment of SAB
- mifepristone and misoprostol combination
- helps cervix dilate and soften and contract uterus
- Very Effective especially in 1st trimester
- May have more bleeding, longer time between treatment and passage of fetus, and lower success rate than surgical
surgical treatment of SAB
- dilation and curettage (D&C); dilation and evacuation (D&E)
- Mechanically dilates cervix then use instrument to surgically remove the products by scraping the inside of the uterus or suctioning out the contents
anticipatory guidance for treating SAB
Nurses are often the ones who are talking to these women in the ER, clinic or over the phone. It’s important to explain how much blood and pain can be possible. In addition, women need to be prepared for what the fetus/placenta will look like. Finally, they need to know how to contact additional help if their status changes in the middle of the night. They need to be provided with resources and reassured that they may not yet be ready for them.
ectopic pregnancy
- Implantation of a conceptus in a site other than the endometrial lining of the uterus
- Most common site: ampullar tubal which is where fertilization takes place
Patho of ectopic pregnancy
- Prevented or slowed progress down the tube, fails to implant in uterus
- Trophoblasts grow into and through the wall of tube causing internal hemorrhage- not viable pregnancy
risk factors of ectopic pregnancy
- Previous ectopic, PID, pelvic surgery, endometriosis, smoking, AMA (advanced maternal age), IUD while got pregnant
signs and symptoms of ectopic pregnancy
- Initially, normal pregnancy signs: Missed menses, positive pregnancy test, breast tenderness, nausea
- Bleeding/spotting
- Lower quadrant abdominal or rectal pain
- Fainting, dizziness if tube ruptures
- Right shoulder pain: Sub-diaphragmatic irritation from blood in abdomen
- Hypovolemic shock
- Slow to rise HCG, US with no IUP or mass in tube (don’t see anything in the uterus), low hemoglobin & hematocrit
triad of symptoms = ectopic pregnancy
- missed menses or + pregnancy test
- Lower quadrant pain
- Vaginal spotting, bleeding, brownish discharge
treatment of ectopic pregnancy
- Important to explain to women that this is not a viable pregnancy and can lead to future infertility and potentially death if not treated right away.
- Longer the pregnancy lasts the more chance the fallopian tube will rupture
- medically
- surgically
medical treatment of ectopic pregnancy
-Methotrexate IM
- folic acid antagonist: prevents or inhibits the growth of the trophoblastic cells which then prevents embryo from growing and is reabsorbed by individuals body
- Preserves the tubes
- Works well early on
surgical treatment of ectopic pregnancy
- Can be an emergent situation especially with rupture of the fallopian tube
- Removes pregnancy
- May need to remove part of or entire tube depending on if it has ruptured or not
- Follow up will include H&H/blood replacement and RhoGAM as indicated (Rh negative)
Gestational Trophoblastic Disease (GTD)
- Pathologic proliferation of trophoblastic cells- keep proliferating
- Different degrees
1. Hydatidiform mole (molar pregnancy)
2. Choriocarcinoma - CAN BE DEADLY
Molar Pregnancy signs and symptoms
- Vaginal Bleeding- brown or bright red
- Hydropic villi passed (grape like clusters)
- Uterine Enlargement (Size>Dates)
- No fetal heart tones
- “Snowstorm” on US
- Elevated serum HCG (very high from all of trophoblasts
- Hyperemesis gravidarum: severe N/V
- Early (2nd trimester) Preeclampsia
Molar Pregnancy complications
- Mastitis of cancer cells, anemia, infection, ovarian cysts, hyperthyroidism, embolization to lungs, hemorrhage, death
molar pregnancy treatment
-suction evacuation of mole ASAP
-possible chemotherapy (especially if mastitis is present)
follow up- molar pregnancy
- Chest x-ray to evaluate for metastasis (may do frequently over course of year to make sure that hasn’t been any)
- Monitor hCG
-Frequent monitoring (Monthly to every other month for at least a year)
-If rises, think cancer and treat with chemo - No pregnancy x 1 year, as rising hCG could be a malignancy present with new pregnancy
-Would Cloud diagnosis
-Effective contraception for year
Incompetent Cervix
-Painless dilation of the cervix without contractions before 16-18 weeks gestation
-Caused by: structural or functional defect of the cervix
multiple factors for incompetent cervix
- Congenital (bicornuate uterus)- septum down middle of uterus that may extend completely through uterus
- Acquired (infection, inflammation, twins, extensive treatment of abnormal pap smears with cone biopsy where doesn’t have enough structural integrity to maintain pregnancy )
- Hormonal (endocrine)
- Structural laxity of cervical collagen
Incompetent Cervix and getting Obstetric history
- gives provider clues of higher risk:
1. repetitive 2nd trimester loss especially if no pain involved and deliver without contractions
2. progressively early births
treatment of Incompetent Cervix
- Close surveillance with serial US of cervical length checks- does it shorten
- Cerclage: suture around cervix to hold closed
-Done Around 14-16 weeks or if have shortened cervix that is opening or part of the baby is coming out or as rescue measure (but riskier cuz could cause ROM or infection)
-If contracting at all at any point then suture wont hold any longer and suture starts to tear and bleed- will need to be removed
-Removed around 36 weeks and is allowed to labor after that
Abruptio Placentae
premature separation of a normally implanted placenta from uterine wall
classification of abruptio placentae
- Partial- part of the placenta separates from uterine wall
- Complete- the entire placenta detaches from the uterus wall
-Massive bleeding
-Increased fetal and maternal death
types of abruptio placentae
- marginal
- central
marginal abruptio placentae`
- separation is at edge of placenta
- Blood passes between membranes and uterine wall
- Moderate to severe vaginal bleeding that is visible because edge of placenta is not in-tact against uterine wall anymore
central abruptio placentae
- in center of placenta
- Blood is trapped between the placenta and the uterine wall
- Little or no visible vaginal bleeding because the edges of the placenta are holding all blood in
Abruption
-Sudden onset
-Bleeding: Dark, External or concealed, Shock and anemia may or may not be reflective of blood lost
-Severe pain
-Uterus: Tender and firm to palpation all the time ,Abruption pattern (tachysystole)- frequent contractions with no return to the resting tone of uterus
Risk Factors for Abruption
- hypertension- most common
- trauma: DV, FALLS, MVA
-Cocaine or methamphetamine use
-History of abruption
-Smoking- from vasoconstriction of BV
-Uterine over- distention: Multifetal pregnancies, Hydramnios
-pPROM
-Age > 40
-High parity
-Unknown
how does hypertension put you at risk for abruption
High pressure causing vasospasm of blood vessels= damage, platelet aggregation, and obstruction
how does Cocaine or methamphetamine use put you at risk for abruption
Causes vascular disruption of placental bed
Will have high elevations of BP and tachysystole after using which both are risks for abruption
Maternal Risks of Abruption
- Depends on severity of abruption
- Hemorrhage may result in:
-Anemia
-Hysterectomy
-Shock
-Death - DIC (disseminated intravascular coagulation)
-Uses up all clotting factors trying to control the hemorrhage that is occurring
Fetal-Neonatal Risks of abruption
- Depends on degree of abruption and gestational age
-Preterm labor (and associated complications)
-Anemia/hypovolemia from the bleeding
-Hypoxia from lack of perfusion to fetus: Brain damage , Neurological deficits, Death - Perinatal mortality:
-Moderate abruption- 25%
-100% death rate if >50% of placenta is involved
Nursing Care of abruption
- After diagnosis, plan depends on status of mother & fetus, as well as gestational age
-Vaginal or c-section delivery depending on severity of situation - Evaluate for disseminated intravascular coagulation (DIC )
-Clotting studies and CBC - Correct hypovolemia and blood loss
- Multiple lab tests
-Clotting studies
-Hemoglobin/hematocrit
What is Placenta Previa
- placenta improperly implanted in lower uterine segment: can be over, or near, or partially covering the cervix
- Placenta villi are torn from uterine wall exposing uterine sinuses at placental site when uterus contracts
- Bright red bleeding
- Generally painless
Risk Factors of Placenta Previa
Multiparity
AMA- advanced maternal age
Placenta Accreta
Prior C-section- highest risk
Smoking
Large placenta- multiple babies
Recent SAB or TAB (spontaneous or therapeutic abortion)
Cocaine use
Placenta Previa most commonly seen when
- at 18-22 weeks ultrasound
- may be present and later on could not be an issue anymore because the wall of the uterus that the placenta is attached to because as the uterus grows the wall where placenta is implanted grows and pulls away from cervical os
Treatment of Placenta Previa depends on
Gestational age
Severity of bleeding
Expectant Management of placenta previa
-if less than 38 weeks and limited or minimal bleeding
-“Pelvic rest” (no SVE, no sex, nothing in vagina)
-No vaginal exams
-Could poke through placenta and worsen it or can increase the separation of villi from lower part of uterus
-Corticosteroids to mom to mature fetal lungs if under 34 weeks
-Evaluation of maternal/fetal status
-Monitor blood loss
when do you need a c section with placenta previa
if placenta is partially or completely covering cervix
laboring and placenta previa
- Can labor as long as the placenta is at least 2 cm away from internal cervical os
- Monitor bleeding and fetus closely
Nursing Care when presenting with bright red bleeding
-Do you have evidence of placental location (US report)?
-If no records, ask her if her placenta is “in the right place”
-No SVE unless location of placenta known: SVE can cause bleeding because you accidentally tear cotyledon tissue
-Ultrasound prior to SVE if no records and no sono
-Help determine cause (use your nursing instincts): Previa vs abruption vs healthy bloody show (i.e advanced labor)
placenta abruption
- painful
- uterine tone:
1. Elevated uterine resting tone
2. Uterine irritability/tachysystole
3. Uterus is Taut/board like when palpate
4. Uterus tenderness to touch
-bleeding: dark red
placenta previa
- painless
- uterine tone:
1. Normal uterine tone
2. Contractions only with labor
3. Uterus soft - bleeding: Bright red
*Usually diagnosed during routine US at 18-22 weeks if the patient has not experienced bleeding prior to that
Induction of labor (IOL)
Stimulation of uterine contractions during pregnancy before labor begins on its own
AUGUMENTATION of labor
Strengthens and increases frequency of uterine contractions with medications or interventions
cervical ripening
- Softening of the cervix that prepares the cervix for labor
- Medications or other interventions can be used to ripen the cervix for induction
rationale behind IOL
- Goal is to prevent complications when there is a concern for maternal or fetal health
rationale behind elective inductions
- There was a growing trend in elective IOL in the early term GA (37-38 6/7 weeks) until 2012 then research showed the risk of early term newborns outweighed the benefits
- ARRIVE trial: IOL at 39 weeks
- Inductions are associated with additional interventions that may not always benefit the mother
maternal medical indications for IOL
- Chronic conditions: DM, HTN, renal, pulmonary, cardiac disease, etc.
- Pregnancy related complications: Preeclampsia, PROM, intra-amniotic infection
- Other: fetal demise, h/o precipitous labor or extensive distance from hospital (elective)
fetal indications for IOL
- Fetal compromise: IUGR, oligo, mild abruption, non-reassuring FHT’s
- Late term (41 weeks), post term (42 weeks)
reasons for Elective IOL not recommended..but
-Suspected large baby
1. C-section would be more appropriate
-Mother in town and leaving in 2 weeks
-2 days after due date
-Aching back and swollen feet
-Tired of being pregnant
-Wanting baby to have specific birth stone, same birthday as Uncle Jim
-Caregiver convenience
ARRIVE trial: how did we interpret the results of the trial
-Not generalizable
-May be a reasonable option
-Promote/encourage other methods of reducing risks of c-section– i.e. doulas, ambulation in labor, IA, etc.
ARRIVE trial: IOL at 39 weeks in low risk first time mothers
-Did not improve the primary outcomes studied (death or serious newborn complications)
-Decreased risk of developing Pre-e/GHTN (9% vs.14%)
-Lower rate of c-section– 19% vs. 22%
Increased risks associated with IOL:
-Increased chance for cesarean birth (questionable)
-Increased epidural use
-Postpartum hemorrhage
-Oxygen requirements for the baby at delivery
-Longer hospital stays
-Increased iatrogenic prematurity
Increased elective IOL and cesarean section rates have NOT …
- been associated with improved outcomes for babies among low-risk patients
- Risk/benefit, shared-decision making conversation between the provider and the patient and family
bishop score
- Used to rate the readiness of the cervix for IOL
> /= 8 bishop score
associated with greater chance of having a vaginal delivery (cervix favorable/ripe for IOL)
</= 6 bishop score
associated with lower chance of vaginal delivery; prolonged labor (cervix is unfavorable/unripe for IOL)
cervical ripening: medications
- cytotec
- Dinoprostone (prostaglandin E2):
cytotec for cervical ripening
-SL: 25-50mcg q 2-4 hours x up to 6 doses in a 24 hour period; useful for PROM/PPROM
-Vaginally: 25 mcg q 4 hours x 4-6 doses
-Contraindicated for ripening if history of previous c/s
-Note: difference in dosing and route for ripening vs. postpartum hemorrhage!
-Very inexpensive
benefits to cytotec for cervical ripening
- Effective cervical ripening agent
- May cause onset of labor
risks of cytotec for cervical ripening
-Tachysystole
-Uterine rupture
-Fetal bradycardia (related to tachysystole)
-Amniotic fluid embolism- VERY RARE
Dinoprostone (prostaglandin E2) for cervical ripening
- Cervidil: 1 string per vagina x 12 hours ($218 per dose)
- Prepidil: 0.5 mg dinoprostone in 2.5 ml gel q 6-12 hrs x 3 doses ($185 per dose)
goal of cervical ripening
to improve Bishop score, however, sometimes these interventions are enough to start labor.
cervical ripening other methods
- Foley bulb
- Cook balloon
- Laminaria (Seaweed)
foley bulb used for cervical ripening
- insert bulb into cervix and fill with 60 ml
- makes the membranes separate and makes the cervix dilate
- Falls out when 3-4 cm dilated
pitocin in IOL
- Medical stimulation of uterine contractions
- Induction or augmentation
Cook balloon
- 80 ml in the uterine balloon (internal os on top of the cervix
- 60 ml in the vaginal balloon (external os in the vagina)
- Squeezes cervix between two balloons
- Falls out when ~4-5 cm
laminaria (seaweed)
- See more with IOL for demise especially in the 2nd trimester
- put into the cervix- absorb mucous and expands
risks to foley bulb and cook balloon for mechanical cervical ripening
- rupture of membranes when inserting
- uncomfortable
requirments for pitocin in IOL
-Need main line IV with LR or NS
-IVPB on a pump (closest port to patient)- own line, always on a pump with own channel
-Low dose: begin at 1-2 mIU/minute
-Increase by 1-2 q 30 min based on CTX pattern (if not palpating moderate to strong go up)
-T-1/2 of oxytocin is ~ 5 min
membrane stripping/sweeping
- Stimulates prostaglandin release and loosens the membranes
- Done at 41 weeks– decreases risks of going past 42 weeks
- Average decrease in length of pregnancy– 4 days
- Lowers risk of needing other IOL methods
risks of membranes stripping/sweeping
- Pain/discomfort/contractions
- Inadvertent ROM
- Bleeding
risks of pitocin in IOL
- Uterine tachysystole
- Uterine rupture (Rare)
- Water intoxication (Rare)
natural methods of induction
- may cause cervical ripening
- Acupuncture, Shiatsu, Acupressure
- Breast Stimulation
- Castor oil
- Date Fruit
- Evening Primrose Oil (EPO)
No evidence of: pineapple, sex, red raspberry leaf
pitocin in IOL management
- IV fluids
- Continuous EFM (FHR and CTX pattern)
- Restricted movement due to tethering (mobile monitor option)
- Restricted diet (provider dependent)
OTHER nursing considerations with pitocin in IOL
- Assess for cervical change as indicated (SVE)
- Provide comfort measures/labor support
- D/C Pitocin when FHT’s or CTX pattern (tachysystole) indicates ***
Artificial rupture of membranes (AROM)in IOL reasons
- Augmentation or Induction
- Placement of internal monitors/amnioinfusion
- With or without other methods of IOL/augmentation
1. Evidence has shown most effective method of IOL is AROM with Pitocin
how to AROM
- Amniohook used to make a hole in the sac
- Most women express more intense contractions after AROM
- “Commits” you to birth
risks of AROm
- Cord prolapse, infection, increased molding,
- laceration from hook,
- fetal heart rate changes
- SAFETY– ensure fetal head is “engaged”
take home message of IOL
- Use interventions APPROPRIATELY based on available evidence
- Inform patients of risk of interventions/cascade effect
birth variations with vaginal route
- vacuum assisted
- forceps assisted
- VBAC- vaginal birth after cesarean
birth variations with abdominal/surgical route
- C section
for vacuum and forceps to be an option babies have to
be very low in the pelvis for these to be options. + 2 station
Indications for Assisted Delivery
-Fetal bradycardia or non reassuring fetal heart tracing
-Maternal exhaustion
-Maternal heart disease where pushing would cause an unsafe Valsalva effect
-Malposition
Vacuum Extraction
-Used to assist birth of head by applying suction to the fetal head
-Artificial caput pulled into cup
-Pull to steer w/ contraction & maternal pushing efforts
Forceps Assisted Birth
- Provides traction or means to rotate the fetal head to an OA position
- Many types of forceps
-Low or outlet forceps: Simpson’s
- High forceps – rarely used any more
neonatal complications with assisted delivery
-Scalp lacerations
-Ecchymosis, edema along side of face
-Cephalohematoma
-Retinal hemorrhage
-Ocular trauma
-Fractured clavicle
-Intracranial hemorrhages
-Sub conjunctival hemorrhages
-Erb’s palsy
-Death
maternal complications of assisted delivery
-Trauma, lacerations
-Pelvic floor injury
-Edema
-Third/fourth degree lacerations
-Pain
-Infection
-Dyspareunia
-Genital tract/sphincter injury (incontinence)
Nursing Care for Vaginal Assisted Birth
-Prepare family before then debrief after as needed (often not time for them to process fully during assisted birth)
-Empty patient’s bladder to make room and prevent bladder trauma
-Alert Peds, Charge RN
-2nd RN -Record/time-keeper: ≤ 3 pulls and ≤ 2-3 pop offs
-Assess for injuries after birth on newborn and patients
- Additional analgesia and ice PRN
Cesarean Birth
- Birth through an abdominal and uterine incision
- Reasons for their high rate are varied– doctors are not paid by the hour so want to decrease time spent in delivery; thought that “once a c-section always a c-section” prevalent; lack of patient education; 1 in 4 women report experiencing obstetric violence during vaginal birth– tied down, berated, etc.
factors affecting c section rate in the US
-Medical malpractice litigation*
-Low TOLAC rates*
-Increase in continuous EFM*
-Decrease in vaginal assisted birth*
-? Increase in IOL rates
-Rise in maternal age
-Practice changes i.e. breech management
-Maternal health conditions—obesity, diabetes, and HTN
indications for c-section
-Complete placenta previa
-Cephalopelvic disproportion
-Active genital herpes
-Umbilical cord prolapse
-Failure to dilate despite adequate contractions
-Non-reassuring FHR especially if remote from delivery
-Placental abruption
some more controversial indications for c section
-Breech presentation
-Previous C-section
-Masses that obstruct birth canal
-Congenital anomalies
-Multiple gestation
-Maternal preference
Types of Incisions
- skin: vertical or transverse (bikini cut)
- uterine: classical (upper part of uterus going up and down), low vertical, T (low transverse then needed a vertical cut cuz cant get baby out), low transverse (what we want)
low transverse uterine incision
- like the bikini cut
- least uterine rupture
- this is the only one where they can have TOLAC with next baby
when to use classical uterine incision
cases in which it is difficult to access the lower uterine segment, such as that in preterm labor, dense adhesion, placenta previa/accrete
Risks Associated with Cesarean Births
- Major abdominal surgery and carries associated risks:
Infection, bleeding, vessel/bladder/bowel injury, increased pain, complications from anesthesia, etc. - In the U.S., 4X risk of death
- Other maternal risks:
- Neonatal risks
maternal risk of c sections
-Increases risks for blood clots, breastfeeding difficulties, longer duration of pain, longer hospital stays, increased hospital readmissions, abnormal placentation in future pregnancies
neonatal risks of c sections
-Increases immediate risks for TTN, birth injury as well as increased risk for childhood asthma, diabetes and allergies, possible connection with increased risk of autism
What can we do to use this technology more appropriately- ACOG recommendations for first stage
- 1st stage:
-Prolonged latent phase not an indication for C/S
-Should be considered latent until SIX cm
What can we do to use this technology more appropriately- ACOG recommendations for 2nd stage
- pushing stage
- Allow up to 3-4 (or more) hours for 2nd stage as long as tolerated by fetus
What can we do to use this technology more appropriately- ACOG recommendations for induction/cervical ripening
Before 41 weeks, induction of labor should be performed based on maternal and fetal medical indications
other ACOG Recommendations
- Suspected fetal macrosomia
-C/S should be limited to EFW of AT LEAST 5,000 g in women without diabetes (> 4,500 g with DM) - Maternal weight gain
-Women should be counseled about the Institute of Medicine maternal weight guidelines in an attempt to avoid excessive weight gain. - Twin gestations
-Women with 1st twin cephalic should attempt vaginal birth
Nursing Interventions: Prior to C/S
- Dependent on situation
-Scheduled, non-emergent, emergent - Antacids 30 min prior (if possible)
- NPO 8 hours prior (if possible)
- IV access
- Anesthesia – general vs. regional
- Foley catheter – typically after epidural/spinal
- Displace uterus from inferior vena cava (put roll under side)
- Suction set up
- Ground cautery (apply Bovie pad)
- FHT’s until surgery imminent : Take FSE off to prevent burns
- Instrument count
- Reassurance to client & family
Nursing Interventions: During and After C/S
- Support father or other support person in OR
- Assist mom & partner in bonding in OR
-Facilitate skin-to-skin contact if baby stable
-Partner/FOC hold baby
-Clear the view or take digital pics - Postoperative patient when out of OR
-Standard post-op
-Initiate Breastfeeding/bonding support
-Standard focused postpartum assessment (BUBBBLEE)
-Emotional support-may have PTSD/unresolved grief response
Newborn Considerations after c section
-Keep them warm
-Watch for TTN
-Hypoglycemia
-Breastfeeding issues
-Delayed Bonding
TOLAC
- Trial of Labor after Cesarean
- Allow labor and attempt a vaginal delivery
VBAC
-Vaginal Birth After Cesarean
-Successful TOLAC that results in a vaginal birth
Benefits of successful VBAC
Decreased levels of maternal morbidity (infection, blood loss, pain, etc.) and decreased mortality over a scheduled repeat C/S.
Most promising predictor of a successful VBAC:
Previous vaginal delivery after c-section
Guidelines for TOLAC in Hospitals
- Previous cesarean sections
- Up to 2 previous Cesarean births with low transverse uterine incision
- more than 2 c-sections = dont risk TOLAC - Pelvis
- Adequate (not been told CPD with last cesarean)
-CPD= cephlopelvic disproportion - Other Factors
-No other uterine scars or previous uterine rupture
-Contraindications to vaginal birth – previa, transverse lie, etc - Personnel
- MD available to do Cesarean section during TOLAC
- In-house anesthesia
risks of TOLAC
- Uterine rupture
- abnormal placental implantation: accreta, percreta, increta
- Cesarean Birth After Cesarean (C/S after labor has started)`
Benefits of VBAC
- Prior vaginal birth increases the likelihood of successful VBAC - doesn’t matter if it was prior to or after the CS
- Spacing between birth
1. Longer birth interval likely protective against uterine rupture (>18 months)
Risks of TOLAC- uterine rupture
- small risk with induction of labor and repeat rupture
- Associated complications of rupture: hysterectomy, blood transfusion, hypoxic-ischemic encephalopathy in babies, maternal death, fetal death
-perinatal death - Abnormal placental implantation- Accreta, percreta, increta
- Cesarean Birth After Cesarean (C/S after labor has started)
risk of TOLAC: Abnormal placental implantation- Accreta, percreta, increta
- The placenta can’t always implant normally do to the previous C-section scar so sometimes implant too deeply into uterine wall and attach to myometrium (accreta) or invades into the myometrium (increta) and even as much as all the way through the myometrium and into another organs (percreta)
- Maternal mortality – 7%
-Severe hemorrhage
-Higher risk of hysterectomy
-Greater risk when placenta lies over uterine scar
-Increases risk with each subsequent CS
risk of TOLAC: Cesarean Birth After Cesarean (C/S after labor has started)- CBAC
- failed TOLAC or VBAC
-Increased risk of uterine infection (2.9% vs. 1.8% in planned C/S)
-Increased risk of pelvic floor damage/incontinence (as with any vaginal birth) – though no effects by 2 years
-Increased blood loss
-Longer hospital stay and recovery
