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Induction/Birth variations Flashcards

1
Q

What is induction of labor?

A

Stimulation of uterine contractions during pregnancy before labor begins on its own

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2
Q

What is augmentation of labor?

A

Strengthens and increases frequency of uterine contractions with medications or interventions

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3
Q

What is cervical ripening?

A

Softening of the cervix that prepares the cervix for labor
Medications or other interventions can be used to ripen the cervix for induction

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4
Q

What are the maternal indications for an induction?

A

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)

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5
Q

What does fetal demise in the uterus increase moms risk for?

A

DIC
Sepsis
Death

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6
Q

What are the fetal indictions for induction of labor?

A

Fetal compromise: IUGR, oligo, mild abruption, non-reassuring FHT’s

Late term (41 weeks), post term (42 weeks)

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7
Q

What are some reasons mom might elect to have induction of labor?

A

Suspected large baby
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

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8
Q

What gestational age can mom elect to have an induction?

A

39 weeks

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9
Q

What are the increased risks associated with induction? (6)

A

Increased chance for cesarean birth (questionable)
Increased epidural use
Postpartum hemorrhage
Oxygen requirements for the baby at delivery
Longer hospital stays
Increased iatrogenic prematurity

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10
Q

What assessment information should be collected for induction?

A

Confirm presenting part by SVE or US to be cephalic
Collect Baseline Info such as Vital signs (Prostaglandins can raise temp), CTX pattern, FHT’s
Bishop score- determines “ripeness” of cervix

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11
Q

What does a higher bishop score mean? What does a lower bishop score mean?

A

Higher scores (≥8) associated with greater chance of having a vaginal delivery (cervix favorable/ripe for IOL)

Lower scores (≤6) associated with lower chance of vaginal delivery; prolonged labor (cervix is unfavorable/unripe for IOL)

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12
Q

A score less than 6 is associated with?

A

Unsuccessful induction
Prolonged labor
Higher risk for c-section

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13
Q

What is cytotec? Use? What is the dose?

A

Cervical ripening

Misoprostol, prostaglandin

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

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14
Q

When is cytotec contraindicated?

A

Contraindicated for ripening if history of previous c/s or any other uterine scar

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15
Q

What is dinoprostone? Use? Dose?

A

prostaglandin E2

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)

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16
Q

What is the goal of cervical ripening?

A

to improve Bishop score, however, sometimes these interventions are enough to start labor

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17
Q

How can you mechanically ripen the cervix?

A

Foley bulb (with 60 mls): Falls out when 3-4 cm dilated
Cook balloon (80/50): Squeezes cervix between two balloons and falls out 4-5 cm
Laminaria (Seaweed): See more with IOL for demise

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18
Q

How does a foley balloon work?

A

makes membranes separate helping with stimulation of own prostaglandins

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19
Q

How does a cook balloon work? Risks?

A

squeezes cervix and usually falls out on own at 4-5 cm dilated

Risks: cause membranes to rupture, can cause fetus to move up out of pelvis and not be head down anymore, uncomfortable

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20
Q

How does laminaria work? When is it often used?

A

absorb mucus and expand –> mechanical dilation.

Used more for induction of labor with fetal demise

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21
Q

What does membrane stripping/sweeping do? When is it done? Benefit?

A

Stimulates prostaglandin release by sweeping in between bag or waters and cervix

Done at 41 weeks decreases risk of going past 42 weeks​
​
Lower risk of needing other IOL methods

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22
Q

What are the risks/disadvantages to membrane stripping/sweeping?

A

Pain/discomfort/contractions
Inadvertent ROM
Bleeding

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23
Q

What are evidence based natural methods that may cause cervical ripening?

A

Acupuncture
Shiatsu acupressure
Breast stimulation
Castor oil (laxitate-NV)
Date fruit
Evening primrose oil (EPO)

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24
Q

What are natural methods that have no evidence behind causing cervical ripening?

A

Pineapple
Sex
Red raspberry leaf tea (increases risk of hemorrhage if used a lot)

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25
What are the benefits of cytotec?
Effective cervical ripening agent​ May cause onset of labor
26
What are the risks of cytotec?
Tachysystole​ Uterine rupture (high risk after c-sec, uterine scar)​ Fetal bradycardia​ Amniotic fluid embolism very rare-death
27
How long should you monitor after initial dose of cytotec? How often after that? What are you watching for?
Monitor for at least an hour after giving the dose and then at least every 30 minutes watching for tachysystole and FHR decelerations Tachysystole --> late decels or prolonged decels because no enough time to recover
28
What is Pitocin used for?
Medical stimulation of uterine contractions Induction or augmentation
29
What are the requirements for Pitocin use? Dose?
Need main line IV with LR or NS Secondary on a pump Closest port to pt b/c do not want to bolus, want to mix T-1/2 of oxytocin is ~ 5 min Multiple methods of mixing 10 U Pitocin w/ IV fluids Low dose: begin at 1-2 mIU/minute Increase by 1-2 q 30 min based on CTX pattern
30
What are the risks of using Pitocin?
Uterine tachysystole Uterine rupture (Rare) Water intoxication (Rare)
31
What does mom need to have with Pitocin? Does monitoring need to happen? Can they have anything that want to eat?
IV fluids Continuous EFM (FHR and CTX pattern) Restricted movement due to tethering (mobile monitor option) Restricted diet (provider dependent)
32
What should nurse be assessing with Pitocin use? Any interventions? When should Pitocin be stopped?
Assess for cervical change as indicated (SVE) Provide comfort measures/labor support D/C Pitocin when FHT’s or CTX pattern (tachysystole) indicates ***
33
What changes need to occur with an epidural placement?
BP cuff (q3-15min) Pulse ox Continous fetal monitor Diminished ability  for position changes/restricted to bed Foley/straight cath/bedpan IV fluid bolus
34
Why would you artificially rupture membranes?
Augmentation or Induction Placement of internal monitors/amnioinfusion
35
Is AROM effective without medication?
With or without other methods of IOL/augmentation, evidence has shown most effective method of IOL is AROM with Pitocin
36
How is AROM done? Are contractions different? Can it be undone?
Amniohook used to make a hole in the sac Most women express more intense contractions after AROM No, “Commits” you to birth
37
What are the risks of AROM?
Cord prolapse Infection Increased molding Laceration from hook Fetal heart rate changes
38
What should you make sure occurs before AROM?
Ensure fetal head is “engaged” (0 station)
39
What are 2 ways for vaginal assisted delivery? What needs to occur to use these?
Vacuum and forceps Babies must be 2+ or more to use these
40
What are the indications for assisted delivery? (4)
Fetal bradycardia or non reassuring fetal heart tracing Maternal exhaustion Maternal heart disease where pushing would cause an unsafe Valsalva effect Malposition - forceps used better to rotate baby
41
What does a vacuum extraction do? How does it work?
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
42
What does forceps assisted do? What is once example of a time when this is used?
Provides traction or means to rotate the fetal head to an OA position Can be used when you have someone you don't want to push such as maternal heart disease because can use more pulling
43
What are 2 types of forceps?
Low or outlet forceps High forceps – rarely used any more
44
What are the neonatal complications r/t assisted birth? (10)
Scalp lacerations Ecchymosis, edema along side of face Cephalohematoma Retinal hemorrhage Ocular trauma Fractured clavicle Intracranial hemorrhages Sub conjunctival hemorrhages Erb’s palsy Death
45
What are the maternal complications r/t assisted birth? (8)
Trauma, lacerations Pelvic floor injury Edema Third/fourth degree lacerations Pain Infection Dyspareunia Genital tract/sphincter injury (incontinence)
46
When there is a vaginal assisted birth, what is the nursing care? (6)
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 “2-3 pop-off” or less than 3 pulls with forceps Assess for injuries on newborn and mom Additional analgesia and ice PRN
47
What is a cesarean birth?
Birth through an abdominal and uterine incision
48
What factors are causing an increase in c/s 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
49
What are the indications for a c-section? (13)
Complete placenta previa Cephalopelvic disproportion Active genital herpes Umbilical cord prolapse Failure to dilate despite adequate contractions Non-reassuring FHR remote from delivery Placental abruption Breech presentation Previous C-section Masses that obstruct birth canal Congenital anomalies Multiple gestation Maternal preference
50
What are the types of incision for a c section?
Classical (Upper part of uterus) Low vertical “T” (cutting up on uterus if low transverse if opening not enough) Low transverse (bikini line)
51
What type of incision is needed for TOLAC?
Low transverse (bikini line)
52
What are the abdominal surgery risks r/t a c-section?
Infection Bleeding Vessel/bladder/bowel injury Increased pain Complications from anesthesia
53
What are the maternal risk r/t a c-section?
Increases risks for blood clots Breastfeeding difficulties Longer duration of pain Longer hospital stays Increased hospital readmissions Abnormal placentation in future pregnancies
54
What are the neonatal risks r/t a c-section?
Increases immediate risks for TTN Birth injury Childhood asthma Diabetes Allergies Possible connection with increased risk of autism Birth injury d/t scalpel
55
During the 1st stage of labor, what is not considered an indication for a c/s?
Prolonged latent phase (until at least 6 cm)
56
During the second stage of labor, how many hours should go by before considering a c/s?
Allow up to 3-4 (or more) hours for 2nd stage
57
Before ______ weeks, induction of labor should be performed based on maternal and fetal medical indications.
Before 41 weeks, induction of labor should be performed based on maternal and fetal medical indications.
58
A fetal weight of _____ should be considered for a c-section in women without diabetes?
5000g
59
Should women have a c-section d/t twins?
Women with 1st twin cephalic should attempt vaginal birth
60
What are nursing interventions that should be done prior to a c-seciton?
Antacids 30 min prior (if possible) NPO 8 hours prior (if possible) IV access Anesthesia – general or regional Foley catheter – typically after epidural/spinal Displace uterus from inferior vena cava (put roll under R 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
61
What does nursing interventions prior to a c-section depend on?
Scheduled, non-emergent, emergent
62
Can anyone support people be in the room during a c-section?
Yes and during c-section nurse should support father or other support person in OR
63
How do you assist mom and partner in bonding in the OR?
Facilitate skin-to-skin contact if baby stable Partner/FOC hold baby Clear the view or take digital pics
64
What is the post-op care with patient is out of OR after c-section?
Standard post-op Initiate Breastfeeding/bonding support Standard focused postpartum assessment (BUBBBLEE) Emotional support-may have PTSD/unresolved grief response
65
What are newborn considerations r/t a c-section?
Keep them warm Watch for TTN Hypoglycemia Breastfeeding issues Delayed Bonding
66
What is TOLAC?
Allow labor and attempt a vaginal delivery
67
What is VBAC?
Successful TOLAC that results in a vaginal birth
68
What are the benefits of a successful VBAC?
Decreased levels of maternal morbidity (infection, blood loss, pain, etc.) and decreased mortality over a scheduled repeat C/S.
69
What is the most promising predictor of a successful VBAC?
Previous vaginal delivery after c-section
70
What are the maternal guidelines for a TOLAC?
Up to 2 previous Cesarean births with low transverse uterine incision Pelvis is adequate (not been told CPD with last cesarean) No other uterine scars or previous uterine rupture Mo contraindications to vaginal birth – previa, transverse lie, etc
71
What personnel need to be available if TOLAC is not successful?
MD available to do Cesarean section In-house anesthesia
72
What helps a VBAC be more successful?
Prior vaginal birth increases the likelihood of successful VBAC - doesn’t matter if it was prior to or after the CS Spacing between birth - longer birth interval likely protective against uterine rupture (>18 months)
73
What are the risks of TOLAC? (3)
Uterine rupture Abnormal placental implantation- Accreta, percreta, increta Cesarean Birth After Cesarean (C/S after labor has started)
74
What are the associated complications of uterine rupture with a TOLAC?
Hysterectomy Blood transfusion Hypoxic-ischemic Encephalopathy in babies Maternal death Fetal death
75
When there is abnormal placental implantation what is patient at increased risk for? What puts patient at increased risk?
Maternal mortality Severe hemorrhage Higher risk of hysterectomy Greater risk when placenta lies over uterine scar Increases risk with each subsequent CS
76
What are the risks of a cesarean birth after cesarean?
Increased risk of uterine infection 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

OB (16 decks)

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