Intrapartum Interventions: Sherpath Flashcards
Intrapartum Interventions
Induction of labor
an obstetric procedure in which labor is initiated artificially by means of amniotomy or administration of oxytocics.
Indications for induction
- Fetal compromise (such as intrauterine growth restriction, maternal-fetal blood incompatibility) *Spontaneous rupture of the membranes at or near term without onset of labor (premature rupture of the membranes [PROM])
- Postterm pregnancy
- Chorioamnionitis (inflammation of the amniotic sac) *Gestational or chronic hypertension, both associated with reduced placental blood flow
- Abruptio placentae (Large abruptions require immediate delivery.)
- Maternal medical conditions that are worsening with continuation of the pregnancy (e.g., diabetes, renal disease, pulmonary disease, chronic hypertension)
- Fetal death
Amniotomy
the artificial rupture of the fetal membranes, usually performed to stimulate or accelerate the onset of labor.
Procedures for induction and augmentation labor
Prostaglandin cervical ripening
Mechanical cervical ripening
Oxytocin administration
Oxytocin administration
to stimulate or augment contractions in an effort to promote cervical dilation.
Mechanical cervical ripening
–use of a variety of cervical inserts, such as a Foley catheter or hydrophilic (water-absorbing) inserts, to gradually stretch and soften the cervix before induction of labor with oxytocin.
Prostaglandin cervical ripening
use of prostaglandin in the form of a gel, timed–release insert, or tablet to soften the cervix and promote dilation; often precedes induction with oxytocin.
bishop scoring system
five factors to estimate cervical readiness for labor: cervical dilation, effacement, consistency, position, and fetal station. The Bishop score remains popular because of its ability to predict probable success of induction. The likelihood of vaginal delivery is similar to that of spontaneous labor if the score is greater than 8. A grade below 6 usually indicates that a patient would need cervical ripening before other treatment.
Placenta previa
(implantation in lower uterus), which may result in hemorrhage during labor
Vasa previa
in which fetal umbilical cord vessels branch over the amniotic sac rather than inserting into the placenta (Fetal hemorrhage is a possibility if the membranes rupture.)
other contraindicatons and risks of induction and labor
- Abnormal presentation for which vaginal delivery is often hazardous
- Umbilical cord prolapse, because immediate cesarean delivery is indicated
- Some uterine surgery, such as classic cesarean delivery or extensive surgery for uterine fibroids
other contraindicatons and risks of induction and labor (2)
One or more previous low transverse cesarean deliveries
- Breech presentation (Vaginal delivery may be more hazardous; also the fetus may turn to a normal position by the time spontaneous labor occurs.)
- Maternal heart disease, which varies in severity
- Severe maternal hypertension
- Uterine overdistention, as in the case of a multifetal pregnancy, especially triplets or higher, and hydramnios
- Fetal presenting part is above the pelvic inlet, which may be associated with cephalopelvic disproportion (fetal head size that is too large to fit through maternal pelvis) or a preterm fetus
- Nonreassuring fetal heart rhythm (FHR) patterns that do not yet mandate emergency delivery
Induction and augmentation of labor: risks
- Uterine tachysystole (hyperstimulation), which can reduce placental perfusion and fetal oxygenation as a result of excessive frequency, duration, or intensity of contractions or from poor uterine relaxation between contractions. Tachysystole may be accompanied by nonreassuring FHR patterns.
- Uterine rupture, which is more likely to occur with overdistention
- Maternal water intoxication caused by oxytocin’s antidiuretic effects, which is more likely if hypotonic solutions are used to dilute the oxytocin
- Greater risk for chorioamnionitis and need for cesarean delivery
S/s of stachystole
- Contraction duration longer than 90 sec
- Contractions occurring less than 2 min apart or relaxation of less than 30 sec between contractions
- Uterine resting tone above 20 mm Hg or peak pressure higher than 90 mm Hg during first-stage labor (with intrauterine pressure catheter)
- Montevideo units greater than 400
- An FHR pattern of late decelerations accompanying hypertonic uterine activity
Nursing Actions for Tachysystole
- Reduce or stop the oxytocin infusion.
- Increase the rate of the primary nonadditive infusion.
- Maintain the laboring patient in a lateral position.
- Give oxygen by snug facemask, 8 to 10 L/min.
- Notify the health care provider.
The nurse is caring for a patient who has just been prescribed intravenous (IV) oxytocin for the induction of labor. The nurse’s subsequent assessments should address the risk for which complication of induction?
Tachysystole
Oxytocin directly stimulates contractions, creating a risk for uterine hyperstimulation and tachysystole. For this reason, the nurse must prioritize assessments of the frequency, intensity, and duration of contractions.
The nurse is caring for a pregnant patient receiving intravenous (IV) oxytocin for induction of labor. The most recent fetal heart rates indicate fetal bradycardia unresponsive to repositioning. Which order would the nurse anticipate?
Discontinue the oxytocin infusion: Fetal bradycardia (fetal heart rate <110 beats/min lasting for more than 10 minutes) is a sign of potential uterine tachysystole and reduced placental exchange caused by oxytocin administration. Therefore, discontinuing the IV oxytocin infusion is the next step taken to relax the uterus, thus increasing blood flow to the fetus.
The charge nurse is making patient assignments for the next shift of nurses. The nurse anticipates that induction of labor likely will be indicated for which patient?
A patient at >42 weeks’ gestation
Postterm pregnancy (>42 weeks) is an indication for induction of labor. Postterm pregnancy is linked with both fetal and maternal health complications; as a result, health care providers usually do everything they can to ensure that an infant is delivered as close to the due date as possible.
Episiotomy
a surgical procedure in which an incision is made in a woman’s perineum to enlarge her vaginal opening for delivery. It is performed most often electively to prevent tearing of the perineum, to hasten or facilitate birth of the baby, or to prevent stretching of perineal muscles and connective tissue.
First degree laceration
Extends through the skin and tissue, superficial to muscular system.
Second degree laceration
Extends through perineal muscles.
Thrid degree laceration
Continues through anal sphincter muscle.
Fourth degree laceration
Involves anterior rectal wall.
The nurse is caring for two women in early labor. Which patient is at greatest risk for perineal laceration?
A patient whose delivery will be assisted with a vacuum extractor: Patients who experience operative delivery, which is delivery assisted by forceps or vacuum extractor, are at increased risk for perineal laceration because of the introduction of a mechanical instrument into the vagina.
The nurse is caring for a patient in the second stage of labor. Which patient condition is most likely to result in the need for an episiotomy?
A patient whose fetus is experiencing shoulder dystocia
Shoulder dystocia is an indication for episiotomy because it is necessary to allow as much room as possible for the delivery of the shoulder.
The nurse is caring for a patient with an episiotomy 4 hours after delivery. While examining the wound, the nurse notices a hard, turgid area alongside the incision. Which is the next step in nursing management?
Apply an ice pack to the perineum: Ice should first be applied to the site to promote vasoconstriction. With less blood flowing to the area of the incision, inflammation may decrease. The nurse should follow up by notifying the health care provider.
