Nursing Care During Obstetric Procedures Flashcards
“Special procedures are sometimes needed to help the mother or fetus. A physician or nurse midwife performs these procedures while nurses provide supportive care.”
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Is done during the late pregnancy to prevent C-section; around 37 weeks gestation (before going into labor)
Don’t want baby to rotate back into breech position
Cannot be done if woman is contraindicated for a vaginal delivery; if any uterine malformations present (e.g. a bicornuate uterus); had a previous C-section; if there’s CPD, placenta previa, multifetal gestations; if oligohydramnios present; if membranes have already ruptured; if fetus has a nuchal cord; if there’s any signs of uteroplacental insufficiency, or fetal presenting part is already engaged
External Cephalic Version (ECV)
External Cephalic Version (ECV) - Preparation
Perform an NST
Can give a tocolytic like terbutaline to relax uterus
An epidural or other form of regional anesthesia might be in place
ECV is guided by US
Rh(-) mother will get RhoGAM
External Cephalic Version (ECV) - Risks
* Fetal HR changes
* Fetuses could experience cord entanglement and cord accidents (can result in fetal death)
* Cord compression
* Placental abruption
* Risk of hemorhage to fetus and mother
- Nurse ensures patient understands the informed consent and consent of a C-section; the general anesthesia
- IV line in mother
- Take maternal and fetal vital signs
- Some women can be induced after
- Monitor pain in mother
Induction and Augmentation of Labor
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Artificial stimulation of uterine contractions
> Labor has begun, but needs to increase frequency or strength of uterine contractions
Indications for
- Intensify with Oxytocin to strengthen uterine contractions; have be closer together and progress the labor at a more expected rate
Augmentation
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Artificial initiation of labor
> Labor has not yet started
Indications for
- Fetal compromise; spontaneous rupture of membranes (when at or near term) without onset of labor (PROM); post-term pregnancies; chorioamnionitis; htn; abruptio placentae; worsening maternal medical conditions; fetal death
Induction
Bishop scoring system
A score of 8 or higher is similar to that of spontaneous vaginal birth
Less than 8 = cervix isn’t ready for labor
Remeber, Oxytocin is not a ripening agent; they are prostaglandins
Contraindications to Induction and Augmentation of Labor
* Any contraindication to labor and vaginal birth
- Placenta previa
- Vasa previa = velamentous cord insertion
- If baby in abnormal presentation; an umbilical cord prolapse or history of uterine surgeries (classic C-section of a vertical incision), or extensive uterine fibroids
> Can use mechanical dilators or a low dose Oxytocin in a transverse, low classic (can’t really induce, no prostaglandins) - For 1 prior surgery
Some conditions are not total contraindications, but require individual evaluations
> One or more previous low-transverse cesarean sections
> Breech presentation
> Maternal heart disease
> Severe maternal htn (increases clot risk)
> Uterine overdistension (multifetal pregnancies; polyhydramnios)
> Fetal presenting part above pelvic inlet
> Nonreassuring fetal heart rate patterns
- Can be a Category 2 but more Category 3 that we’re referring to
Techniques for Induction and Augmentation of Labor
Cervical ripening can help prepare the cervix for labor and is a common adjunct to induction
* Use prostaglandins (e.g. Dinoprostone, Misoprostol)
- Be careful in women with asthma, glaucoma, an ischemic heart disease, or pulmonary/hepatic/renal diseases
- Monitor fetal HR and uterine activity before and after
* Surgical Methods
> Amniotomy
* Medical Methods
* Mechanical Methods
- Intra-cervical inserts like the trans-cervical catheter or Cook’s balloon
* Need effacement before dilation
- Hydrophilic inserts (Dilapan, Lamisil) [see image]
Oxytocin (aka Pitocin) - a NEED TO KNOW [Drug Guide, McKinney p. 384]; HIGH RISK
Precautions
- Ensure proper time delay between any cervical ripening administration and start of oxytocin infusion
- Diluted in an isotonic solution and given as a piggyback
- Oxytocin line inserted to primary line closest to the venipuncture site
- Start slowly, increase gradually
- Uterine activity and FHR patterns are monitored before, when started, and throughout labor
The nurse is responsible for maintaining safeguards for both mother and fetus, and must recognize when to start, change, or stop its infusion and notify the physician.
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Signs of
> Contraction duration longer than 90-120 seconds
> Contractions occurring less than 2 minutes apart OR relaxation of less than 30 seconds between contractions
> Uterine resting tone above 20 mmHg or peak pressure higher than 90 mmHg during the first stage of labor (with IUPC)
> Montevideo units greater than 400
> A FHR pattern of late decelerations accompanying a hypertonic uterus
> Fetal O2 exchange is reduced
Uterine tachysystole
Intrauterine Resuscitation of the Fetus
* Reduce or stop the Oxytocin infusion and increase the rate of the primary nonadditive IV fluid infusion
* Keep the woman positioned on her side to prevent aortocaval compression and increase placental blood flow. Turn to opposite side as needed
- Left side is best
* Give 100% oxygen by a snug face mask at a rate of 8 to 10 L/min to increase the woman’s oxygen saturation, making more oxygen available for the fetus
* Notify the physician or nurse midwife
* Physician may order tocolytic medications such as terbutaline to reduce uterine contractions (and create an extended resting period to promote fetal oxygenation)
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Artificial rupture of the amniotic sac
> Often performed in conjunction with the induction or stimulation [augmentation] of labor
Risks:
Prolapse of the umbilical cord (a risk especially if the fetus is high up)
Infection
Abruptio Placentae
Amniotomy
Amniotomy - Nursing Considerations
> Obtain a baseline fetal HR tracing (20 min NST = is it reactive?)
> Assist with the amniotomy procedure/provide patient comfort
> Assess fetal tolerance of the procedure
> Document color, quantity, and odor of amniotic fluid (we expect it to be clear; any yellow or green tint? [passage of meconium]; signs of infection?)
> Monitor maternal temperature every 2 hours
- Increased temperature could be a sign of chorioamnionitis that puts mother and baby at risk
Operative Vaginal Birth
The physician applies traction to the fetal head during birth with a vacuum extractor or forceps to aid the woman’s expulsive efforts
- Vacuum or forceps used (based on the provider’s preference)
Indications
> Need to shorten second stage for maternal or fetal wellbeing
- Maternal exhaustion; unable to push effectively; has cardiac or pulmonary diseases; intra-partum infection present
- Cord compression; premature separation of placenta starts (abruptio placentae); pushing and we see a nonreassuring FHR pattern
> Vaginal birth can be accomplished quickly without trauma
Technique/Nursing Considerations
- Offer vacuum, forceps, or cesarean options
- Ensure woman has an empty bladder to reduce risk of trauma (Foley catheter out)
- Assess FHR tracing and report any rate less than 100 bpm
- Membranes must be ruptured and the cervix fully dilated, as well as the fetal head engaged and low in the pelvis
- Maximum of 3 pulls is the recommended limit for vacuum-assisted deliveries
Review Episiotomies
* Used to provide more room in a quick manner; only done as needed and NOT routine
* Mediolateral versus midline
Incisions
* Vertical
* Pfannenstiel
* Low transverse
* Low vertical
* Classic
Which is the most common? Which places mother at greater risk for uterine rupture?
Most common = low transverse
Greater risk for uterine rupture = low vertical
