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
- We want this to happen quickly without trauma (may see 3rd and 4th degree lacerations)
- Is a safe option
- More safe than a cesarean
- Risk of vaginal hematoma
- Episiotomies more likely
- Ecchymoses (can also happen with baby)
- For baby, facial and scalp lacerations, also abrasions; may be facial nerve injury (especially if forceps was used depending on where they’re placed)
- Cephalohematoma (is more common with a vacuum extractor)
- Subgaleal hemorrhage
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
Vaginal Birth After Cesarean (VBAC) [is only called this when it’s successful]
- When being trialed, is called a TOLAC
- 60-80% of women with one previous low transverse cesarean section have had successful vaginal births
- Identify the cause of the first cesarean to evaluate risk
- Exercise caution when performing a trial of labor after cesarean (TOLAC) because there is a small, but significant risk, of ___
> Could lead to a C-section and there’s a risk of losing the uterus
> Each incision creates a risk - When attempting a VBAC, the physician and anesthesiologist must be readily available in case an emergency cesarean is needed
- Many women opt for an elective repeat cesarean
uterine rupture
Cesarean Delivery
* Providers opt to use this electively for ease of labor
* A fear of labor and pushing
* We’ve let this become the norm when vaginal birth should be the norm
Cesarean Statistics
* World Health Organization (WHO) identifies 10-15% as the “ideal” rate
* By the late 1980’s, approximately 25% of births were C-sections
> Aimed to reduce this through introduction of VBAC and reduction in primary C-sections
* Reduced rates through mid 1990s, but by 2013 cesarean rates rose to 32.7%
> Some US hospitals have seen rates as high as 60%
* In some countries, cesarean births outnumber vaginal births
* Healthy People 2030 goal to reduce cesarean rates to 23.9%
WHY are C-section rates so high?
* Women are having fewer children and those who have had successful vaginal deliveries in the past are least likely to require cesarean deliveries
* Medically indicated AND elective inductions continue to rise, increasing the risk of a cesarean, particularly for the nulliparous woman
* High primary C-section rate increases overall C-section rate as more women have repeat cesarean deliveries
* Obesity is prevalent and increases the risk for pregnancy complications that can result in a cesarean delivery; risk of wound dehiscence and infections
* Operative vaginal deliveries (vacuum/forceps) has decreased
* Continuous fetal monitoring prompts concerns more frequently
* Breech presentations are mainly delivered by cesarean now
* Fear of litigation
So what can we do?
Increase our knowledge and advocate!
> Spinning Babies campaign
Cesarean Indications
* Cesarean births are performed when waiting for a vaginal birth would compromise the mother, the fetus, or both
> Dystocia (prolonged labor)
> Cephalopelvic disproportion (CPD)
> Hypertension requiring prompt delivery (as in preeclampsia, severe range htn readings)
> Maternal diseases that make labor non-advisable
> Active genital herpes at the time of birth
Cesarean Indications cont’d
* Previous uterine procedures (classic incisions) [vertical]
* Persistent, nonreassuring fetal heart rate tracings
* Prolapsed umbilical cord
* Fetal malpresentations (breech, transverse [shoulder presentation])
* Hemorrhagic conditions (abruptio placentae, placenta previa)
Risks Associated with Cesarean Delivery
* Cesarean birth is one of the safest major surgical procedures
Maternal Risks:
> Infection
> Hemorrhage/transfusion
> Urinary tract trauma or infection
> Thrombophlebitis/thromboembolism
> Paralytic ileus
> Atelectasis
> Anesthesia complications
Infant Risks:
> Inadvertent preterm birth
> Transient tachypnea r/t delayed absorption of fetal lung fluid
> Persistent pulmonary htn
> Injuries: laceration, bruising, or other trauma
Preparing for the Cesarean
* Come in 2 hours prior to get ready before scheduled time
* Ensure up to date lab values (e.g. Hgb, Hct, platelet count) are readily available for the physician and anesthesiologist
* Premedicate with famotidine or citric acid to reduce gastric motility (as at risk for aspiration of gastric contents)
* Clip pubic hair if a low-transverse incision is planned
* Anesthesia block is administered (usually epidural, spinal, or CSE)
* Place indwelling urinary catheter
* Continue to monitor fetus until sterile prep of abdomen is completed
Preparing for the Cesarean cont’d
* Place a wedge under the patient’s hip to prevent aortocaval compression
* Apply an electric grounding pad to the patient’s outer thigh
* Secure legs to the table
* A single dose of IV antibiotics is administered (e.g. cephazolin); more if needed for concern of infection
* Sterile abdominal preparation (with iodine or chlorhexidine); followed by sterile draping
* TIME-OUT
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
Nursing Care for the Woman Undergoing Cesarean Birth
* Provide emotional support
> Tell me about when you had your other baby
> Be calm and confident in what you’re doing
> Provide support to the support person
* Teaching
> Knowledge to reduce fear and anxiety
> Teach about perioperative procedures
> Describe the OR
> Tell partner about estimated wait time
> Information on PACU time
> A healthy newborn stays with mother
Nursing Care for the Woman Undergoing Cesarean Birth cont’d
* Promoting Safety
> Be NPO or on a clear liquid diet
> Can give rx’s to control gastric and respiratory secretions
> Have positioned well and be careful when transferring; wedge pillow and padding, legs secure
> Verify functioning of machines and equipment
* Providing Postoperative Care
> Assess on admission and for every 15 minutes until stable and checks until stable
> Vital signs, EKG pattern, return of motion and sensation, LOC, abdominal dressings, uterus, lochia, urine amount, IV infusions and pain
