OB exam 2 - Artificial Mgt of Labor Flashcards
advantages to labor induction
labor usually occurs in 24-48 hours
disadvantages to labor induction
-contractions may be less gradual
-dysfunctional uterine contractions
-increased bloody discharge
what needs to be down before induction of labor
-review pt, VS & obtain consent
-obtain reactive NST
-vaginal exam
-bishop score (the higher the score, the higher chance of a regular vaginal delivery)
amniotomy (AROM) nursing interventions
-check fetal HR
-note date & time
-note fluid (COAT)
check temp every 2 hours
what is a mechanically induction
cervical ripening
uses a foley bulb which puts pressure on the cervix just like the fetal head would causing prostaglandins to be released to soften the cervix
advantages of cervical ripening
-cervical effacement
-shorter labor
-lower requirements for oxytocin
-vaginal birth is achieved within 24 hrs for most women
-incidence of C section birth is reduced
risks of cervical ripening
-uterine hyperstimulation (for than 5 contractions in 10 mins)
-non reassuring fetal status
-higher incidence of PP hemorrhage
-uterine rupture
what meds can be given to induce labor
misoprostol & dineprostone (prostaglandins)
given vaginally to stimulate contractions to thin cervix & oxytocin
Cytotec
-dose is 25 mcg every 6 hours
-do not start pitocin induction within 4 hrs of last dose
cervidil
-dose 10mg vaginal insert over 12 hours
-bedrest 2 hours after dose then may be up to bathroom (pat dry after voiding)
-to remove, pull string
stripping of the membranes
-non pharm possible induction of labor
-separates the amniotic membranes from the lower uterine segment (can be uncomfortable & my see vaginal bleeding after)
-releases prostaglandins that stimulate contractions
only preformed by OB, nurse midwife or NP
what are the uses of Pitocin (Oxytocin)
induction or augmentation (help labor along)
risks of pitocin
-tachysystole contractions
-uterine rupture
-water intoxication (anti diuretic effect -> confusion, lethargic, vomiting and/or seizure)
-non reassuring fetal heart rate patterns
what do you do if pt experiences water intoxication from pitocin induction
stop pitocin -> give 9% normal saline & give furosemide
what needs to be done before administering pitocin
-need reactive NST
-vaginal score w/ bishop score
-check for foley bulb (can still use if in place)
-continuous fetal monitoring
how is pitocin titrated
increase 1-2 mu/min every 30 mins
what is a major risk if on pitocin for over 7 hours
post partum hemorrhage
what happens if you give pitocin as a bolus
will cause continuous hard contractions and baby will not get perfused well or good oxygen caused a prolonged decel
when does labor augmentation usually occur
during naturally occurring labors w/ hypotonic contractions
what are the main ways of performing labor augmentation
-pitocin
-AROM
amnioinfusion
warmed sterile NS or LR is placed into the uterus via IUPC
reasons for an amnioinfusion
-replacement of lost or absent amniotic fluid
-repetitive variable decelerations w/ increasing intensity
-meconium dilution
what should be occurring when an amnioinfusion is happening
water should be leaking back out
if no fluid noted and you have increased uterine resting tone, stop transfusion immediately
what intervention is done to encourage water to come out after amnioinfusion is turned off because of no fluid return
try to move baby’s head bc it could be acting as a stopper or change maternal position
factors for use of forceps assisted birth
-heart disease
-acute pulmonary edema or pulmonary compromise
-intrapartum infection
-prolonged second stage
-exhaustion
-non reassuring fetal strip
episiotomy
surgical incision of the perineum to enlarge the vaginal outlet -> two types are midline or mediolateral and can be classified from 1st degree to 4th degree
mid forceps
fetal head engaged @ 0 station
used rarely bc higher reach
low forceps
fetal head +2 station
outlet forceps
fetal head at perineum
maternal risks to forceps use
-vaginal and cervical lacerations
-periurethral lacerations
-extension of a median episiotomy into the anus
-anal sphincter injury
-perineal edeam
neonatal risks of forceps use
-ecchymosis, edema, along the sides of face
-caput succedaneum or cephalhematoma
-transient facial paralysis, brachial plexus
-cerebral hemorrhage
-fractures (clavicle)
-elevated neonatal bilirubin levels
nursing mgt for forceps assisted births
-explain procedure to women
-monitor contractions
-inform physician/CNM of contraction
-encourage women to push during contraction
-reassurance
-document length of the forceps used (when applied & removed)
Vacuum Extraction
-suction cup placed on fetal occiput
-pump is used to create suction
-traction is applied
-fetal head should descend w/ each contraction
-document length of time vacuum is used (put on, when pressure was applied, when pressure was turned off and when the vacuum was off)
Cesarean Birth Indications
-complete placenta previa
-CPD
-Placental abruption
-active genital herpes
-umbilical cord prolapse
-failure to progress in labor
-tumors that obstruct the birth canal
-breech presentation
-previous C section
-major congenital anomalies
-non reassuring fetal status
what is the usual uterine incision
low transverse
what does a classical uterine incision or low vertical incision put mother at high risk for
a uterine rupture if vaginal delivery to tried
best practice is to have another c sections future children & placenta previa bc placenta will want to attached to scarring
nursing mgt before C section
-assist w/ epidural or spinal
-unscheduled sections will get get pepcid & reglan to neutralize stomach acid as well as bicitra 30 mins before
- monitor maternal VS
-obtain fetal HR
-insert foley
-prepare abdomen and perineum
-make sure all necessary personnel and equipment are present
nursing mgt during C section
-position the women on the operating table (wedge for left tilt prior to delivery)
-support the couple
-instrument count (before, during, after)
-time out (final checks for consent & safety)
-document
what do you document during a C section
incision, delivery of infant, APGARS, AROM if done, placenta extracted, EBL, & meds received
nursing mgt after c section
-normal newborn post delivery care
-monitor VS every 15 mins
-check the surgical dressing
-palpate the fundus and checking lochia
-monitor intake & output
-administrate IV Oxytocin
visceral pain
slow deep pain that is dull or aching
very common in first stage of labor
somatic pain
sharp and localized and is like a burning or tearing feeling
common during the transition or pushing phase of labor
do pain meds cross through the placenta during labor
yes
when are you going to give systemic analgesia
since fetal liver and kidney excretion is inadequate for metabolizing med you will do it when women is uncomfortable, in a well established labor pattern, contractions are occurring regularly, there is a significant during of contractions and contractions are moderate to strong in intensity
contraindications for systemic analgesia
allergies
hypotension
non reassuring fetal strip
don’t give systemic right before delivery bc could affect respiratory off baby
what medication can you not give to mothers with substance abuse issues
nalbuphine hydrochloride -> can initiate w/draw & cause neonatal abstinence syndrome
major consideration for meperidine
naloxone (Narcan) does not reserve affects on the infant
regional anestesia
temporary and reversible loss of sensation & prevents initiation and transmission of nerve impulse for pain control
epidural disadvantages
-maternal hypotension (give LR bolus)
-post delivery back pain
-meningitis
-cardio respiratory arrest
-vertigo
-onset of analgesia may not occur for up to 30 mins
advantages to a spinal
-immediate onset of anesthesia
-relative ease of administration
-smaller drug volume
disadvantages of a spinal
-high incidence of hypotension
-greater potential for fetal hypoxia
-short acting
advantages to a combined spinal epidural
-spinal has a faster onset
-meds can be added
-low doses
disadvantages to a combined spinal epidural
-higher incidence of nausea
-pruritus
nursing mgt prior to epidural/spinal placement
-assess maternal & fetal status
-assess labor progress
-start an IV and administer preload (warmed LR bolus)
-help women into position
nursing mgt for after an epidural/spinal
-monitor maternal & fetal VS
-assess for hypotension & correct if needed
-administer antiemetics as needed
-monitor respiratory rate
-assess bladder and catheterize if unable to void
corrective measures for hypotension
-additional fluid bolus
-meds: ephedrine IVP
-oxygen if needed
pudendal block (perineal anesthesia)
second stage of labor and episiotomy repair
pudendal block advantages
-ease of administration
-absence of maternal hypotension
pudendal block disadvantages
urge to bear down may be decreased
general anesthesia
-emergent delivers
-low platelet count requiring C section
-scheduled C sections and unable place spinal
cricoid pressure (for general anesthesia)
diminish the chance of aspiration during placement of endotracheal tube
general anesthesia problems
-fetal respiratory depression (=lower apgar score)
-maternal intubation
-higher risk of aspiration
-higher risk for PP hemorrhage
-less feeling of control
-support person may not present
-maternal amnesia
