Birth-Related Procedures Chapter 20 Induction of labor Definition Labor Readiness Table 20-1: p 429 Defined as the stimulation of uterine contractions before spontaneous onset of labor Various reasons: DM, renal problems; Hx of rapid delivery; intraterine fetal demise. Contraindicated : active genital herpes, transverse fetal lie, prior classic uterine incision (vertical incision in upper portion of uterus); patient refusal Labor readiness: Determined by fetal maturity (LMP, EDC, US) Cervical readiness: Bishop’s score, a method of evaluation, scoring 0 – 3 on criteria including cervical dilation, effacement, consistency, position & fetal station. A score of 9 = favorable for induction.

Methods of Induction Chemical Mechanical Nursing management Oxytocin infusion Labor augmentation Prostaglandin E2 Misoprostol Mechanical amniotomy Nursing management Oxytocin initiates contractions or enhances ineffective contractions (labor augmentation). LR 1000ml with 10 units Pitocin infused at rate of 6 mL/hr; rate can be changed, based on protocol and careful assessment of contractions. Goal: contractions q 2 -3 mins, lasting 40 – 60 secs. Risks: hyperstimulation → hypertonic contractions with inc resting tone, ↓ placental perfusion, fetal distress, uterine rupture, H20 intoxication. Prostaglandin E2 – gel or tablets for cervical ripening (softening & effacing the cervix); Prepidil and Cervidil; vaginal birth within 24 hrs avg. Misoprostol: (Cytotec) synthetic prostaglandin E1 analogue in tablet form. Contraindicated in maternal asthma, Hx of uterine scar or bleeding; non-reassuring FHR tracing. Amniotomy – artificial ROM, most common operative procedure in OB. Amnihook inserted through cervix that is dilated to atleast 2 cm. May induce or augment labor or to insert a fetal internal monitor. Nursing management: observe FHR just before & after amniotomy & compare. Marked changes: cord prolapse. Assess fluid for amount, color, odor, presence of meconium. Cleanse perineum & change underpads. Refer to Drug guide, p 430 – 431. Refer to Clinical Pathways: fFor Induction of Labor pp 432 – 433.

Assisted delivery Augmentation – Oxytocin (Pitocin) Episiotomy Forceps –assisted birth Vacuum-assisted birth Cesarean birth TOLAC (Trial of labor after c-section) VBAC (Vaginal birth after cesarean) Cover the following:

Assisted Delivery Amniotomy & Episiotomy Amniotomy: explained Episiotomy: surgical incision of perineum to enlarge opening. Just before birth 3 to 4 cm of fetal head visible during contraction; incision made 2 types: midline & mediolateral (45 º ); with regional or local anesthetic. Nursing care: ice pack, frequent assessment for redness, tenderness, hematoma Recognize perineal pain continues for some time, 1 – 8 weeks. Do not discount this pain. Can interfere with breastfeeding

Assisted Delivery - Forceps Forceps – surgical instruments for assisting birth by providing traction or the means to rotate the fetal head. Outlet, low, or midforceps Criteria: cervix completely dilated; ROM; known pelvis type, empty maternal bladder; no CPD present Baby can develop edema or ecchymosis, caput succedaneum or cephalhematoma, facial paralysis Adequate regional anesthesia: mother may feel pressure but no pain Figure 20-3, p 437 Vacuum assist: applying suction to the fetal head. Pump provides negative pressure under appropriately sized cup and traction is applied. Limit to 3 pulls, 20 – 30 mins Figure 20 – 4, p 438

Assisted Delivery C-Section Cesarean birth takes place through abdominal incision – 1 of oldest surgical procedures known. Popular during 1970’s, declined in late 80’s d/t costs! Up again; in 1999, 22% of births. Indicated for variety of maternal & fetal conditions: placenta previa or abruption, failure to progress, active genital herpes, cord prolapse, etc. Two types of incisions: transverse (Pfannensteil) in lowest, narrowest part of abdomen; requires more time to make & repair; almost invisible after healing Vertical - between navel & symphysis pubis: quicker; for fetal distress, macrosomia. Uterine incision depends on need for the C-sec. Inc risk for ruptured uterus in subsequent vaginal birth

Assisted Delivery C-Section PP recovery: VS q 5 mins till stable, then q 15 min for 1 hr, then q 30 mins till d/c to PP unit. Gently palpate fundus; IV Oxytocin to promote contractility; Turn, cough, deep breath q 2 hrs 24 hrs; monitor I & O. Observe color of urine: possibly nick bladder during surgery. Care of woman undergoing vaginal birth after Cesarean (VBAC): Trend: trial of labor after C-sec (TOLAC) Considerations: previous 1 -2 low transverse uterine incisions; Classic or T-incision is contraindication; adequate pelvis; anesthesia & surgical team available; physician STAT available

Managing Discomfort: Chapter 18 Considerations Cultural influences Anxiety and Fear Preparation Alternative methods The nurse should develop a variety of means to promote comfort. Back rubs, hydrotherapy, encouragement for some Others: discomfort interferes with breathing & relaxation techniques. Pharmacologic methods may be used to ↓ comfort, ↑ relaxation, & reestablish pt’s sense of control. Cultural considerations: Developing Cultural competencies, p 382 Labor is painful; few can experience natural, painless childbirth. Maternal resp & O2 consumption affects O2 available to fetus. Pain & stress → metabolic acidosis & catecholamine release, → constriction & ↓ O2 to fetus. Couples planning to “go natural” during childbirth classes may be unable to cope with discomfort & feel guilty or inadequate. (C-phone: parking lot). Alternative methods: doula, hynotherapy, acupressure: discuss in class

Pharmacologic Analgesia and Nursing Management Narcotic analgesic Stadol Opiate antagonist: Narcan IM or IV: peaks 30-60 min, duration 3-4 hrs SE: maternal/fetal: resp depression; urinary retention; contraindicated for known/suspected opiate dependency Antagonist: for respiratory depression r/t fentanyl, morphine, meperidine, butorphanol (Stadol) and nalbuphine (Nubain) Systemic analgesia crosses the placenta; must monitor for effects to fetus and potential effects to the newborn May cause labor to progress more rapidly. Narcan may be given. Nursing: monitor labor progress; evaluate effectiveness; SE If Narcan given, pt will indicate a return of pain. Narcan may be given to neonate if CNS depression noted. May demonstrate these effects up to 72 hrs /p delivery

Regional Anesthesia and Analgesia Definition Agents/types Epidural Continurous Epidural infusion Regional anesthesia: temporary loss of sensation produced by injecting anesthetic agent (local) into direct contact with nervous tissue. Most common types in OB: epidural, spinal, & combined epidural-spinal blocks. Epidurals are used for analgesia during vaginal births and anesthesia in C-sections. Absorption of agents depends on vascularity of area of injection. Usually hydrate woman well. Several types used. Most familiar with opiods used with epidural blocks: morphine, fentanyl, butorphanol, & meperidine. Various combinations are used. Reactions anesthetic agents: palpitations, tinnitus, metallic tase, N&V, itching; severe include hypotension, resp depression, cardiac arrest. Epidural: anesthetic injected into epidural space; usually used continuously; given as soon as active labor established. ADVANTAGES: woman fully awake; discomfort relieved; actively participates. DISADVANTAGES: maternal hypotension; less effective pushing; delay in return of bladder sensation CONTRAINDICATIONS: client refusal, maternal problems with blood coagulation, allergy to drug, hypovolemic shock. Nursing management: enc pt. to empty bladder; start large-bore IV; help woman to position for adequate spinal flexion; monitor for hypotension, HA, return of sensation; pruritis, resp depression

Regional Anesthesia and Analgesia Epidural Narcotic after birth Spinal Block Pudendal Block Local infiltration Pudendal block Epidural narcotic after birth: provides narcotic analgesia for approx 24 hrs after birth. Anesthesiologists injects opioid such as morphine sulfate (Duramorph) into epidural space STAT /p birth. SE: pruritis, N&V, urinary retention. Resolves in 14 – 16 hrs. Drug guide: p 389 Spinal block: local anesthetic is injected into spinal fluid in spinal canal to provide anesthesia for C-sec, rarely for vag. ADVANTAGE: STAT onset of anesthesia, easy to administer, smaller dose, maintenance of muscle tone (+ or -) DISADVANTAGE: high incidence of maternal hypotension, → fetal hypoxia. CONTRAINDICATED in severe hypovolemia, CNS disease; infection over puncture site, + same as epidural Pudendal block – transvaginal administration; provides perineal anesthesia but no relief of contraction discomfort. Easy to administer, absence of maternal hypotension; no need to monitor FHR. May decrease urge to push; may perforate rectum or sciatic nerve Local anesthesia: injecting agent into areas of perineum for episiotomy incision or repair.

General Anesthesia Definition Complications Nursing management General anesthesia (induced unconsciousness) – for C sec or surgical intervention. Usually combination of IV injection & inhalation of anesthetic agents. Primary danger: reaches fetus in 2 mins → fetal resp depression. Causes uterine relaxation. Problem with food/liquids ingested: Gastric juices are highly acidic → chemical pneumonia if aspirated. Nursing mgmt: prophylactic antacid therapy common. Nonparticulate antacid such as Bicitra. Wedge under R hip to displace uterus and prevent vena caval compression. May need to assist: maintain cricoid pressure to occlude esophagus until endotracheal tube is placed by anesthesiologist.

Questions?

A. First feeling of fetal movement Test Question: At about 38 weeks gestation a client experiences lightening. Lightening refers to the: A. First feeling of fetal movement B. First perceptions of labor contractions C. Settling of the fetal head into the pelvis D. Frequency of urination in the 3rd trimester C

Another test question: When assigning points on the Apgar score a HR of 130 BPM should receive a score of: A. O B. 1 C. 2 D. 3 C

Let’s try again: Immediately after observing late Dcels, the L&D nurse should first: A. Initiate oxytocin augmentation of labor B. Perform a quick vaginal exam to assess the situation C. Turn the client on her left side and administer O2 D. Have the client assume a position of comfort after sedating her C

OK, last try: A client delivers a 7 lb 7oz boy by vaginal delivery. One hour after delivery the client’s vital signs are T 100.3°F, P 78, R 18. Her nurse is aware that the elevation in temperature is likely caused by: A. Vaginitis B. Nosocomial infection C. A urinary tract infection D. Exhaustion and dehydration D.