1. Birth-Related Procedures

2. Impact of Procedures on Childbearing Woman Disappointment Guilt Conflict between expectation and need for intervention

3. Spontaneous Labor

4. The decision to induce labor is not one to be taken lightly

5. The decision to bring pregnancy to an end is one of the most drastic ways of intervening in the natural process

6. Certain specific conditions under which inducing labor has been shown to save lives Serious IUGR Documented placental insufficiency Deteriorating pre- eclampsia

9. Macrosomia/PROM Macrosomia has been used as an excuse for induction, but data do not support this PROM: how long is safe to wait?

10. Postterm Spontaneous birth between 38 & 42 weeks is perfectly normal variation Only about 3% of pregnancies go beyond 42 weeks 1996 study looked at 1800 postdate pregnancies and found no increase in baby deaths as well as no increase in complications compared with babies born “on time” 38-42 weeks Only about 10% of babies at more than 43 weeks get into trouble

11. Induction In about 10% of all births there is a medical indication to induce labor with drugs, and before 1990 10% was the rate of induction in most industrialized countries.

12. Pitocin Synthetic version of the naturally occurring hormone oxytocin, has been used to induce labor for decades. It is approved by the FDA for this purpose after adequate, careful scientific assessment of its efficacy and risks, and we know a great deal about how best to use it.

13. Natural approaches to Induction Sex Nipple stim Foods: spicy(capsasins counteract endorphins), chinese, eggplant parmesean(oregano & basil), licorice(glycyrrhizin), pineapple(acidity stimulates prostaglandins) Herbs: black & blue cohosh, red rasp.leaf tea Castor oil & evening primrose oil Acupuncture: webbing between thumb and index finger, above ankle bone, between tip of shoulder & neck

14. Bishop’s Score

15. cytotec Given that we already have a well-tested drug, why use cytotec? Pit is administered with IV drip Cytotec requires no IV, easier- pill or vag Cytotec comes in 100 and 200mcg tablets. After a decade of unauthorized experimenting, 25 mcg has emerged as the usual dose for labor induction. Ever try breaking a tablet without a line into quarters?

16. Pit vs Cytotec Cytotec is quickly absorbed and stays in the body for hours Whereas Pit IV has short half life and can be quickly stopped if problems arise Cytotec costs less than other drugs used for induction (cheap because no research)

17. Catastrophe June 1999 2 papers published in AJOG reported alarming rate of uterine rupture when using cytotec on women attempting VBAC One study 5.6% of VBACs induced with cytotec had a rupture In another study 3.7%. This is a 28 fold increase in rate of uterine rupture over having a VBAC without cytotec induction.

18. Shut the barn door after thousands of horses were gone ¼ women who had uterine rupture: resulted in death of their babies Several months later ACOG came out with a position statement that Cytotec not be used for induction with women with previous c/s

19. Estimates of Risk of Uterine Rupture During Labor Normal (unscarred uterus) 1 in 33,000 births VBAC - no induction 1 in 200 births VBAC – Pit augmentation 1 in 100 births VBAC – Pit induction 1 in 43 births VBAC – Cytotec induction 1 in 20 births Normal unscarred uterus with cytotec induction – unknown Neurological injury or death of baby after uterine rupture- 30% Death of woman after uterine rupture 1-2%

20. VBAC Complications

21. Where we are today According to the CDC, the rate of drug-induced labor induction in U.S. births doubled from 10% to 20% in the 1990s. An increase almost certainly due to the rampant use of cytotec. A survey in 2002 showed that 44% of all births are induced with uterine stimulant drugs Convenience factor is strong motivation to induce labor

22. Nursing Management of the Client undergoing Induction Monitor: EFM VS Judicious increase of Pit Terbutaline sc for hyperstimulation

23. Version External Cephalic Version (ECV) Podalic Version (Internal)

24. External (or cephalic) version of the fetus. A new technique involves applying pressure to the fetal head and buttocks so that the fetus completes a “backward flip” or “forward roll.”

25. Use of podalic version and extraction of the fetus to assist in the vaginal birth of the second twin. A, The physician reaches into the uterus and grasps a foot. Although a vertex birth is always preferred in a singleton birth, in this instance of assisting in the birth of a second twin it is not possible to grasp any other fetal part. The fetal head would be too large to grasp and pull downward, and grasping the fetal arm would result in a transverse lie and make vaginal birth impossible. B, While applying pressure on the outside of the abdomen to push the baby’s head up toward the top of the uterus with one hand, the physician pulls the baby’s foot down toward the cervix.

26. Both feet have been pulled through the cervix and vagina. D, The physician now grasps the baby’s trunk and continues to pull downward on the baby to assist the birth.

27. Nursing Management Maternal/fetal assessments NST Lab studies Psychological support Education Monitor VS

28. Nursing Management (continued) EFM Mediation administration – Beta-mimetics, RhoGAM

29. Uses of Amniotomy Labor induction Labor augmentation Allow access to fetus and uterus to –Apply an internal fetal heart monitoring scalp electrode –Insert an intrauterine pressure catheter –Obtain a fetal scalp blood sample

30. Cervical Ripening: Prostaglandin E2 Advantages –Cervical ripening –Shorter labor –Lower requirements for oxytocin during labor induction –Vaginal birth is achieved within 24 hours for most women –Incidence of cesarean birth is reduced

31. Cervical Ripening: Prostaglandin E2 (continued) Risks –Uterine hyperstimulation –Nonreassuring fetal status –Higher incidence of postpartum hemorrhage –Uterine rupture

32. Labor Induction: Stripping Membranes Advantages –Labor usually occurs in 24-48 hours Disadvantages –Can be painful –Uterine contractions –Bloody discharge

33. Labor Induction: Oxytocin Risks –Hyperstimulation of the uterus –Uterine rupture –Water intoxication –Nonreassuring fetal heart rate patterns

34. Labor Induction: Natural Methods Sexual intercourse/lovemaking Self or partner stimulation of the woman’s nipples and breasts Use of herbs –Blue/black cohosh –Evening primrose oil –Red raspberry leaves

35. Labor Induction: Natural Methods (continued) Use of homeopathic solutions –Caulophyllum or pulsatilla –Castor oil, enemas –Acupressure/acupuncture Mechanical dilatation with balloon catheter

36. Amnioinfusion Prevent the possibility of variable decelerations Treat nonperiodic decelerations Meconium dilution

37. Episiotomy Types –Midline –Mediolateral

38. The two most common types of episiotomies are midline and mediolateral. A, Right mediolateral. B, Midline.

39. Epis Hartman and colleagues looked at 986 studies on epis conducted over the past 50 years, they found that the 3 main supposed benefits of epis: 1.Prevention of bad tears 2.Prevention of long-term damage to the floor of the woman’s pelvis 3.Protection of the baby from the adverse consequences of an extended labor are NOT supported by the evidence

40. They found women with epis had: 26% greater chance of having a tear requiring suturing 53% greater chance of having pain during sexual intercourse Twice as likely to suffer fecal incontinence Evidence is clear: routine use of epis is not supported by the research and should stop.

41. Epis-EBP 1995 review of best epis research by Cochrane Library found that “when done routinely, the procedure increases the trauma and complication of birth.” UCSF Hospital (1990s) epis rate dropped from 80% to less than 10%, # of 3 rd and 4 th degree tears was cut in half, # of women without epis tripled Mass General: end of 1990s rate fell to between 10 and 15%

42. Not so EBP Mayo Clinic rate in 2002 was 60% A survey of OB practices published in 2002 found nat’l epis rate of 35% Agency for Healthcare Research and Quality (federal watchdog) found epis performed in 1/3 of all vag births (1 million epis/year) 70% of all 1 st time mothers undergo epis General consensus among perinatal scientists and OBs that ideal rate is 5-10% of all vag births

43. Nursing Management Support Assist with communication of woman’s needs Pain relief measures Assessment Education

44. Forceps-Assisted Birth: Maternal Indications Heart disease Acute pulmonary edema or pulmonary compromise Certain neurological conditions Intrapartal infection Prolonged second stage Exhaustion

45. Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone.

46. The right blade is inserted along the right side wall of the pelvis over the parietal bone.

47. With correct placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal.

48. Forceps-Assisted Birth: Fetal Indications Premature placental separation Prolapsed umbilical cord Nonreassuring fetal status

49. Types of Forceps Outlet forceps Midforceps Breech forceps

51. Fetal Risks Ecchymosis, edema, or both along the sides of the face Caput succedaneum or cephalhematoma Transient facial paralysis Low Apgar scores Retinal hemorrhage Corneal abrasions

52. Fetal Risks (continued) Ocular trauma Other trauma (Erb’s palsy, fractured clavicle) Elevated neonatal bilirubin levels Prolonged infant hospital stay

53. Maternal Risks Lacerations of the birth canal Periurethral lacerations Extension of a median episiotomy into the anus More likely to have a third- or fourth- degree laceration Report more perineal pain and sexual problems in the postpartum period Postpartum infections

54. Maternal Risks (continued) Cervical lacerations Prolonged hospital stay Urinary and rectal incontinence Anal sphincter injury Postpartum metritis

55. Nursing Management Explains procedure to woman Monitors contractions Informs physician/CNM of contraction Encourages woman to avoid pushing during contraction Assessment of mother and her newborn Reassurance

56. Indications for Vacuum Extraction Prolonged second stage of labor Nonreassuring heart rate pattern Used to relieve the woman of pushing effort When analgesia or fatigue interfere with ability to push effectively Borderline CPD

57. Vacuum Extraction Procedure Procedure –Suction cup placed on fetal occiput –Pump is used to create suction –Traction is applied –Fetal head should descend with each contraction

58. The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction.

59. Traction continues in a downward direction as the fetal head begins to emerge from the vagina.

60. Traction is maintained to lift the fetal head out of the vagina

61. Nursing Management Inform woman about procedure Pumps the vacuum Supports the woman Assesses the mother and neonate for complications

62. Neonatal Risks with Vacuum Extraction Scalp lacerations and bruising Shoulder dystocia Subgaleal hematomas Cephalhematomas Intracranial hemorrhages Subconjunctival hemorrhages

63. Neonatal Risks with Vacuum Extraction (continued) Neonatal jaundice Fractured clavicle Erb’s palsy Damage to the sixth and seventh cranial nerves Retinal hemorrhage Fetal death

64. Maternal Risks with Vacuum Extraction Perineal trauma Edema Third- and fourth-degree lacerations Postpartum pain Infection More sexual difficulties in the postpartum period

65. Cesarean Birth

69. c/s More common than tonsillectomy or appendectomy Risks: Baby nicked by scapel Increased liklihood of difficulty with initail BF attempts Pain can supress mild production Mom more prone to PPD, infertility and placenta abnormalities in future pregnancies Previa, acreta and abruption can lead to hemorrhage

70. Julius?

71. Indications for Cesarean Birth Complete placenta previa CPD Placental abruption Active genital herpes Umbilical cord prolapse Failure to progress in labor

72. Indications for Cesarean Birth (continued) Proven nonreassuring fetal status Benign and malignant tumors that obstruct the birth canal Breech presentation Previous cesarean birth Major congenital anomalies Cervical cerclage

73. Indications for Cesarean Birth (continued) Severe Rh isoimmunization Maternal preference for cesarean birth

74. This transverse incision in the lower uterine segment is called a Kerr incision.

75. The Sellheim incision is a vertical incision in the lower uterine segment.

76. This view illustrates the classic uterine incision that is done in the body (corpus) of the uterus. The classic incision was commonly done in the past and is associated with increased risk of uterine rupture in subsequent pregnancies and labor.

77. Impact on the Family Stress and anxiety Sense of loss of vaginal birth experience Fear Relief

78. Preparation for Cesarean Birth Preoperative teaching –Coughing and deep breathing –Splinting –What to expect

79. Nursing Management Before Cesarean Birth Assisting with the epidural Monitoring maternal vital signs and fetal heart rate Inserting an indwelling urinary catheter Preparing the abdomen and perineum Making sure that all necessary personnel and equipment are present Positioning the woman on the operating table

80. Risks Even with elective c/s, no emergency, 2.84 fold greater chance than vag birth of resulting in the woman’s death Estimated that 12 American women die every year because of unnecessary elective c/s Anesthesia, hemorrhage, infection, adhesions Infertility, ectopics, unexplained stillbirth, placenta problem 2-6% of the time cut into baby

81. Nursing Management Before Cesarean Birth (continued) Supporting the couple Instrument count

82. Nursing Management After Cesarean Birth Normal newborn post-delivery care Monitoring vital signs Checking the surgical dressing Palpating the fundus and checking lochia Monitoring intake and output Administration of oxytocin and pain management

83. Vaginal Birth After Cesarean (VBAC): Criteria One previous cesarean birth and a low transverse uterine incision An adequate pelvis No other uterine scars or previous uterine rupture An available physician who is able to do a cesarean In-house anesthesia personnel

84. Vaginal Birth After Cesarean (VBAC): Risks Uterine rupture Stillbirths Hypoxia