Birth-Related Procedures

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Birth-Related Procedures
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Impact of Procedures on Childbearing Woman

• Disappointment
• Guilt
• Conflict between expectation and need for
  intervention

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Spontaneous Labor
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The decision to induce labor is not one to be
taken lightly
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The decision to bring pregnancy to an end is one
of the most drastic ways of intervening in the
natural process
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Certain specific conditions under which inducing
labor has been shown to save lives

• Serious IUGR
• Documented placental insufficiency
• Deteriorating pre-eclampsia

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Macrosomia/PROM

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

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Runaway gestational diabetes

• According to the Guinness Book of Records the
  heaviest baby ever born weighed 29 lbs 4 oz.
  (29.25 lbs). (Historical Note The birth occurred
  in Effingham IL in 1939 and due to respiratory
  problems the baby died two hours later. The
  heaviest babies to survive weighed 22.5 lbs and
  were born in 1955 and 1982.)

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Supersize Delivery! Woman Gives Birth to
19.2-Pound Baby Friday, September 25, 2009
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Big Babies

• Babies in developed countries are being born
  heavier.
• In Australia in 2002 report found that there had
  been a 12 increase since 1993.
• In Ireland, researcher at Dublins Rotunda
  maternity hospital looked at birth weights for
  first-time mothers between 1950 and 200 and found
  that millenium NBs weighed an average of 7lbs
  10oz, about a pound more than they did half a
  century earlier.
• Why such a boost in birth weight in so short a
  time? Large babies are not the result of
  evolutionary changes, rather a by-product of
  rapidly shifting environment and cultural
  landscape.

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• Mums with a diabetic tendency and obese mums
  tend to be more likely to have bigger babies
  because there is more fat laid down and more
  sugar present. The fast food diet also
  predisposes to increased gestational diabetes,
  which develops in pregnancy.
• Dr. Alen
  Cameron
• Consultant OB at Queen Mothers Hospital
• Glasgow

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Diet advice

• 1920-1975 women dieted thruout their pregnancies
  to make sure they did not gain more than 15-20
  lbs.
• Late 1970s docs relaxed
• 25-35, based on prepreg BMI
• Women now healthier vits, folic acid, avoid
  ETOH, tobacco, caffeine
• Face the Nation 1971, chairman of Phillip Morris
  was confronted with evidence that smoking in
  pregnancy leads to LBW, he famously said Some
  women prefer to have small babies.

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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

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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.

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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.

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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

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Bishops Score
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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?

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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)

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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.

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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

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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

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VBAC Complications
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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 (God-send to a busy doc, convenient
  hospital assembly line.)

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Nursing Management of the Client undergoing
Induction

• Monitor EFM
• VS
• Judicious increase of Pit
• Terbutaline sc for hyperstimulation

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Version

• External Cephalic Version (ECV)
• Podalic Version (Internal)

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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.
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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 babys
head up toward the top of the uterus with one
hand, the physician pulls the babys foot down
toward the cervix.
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Both feet have been pulled through the cervix and
vagina. D, The physician now grasps the babys
trunk and continues to pull downward on the baby
to assist the birth.
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Nursing Management

• Maternal/fetal assessments
• NST
• Lab studies
• Psychological support
• Education
• Monitor VS

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Nursing Management (continued)

• EFM
• Mediation administration Beta-mimetics, RhoGAM

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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

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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

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Cervical Ripening Prostaglandin E2 (continued)

• Risks
• Uterine hyperstimulation
• Nonreassuring fetal status
• Higher incidence of postpartum hemorrhage
• Uterine rupture

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Labor Induction Stripping Membranes

• Advantages
• Labor usually occurs in 24-48 hours
• Disadvantages
• Can be painful
• Uterine contractions
• Bloody discharge

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Labor Induction Oxytocin

• Risks
• Hyperstimulation of the uterus
• Uterine rupture
• Water intoxication
• Nonreassuring fetal heart rate patterns

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Labor Induction Natural Methods

• Sexual intercourse/lovemaking
• Self or partner stimulation of the womans
  nipples and breasts
• Use of herbs
• Blue/black cohosh
• Evening primrose oil
• Red raspberry leaves

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Labor Induction Natural Methods (continued)

• Use of homeopathic solutions
• Caulophyllum or pulsatilla
• Castor oil, enemas
• Acupressure/acupuncture
• Mechanical dilatation with balloon catheter

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Amnioinfusion

• Prevent the possibility of variable decelerations
• Treat nonperiodic decelerations
• Meconium dilution

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Episiotomy

• Types
• Midline
• Mediolateral

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The two most common types of episiotomies are
midline and mediolateral. A, Right mediolateral.
B, Midline.
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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
• Prevention of bad tears
• Prevention of long-term damage to the floor of
  the womans pelvis
• Protection of the baby from the adverse
  consequences of an extended labor
• are NOT supported by the evidence

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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.

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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 3rd and 4th degree tears
  was cut in half, of women without epis tripled
• Mass General end of 1990s rate fell to between
  10 and 15

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Not so EBP

• Mayo Clinic rate in 2002 was 60
• A survey of OB practices published in 2002 found
  natl 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 1st time mothers undergo epis
• General consensus among perinatal scientists and
  OBs that ideal rate is 5-10 of all vag births

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Nursing Management

• Support
• Assist with communication of womans needs
• Pain relief measures
• Assessment
• Education

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Forceps-Assisted Birth Maternal Indications

• Heart disease
• Acute pulmonary edema or pulmonary compromise
• Certain neurological conditions
• Intrapartal infection
• Prolonged second stage
• Exhaustion

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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.
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The right blade is inserted along the right side
wall of the pelvis over the parietal bone.
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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.
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Forceps-Assisted Birth Fetal Indications

• Premature placental separation
• Prolapsed umbilical cord
• Nonreassuring fetal status

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Types of Forceps

• Outlet forceps
• Midforceps
• Breech forceps

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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

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Fetal Risks (continued)

• Ocular trauma
• Other trauma (Erbs palsy, fractured clavicle)
• Elevated neonatal bilirubin levels
• Prolonged infant hospital stay

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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

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Maternal Risks (continued)

• Cervical lacerations
• Prolonged hospital stay
• Urinary and rectal incontinence
• Anal sphincter injury
• Postpartum metritis

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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

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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

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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

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The cup is placed on the fetal occiput, creating
suction. Traction is applied in a downward and
outward direction.
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Traction continues in a downward direction as the
fetal head begins to emerge from the vagina.
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Traction is maintained to lift the fetal head out
of the vagina
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Nursing Management

• Inform woman about procedure
• Pumps the vacuum
• Supports the woman
• Assesses the mother and neonate for complications

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Neonatal Risks with Vacuum Extraction

• Scalp lacerations and bruising
• Shoulder dystocia
• Subgaleal hematomas
• Cephalhematomas
• Intracranial hemorrhages
• Subconjunctival hemorrhages

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Neonatal Risks with Vacuum Extraction (continued)

• Neonatal jaundice
• Fractured clavicle
• Erbs palsy
• Damage to the sixth and seventh cranial nerves
• Retinal hemorrhage
• Fetal death

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Maternal Risks with Vacuum Extraction

• Perineal trauma
• Edema
• Third- and fourth-degree lacerations
• Postpartum pain
• Infection
• More sexual difficulties in the postpartum period

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Cesarean Birth
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c/s

• More common than tonsillectomy or appendectomy
• Risks
• Baby nicked by scapel
• Increased liklihood of difficulty with initial BF
  attempts
• Pain can suppress mild production
• Mom more prone to PPD, infertility and placenta
  abnormalities in future pregnancies
• Previa, acreta and abruption can lead to
  hemorrhage

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Julius?
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Indications for Cesarean Birth

• Complete placenta previa
• CPD
• Placental abruption
• Active genital herpes
• Umbilical cord prolapse
• Failure to progress in labor

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Indications for Cesarean Birth (continued)

• Proven non-reassuring fetal status
• Benign and malignant tumors that obstruct the
  birth canal
• Breech presentation
• Previous cesarean birth
• Major congenital anomalies
• Cervical cerclage

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Indications for Cesarean Birth (continued)

• Severe Rh isoimmunization
• Maternal preference for cesarean birth

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This transverse incision in the lower uterine
segment is called a Kerr incision.
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The Sellheim incision is a vertical incision in
the lower uterine segment.
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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.
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Impact on the Family

• Stress and anxiety
• Sense of loss of vaginal birth experience
• Fear
• Relief

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Preparation for Cesarean Birth

• Preoperative teaching
• Coughing and deep breathing
• Splinting
• What to expect

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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

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Risks

• Even with elective c/s, no emergency, 2.84 fold
  greater chance than vag birth of resulting in the
  womans 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

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Nursing Management Before Cesarean Birth
(continued)

• Supporting the couple
• Instrument count

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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

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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

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C/S A jaded view on the most performed surgery

• http//www.xtranormal.com/watch/7000271/

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Vaginal Birth After Cesarean (VBAC) Risks

• Uterine rupture
• Stillbirths
• Hypoxia

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