Nursing Care During Obstetric Procedures

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Nursing Care DuringObstetric Procedures

• Chapter 16

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Amniotomy

• breaking the water
• Induction/augmentation
• Allows for internal monitoring
• Performed by MD

• RISKS
• Umbilical cord prolapse
• Infection
• abruption

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AmniotomyNursing Considerations

• Obtain baseline FHR
• Prepare client
• Assist MD
• Identify complications
• Document findings

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Induction/Augmentation

• Use of artificial methods to stimulate uterine
  contractions
• Becoming more common1989 9 live births2002
  19.9 live births
• Should be limited to medical indications
• Informed consent

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Indications

• Pregnancy Induced Hypertension(PIH)
• Premature Rupture of Membranes(PROM)
• Post-term pregnancy(42 wks)
• Chorioamnionitis
• Maternal medical conditions
• Hostile intrauterine environment
• Fetal demise

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Contraindications

• Placenta previa
• Abnormal fetal presentation
• Active genital herpes
• Previous classical uterine incision

• Overdistended uterus
• Severe maternal conditions
• Non-reassuring FHR patterns

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Risks

• Hyperstimulation
• Uterine Rupture
• Maternal water intoxication
• Increased risk of cesarean birth
• Increased risk of operative vaginal delivery
• Bishops Score lt5

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Cervical Ripening

• Bishop scorecervical readinessgt8 more likely to
  be successful
• Prostaglandin is a drug used to cause cervical
  ripening(PGE1 and PGE2)
• Prepidil, Cervidil, Cytotec
• Hydrophilic inserts (Laminaria)

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Oxytocin(Pitocin)

• Most common drug given for induction/augmentation
• 20U/1000CC Lactated Ringers
• Always give as piggy-back closest port to
  angionever mainline
• Titrate 1mu3cc start _at_ 2mu and increase by 2mu
  Q 30min. Max 30mu
• Continuous EFM

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Nursing Considerations

• Fetal response hyperstimulation reduces
  uteroplacental blood flow
• Continuous EFM
• Initiate intrauterine resuscitative measures for
  non-reassuring FHR patterns
• Maternal response hyperstimulation, uterine
  rupture, fluid retention, PP hemorrhage
• Assess VS frequently, monitor IO, watch for
  uterine atony in the PP period

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Operative Vaginal Delivery

• The use of forceps or vacuum extraction by the MD
  to apply traction to the fetal head during birth
  to assist maternal expulsive efforts and
  facilitate birth.
• Assist descent and rotation of the fetal head

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Indications

• Maternal
• Exhaustion
• Ineffective pushing
• Cardiac/pulmonary disease

• Fetal
• Non-reassuring FHR
• Failure of presenting part to rotate and descend

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Contraindications/Risks

• Severe fetal compromise
• Acute maternal conditions
• High fetal station
• Cephalopelvic disproportion(CPD)

• Trauma to maternal and fetal tissues
• Vaginal lacerations and hematoma
• Fetal bruising, facial lacerations,
  cephalhematoma, intracranial hemorrhage

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Nursing Considerations

• Observe for trauma to mother and neonate
• Potential for vaginal wall laceration and
  hematoma
• Potential for bruising or lacerations to fetal
  head or face

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Episiotomy

• Routine performance remains controversial
• May be used to reduce pressure on fetal head
• Midline most common
• Associated with higher incidence of 3rd and 4th
  degree lacerations

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Episiotomy

• Infection main risk
• Perineal pain may last longer
• Impairs resumption of sexual intercourse
• Nursing intervention promote gradual stretching
  by perineal massage and warm compresses to
  perineum

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Cesarean Birth

• 1965 US C/S rate 4.5
• 1980s US C/S rate 24
• 2003 US C/S rate 27.6 of which, 19.1 were
  primary
• WHY?? EFM, VBAC, Litigation, Maternal age, Breech
• Women who are induced are 2-3 times more likely
  to have an operative birth
• Women are choosing to deliver by C/S

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C/S Indications

• Dystocia
• CPD
• PIH
• Maternal Diseases
• Active genital herpes
• Previous Classic C/S

• Persistent non-reassuring FHR
• Prolapsed cord
• Fetal malpresentation
• Placental abnormalities

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C/S Risks

• Maternal Risks
• Infection
• hemorrhage
• UTI or trauma
• DVT/embolism
• paralytic ileus
• atelectasis
• anesthesia complications

• Fetal Risks
• inadvertent premature birth
• TTN due to delayed absorption of lung fluid
• PPHN pulmonary vasoconstriction
• Injury
• Lung immaturity

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C/S Prep

• Large bore IV(18g preferred)
• NPO or Meds to reduce gastric acidity(Reglan/Bici
  tra)
• Shave prep
• Insert Foley catheter
• Routine labs(CBC HC)
• Regional anesthesia preferred
• Informed consent

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Nursing Considerations

• Providing emotional support
• Teaching
• Promoting safety
• Providing PACU
• Considering VBAC