Birth Related Procedures

1. Birth Related Procedures • Linda L. Franco RN MSN NE-BC • Blue = history • Green = Need to know • Red = important to know

2. Version (turning of the fetus) • Methods • External • External cephalic version (ECV) fetus is changed from breech to cephalic thru external measures • Internal • Rarely used, occurs when the 2nd fetus during a vaginal twin birth isn’t doing well. Med is given to relax uterus and dr reaches in and pulls the fetus out. Usually the woman is given a c-section • Risks • Hypoxia • Fetal Distress • AbruptioPlacentae

3. Criteria for External Version • Must be at least 36 or more weeks gestation • Must have a Reactive NST immediately prior • Fetal breech is not engaged • So if they baby is breech and is not engaged (or dropped)

4. Contraindications for Version • Maternal problems • Uterine anomalies, uncontrolled PIH (pregnancy induced hypertension), third trimester bleeding • Make sure the mom has IV access for meds or blood or whatever • Complications of pregnancy • ROM, oligohydramnios, polyhydramnios, placenta previa • Previous C/S or uterine surgery • Multiple gestation • Nonreassuring FHR • IUGR

5. Amniotomy • Defined as: Artificial rupture of the amniotic membrane • Need 2 cm of dilation • Indications • Induce labor • Internal monitoring • Risks • Infection • Prolapse of cord • Abruptioplacentae

6. Cervical Ripening • Soften the cervix • Cervical readiness is the most important thing when thinking about inducing labor in a mom • Successful induction • Management of intrauterine fetal death • Drugs – Prostaglandins, Cytotec

7. Induction & Augmentation of Labor • Indicated – health of mother & baby • Elective – convenience • Risks • Hypertonic uterine activity • Uterine rupture • Water intoxication • Retention of water with sodium depletion. Pt is lethargic, nauseated, vomiting, and in severe cases may convulse or go into coma • Antidiuretic effect of oxytocin decreases water exchange in the kidney and reduces urinary output leading to fluid overload

8. Induction con. • Amniotomy • Cervical Ripening (or readiness) • Bishop score of 8 or 9 • Table 23-1 – 1 pg. 540 • The higher the score the more likely it is that labor will occur • Cervical readiness is the most important criteria for labor induction • Natural methods – sexual intercourse, breast stimulation, enemas, castor oil • Drugs • Oxytocin • Prostaglandins • Oxytocin Administration • Secondary IV • Infusion started slowly • Contractions q 2-3 min with relaxation between

9. Bishop Scoring System

10. Oxytocin Infusion • RL 1,000 ml with 10 - 20 units pitocin; infuse at 1-2 mu/min • Observe fetal response • Observe for uterine hypertonus • Nursing actions • Stop Pitocin • Increase primary IV rate • Turn to left side • Give Oxygen • Notify physician • You want stable contractions every 2-3 mins that last 40-60 seconds, this is why we give pitocin • Risk of pitocin is hyperstimulation of the uterus. If this happens we must discontinue the pitocin. If you don’t then placenta perfusion isn’t taking place and the baby isn’t getting oxygen

11. PITOCIN INFUSION CALCUALTION – 20 u pitocin (don’t need to know for exam) 1000ml x 2mu x 1u x 60min = 6ml 20u min 1000mu 1hr hr 1000ml x 1mu x 1u x 60min = 3ml 20u min 1000mu 1hr hr

12. PITOCIN INFUSION CALCUALTION – 10u pitocin (don’t need to know for exam) 1000ml x 2mu x 1u x 60min = 12ml 10u min 1000mu 1hr hr 1000ml x 1mu x 1u x 60min = 6ml 10u min 1000mu 1hr hr

13. Amnioinfusion • Infusion of warmed sterile Normal saline into the uterus through an IUPC (intrauterine pressure catheter) • If the mom’s bag of water isn’t enough then we put more fluid in there. Helps the baby move around. • May also be used to dilute miconium (sp?) if the infant inhales the miconium and it’s not diluted they can inhale it, which is bad • Indications • Oligohydramnios, relieve cord compression, dilute meconium stained amniotic fluid

14. Episiotomy • Surgical incision of the perineum • Indications • Decrease pressure on fetal head • Control direction of extension of the vaginal opening • Clean incision easier to repair and heals better • Cuts by the dr heal faster than if they rip on their own… • Risks • Infection • Kind of makes it more likely to have an anal sphincter tear • Nursing care • Ice to perineum • Observe for edema, hematoma, redness • Controversial

15. Forceps Assisted Birth • Metal Instruments shaped to grasp fetal head • Indications • Shorten second stage of labor • Any condition that threatens the mother or baby that will be relieved with birth • Regional anesthesia has effected the moms motor functions… like they are too drugged to push • Risks • Vaginal laceration or hematoma • Trauma to baby’s face or scalp • Intracranial or subgaleal hemorrhage

16. Forceps Assisted Birth

17. Vacuum Extraction • Suction to help deliver fetal head • Risks • Cephalhematoma • Hyperbilirubinemia • Because of bruising • Intracranial hemorrhage

18. Vacuum Extraction

19. Cesarean Section • Incision in abdominal and uterine walls • Indications • Complete placenta previa or abruption • CPD • Malpresentations • Herpes – active lesions • Fetal distress • Chronic Maternal Disease • Previous C/S

20. Cesarean Section con. • Risks • Anesthesia • Infection • Hemorrhage • Trauma to baby • Procedure • Skin incision • Cut into the uterus… • Transverse is usually low and invisible once healed, takes longer • Vertical is better, used when baby needs to be out quick • Uterine incision

21. Vaginal Birth After CesareanVBAC • Low transverse uterine incision • Contraindication with vertical uterine incision • Risks • Hemorrhage • Uterine Rupture • Hysterectomy • Infant death • Neurological complications