Birth Related Procedures Term: AROM- artificial rupture of membrane, someone else broke the bag

1. Birth Related ProceduresTerm: AROM- artificial rupture of membrane, someone else broke the bag - Tie everything together • Sue Nesbitt, RN, MSN

2. Version (turning fetus by abd manipulation) pg535 • Methods • External (turn from breech to cephalic- External Cephalic Version, ECV) More common. • Internal (meds given to relax) Podalic Version. Less common; when the 2nd fetus has not descended like it should or if the HR is non-reassuring. • Risks • Hypoxia • Fetal Distress • AbruptioPlacentae

3. Criteria for External Version pg 535 • 36 or more weeks gestation • Must have a Reactive NST immediately prior which indicates the fetus is well • Fetal breech is not engaged “dropped” • Note: before doing a Version, make sure the mother has a IV line for emergency meds.

4. Contraindications for Version pg535-6 • Maternal problems • Uterine anomalies, uncontrolled PIH “Pregnancy induced HTN”, third trimester bleeding • Complications of pregnancy • ROM, oligohydramnios “deficiency of amniotic fluid”, polyhydramnios “too much amniotic fluid”, placenta previa “the placenta is attached to the uterine wall close to or covering the cervix” • Previous C/S or uterine surgery • Multiple gestation • Nonreassuring FHR • IUGR- Intra uterine growth restriction, retardation

5. Amniotomy pg 536-7 • Artificial rupture of the amniotic membrane (w/ hook after 2cm of dilation)amniotic fluid test… • AROM • Indications • Induce labor • Internal monitoring • Risks • Infection • Prolapse of cord • Abruptio placentae

6. Cervical Ripening pg 537 • Soften the cervix • Cervical readiness is most important for Successful induction • Management of intrauterine fetal death • Drugs – Prostaglandins agents • Cytotec-tablet given by many diff routes to control post partum hemorrhaging • *Cervidil- resembles a thin piece of cardboard to thin cervix, shorten labor, and lower requirement for Pitocin “Synthetic Oxytocin”

7. Induction & Augmentation of LaborInduction- to induce labor • Indicated – health of mother & baby • Elective – convenience • Risks • Hypertonic uterine activity • Uterine rupture • Water intoxication- brought on when mother is overloaded (retention of water w/ Na+ depletion  lethargy  N/V  leading to coma) • Term: Pitocin- synthetic oxytocin used to enhance labor

8. Induction con. • Amniotomy • Cervical Ripening “readiness” • Bishop score of 8 or 9  favorable of successful induction • Table 23-1 – 1 pg. 540 (higher the score the more likely that labor will occur) • Crevix is most important criteria for successful 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 pg 540 • LactatedRinger’s 1,000 ml with 10 - 20 units pitocin; infuse at 1-2 mu/min • Pitocin- synthetic oxytocin used to enhance labor • Observe fetal response • Observe for uterine hypertonus • Nursing actions • Stop Pitocin • Pitocin stopped, else placenta perfusion (placenta getting no oxygen = baby no oxygen) • Increase primary IV rate • Turn to left side • Give Oxygen • Notify physician • ***Goal is to establish contractions that are q 2-3min and last 40-60sec • Antidiuretic effect of oxytocin, decreases water exchange in the kidney and reduces urinary output leading to fluid overload (water toxicity)

11. PITOCIN INFUSION CALCUALTION – 20 u pitocinThis math not on test 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 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 • If mom water/fluid is not enough, then we can put some in there, else cord compression or decrease in fetal movement • Infusion of warmed sterile Normal saline into the uterus through an IUPC • 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 • Risks • Infection • Caution chance of 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 • Risks • Vaginal laceration or hematoma • Trauma to baby’s face or scalp • Intracranial or subgaleal hemorrhage • Cervix must be completely dilated, membranes must be ruptured, pelvis type must be known,…

16. Forceps Assisted Birth

17. Vacuum Extraction • Suction to help deliver fetal head • Risks • Cephalhematoma- collection of blood under the scalp of a newborn • Hyperbilirubinemia- abnormally high amounts of bile pigment (bilirubin) in the blood • Intracranial hemorrhage- bruising

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- made into the uterus, … • 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