Assisted Delivery and Cesarean Birth Chapter 11: Assisted Delivery and Cesarean Birth

Induction of Labor Indications for induced labor Postdate pregnancy Premature rupture of membranes (PROM) Chorioamnionitis Gestational hypertension Intrauterine fetal growth restriction Fetal demise Maternal medical conditions, such as maternal diabetes

Induction of Labor (cont.) Labor readiness The Bishop score helps determine cervical readiness for labor. Five factors are evaluated: cervical consistency, position, dilatation, effacement, and fetal station. Newer methods to evaluate cervical readiness include measuring cervical length and fetal fibronectin.

Induction of Labor (cont.) Mechanical methods to enhance ripening of the cervix include membrane stripping and mechanical dilation of the cervix with either a catheter or laminaria.

Induction of Labor (cont.) Pharmacologic methods to ripen the cervix include local application of prostaglandin gel or vaginal inserts, or insertion of a prostaglandin tablet. Pharmacologic methods require closer monitoring of the woman.

Induction of Labor (cont.) Artificial rupture of membranes (AROM), also called an amniotomy, is done by the birth attendant to induce or augment labor. The amniotic sac is ruptured by a plastic hook. Nursing care after an amniotomy includes noting the color and amount of the amniotic fluid and fetal heart rate.

Induction of Labor (cont.) Oxytocin induction requires continuous fetal monitoring, a mainline IV, and a secondary IV line that contains the oxytocin on an IV pump. Complications associated with the use of oxytocin include higher risk for cesarean delivery, hyperstimulation of the uterus with possible uterine rupture, water retention, and fetal distress.

Two basic types of episiotomy. A Two basic types of episiotomy. A. Midline episiotomy extends straight down into the true perineum. B. Mediolateral episiotomy angles to the right or the left of the perineum

Assisted Delivery An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening just before delivery. Some instances when an episiotomy is used include cases of shoulder dystocia, when the infant must be delivered quickly, or when forceps are used. A midline episiotomy extends straight downward into the true perineum. A mediolateral episiotomy angles to the right or the left of the perineum. Complications of an episiotomy include extension of a midline episiotomy into the anal sphincter or increased risk of blood loss and infection.

Delivery assisted by vacuum extraction. A. The birth attendant has just placed the suction cup on the fetal head and is using the hand pump to increase the pressure. B. Gentle traction is placed on the fetal head to assist it through the last maneuvers of delivery.

Assisted Delivery (cont.) Vacuum extraction involves a suction cup placed on the fetal head, which allows the birth attendant to provide gentle traction to assist delivery. Nursing considerations for the nurse during the procedure include assisting with creating the suction, monitoring the fetal heart rate pattern, and supporting the woman. After delivery, the neonate must be evaluated for complications from the vacuum extraction and the postpartum/nursery report must include the use of vacuum during delivery. The woman must be monitored for pain, excess blood loss, hematoma, urinary retention due to edema, and infection.

Assisted Delivery (cont.) In a forceps-assisted delivery, hard metal tools shaped like large hollowed-out spoons are applied to the fetal head. Midforceps can help rotate the fetus to an anterior position. Low and outlet forceps can assist delivery when the fetus is at a low station and the woman is too fatigued to push effectively, pushing is contraindicated (e.g., maternal heart disease), the second stage of labor is prolonged, or the fetal monitor tracing is nonreassuring. Nursing considerations are similar to those for a vacuum extraction delivery.

Cesarean Birth The most common indications for cesarean delivery are history of previous cesarean, labor dystocia, nonreassuring fetal status, and fetal malpresentation. Other less common indications include placenta previa, abruptio placentae, cephalopelvic disproportion, active vaginal herpes lesions, prolapse of the umbilical cord, fetal malformation (such as spina bifida), and ruptured uterus

Cesarean Birth (cont.) Cesarean delivery is a major surgical procedure. For the woman it carries with it all the risks and complications associated with abdominal surgery including excess blood loss, infection, and prolonged recovery time. In addition, the woman who has a Cesarean delivery also has the same risks that are associated with normal birth. Fetal complications include respiratory distress and accidental laceration from the scalpel.

Types of uterine incisions used for cesarean delivery. A Types of uterine incisions used for cesarean delivery. A. Classical (vertical) approach. B. Low (cervical) vertical approach. C. Low (cervical) transverse approach.

Cesarean Birth (cont.) Both skin and uterine incisions can be vertical or transverse. The uterine incision is the most important of the two. The classical (vertical) uterine incision is associated with the highest risk for uterine rupture in subsequent pregnancies. The low cervical transverse uterine incision is the preferred method.

Cesarean Birth (cont.) During the preoperative phase of a cesarean delivery, the LPN/LVN may assist the RN in preparing the client for surgery including obtaining vital signs, urinary catheter insertion, and assisting with positioning of the woman for anesthesia and on the operating table. After the woman has fully recovered in the PACU, the LPN/LVN may provide postoperative care for the woman and the newborn after a cesarean delivery.

Vaginal Birth after Cesarean Much controversy surrounds VBAC deliveries. The greatest concern in a VBAC delivery is the increased risk for uterine rupture during labor. The woman most likely to have a successful VBAC has only had one previous cesarean, has previously delivered a child vaginally, and whose labor has spontaneous onset and does not require augmentation. History of a classical uterine incision or a previous uterine rupture is a contraindication for VBAC.