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

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 2 nd 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 – Abruptio Placentae

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)

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

Amniotomy Defined as: Artificial rupture of the amniotic membrane – Need 2 cm of dilation Indications – Induce labor – Internal monitoring Risks – Infection – Prolapse of cord – Abruptio placentae

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

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

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

Bishop Scoring System

Oxytocin Infusion RL 1,000 ml with 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 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

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

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

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

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

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

Forceps Assisted Birth

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

Vacuum Extraction

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

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

Vaginal Birth After Cesarean VBAC Low transverse uterine incision Contraindication with vertical uterine incision Risks – Hemorrhage – Uterine Rupture – Hysterectomy – Infant death – Neurological complications