1. C. Lutkenhaus, MSN, RNC-OB, C-EFM Updated 8/2015

2.  Purpose:  Induce or augment labor  Allows for internal EFM  Risks:  Cord prolapse  Infection  Abruptio placenta Indications:  Fetal compromise  Assist with procedure  Assess EFM X 1 min  Chart fluid characteristics  Assess temp q 2 hrs  Promote comfort web73.confixx01.giracom.info pregnancy.about.com

3. What is the nursing action with the highest priority after an amniotomy occurs? 1. Observe and record fluid characteristics 2. Provide hygienic measures 3. Observe the fetal heart rate

4. Observe the fetal heart rate 3. Monitoring the fetal heart rate for one full minute will allow you to observe for a rapid decline in the heart rate (variable deceleration) which would indicate the cord has become trapped between the fetal body and the wall of the uterus. When the pressure of the cord is resolved, the fetal heart rate will rapidly increase to baseline. Your priority action if this deceleration is noted is to turn the mother.

5. http://www.youtube.com/watch?v=Wn6V3yo1NLQ Includes cervical ripening, amniotomy, and birth

6.  Indications  Post-term pregnancy  Chorioamnionitis  Gestational hypertension  Maternal medical conditions  Fetal death  Slowed/stopped labor  ROM at term without labor  Hostile intrauterine environment  Contraindications  Placenta previa  Abnormal presentation  Cord prolapse  Previous uterine surgeries  Conditions for evaluation  Previous cesareans  Breech presentation  Maternal heart disease  Severe maternal hypertension  Multi-fetal pregnancy/hydramnios  CPD  Non-reassuring FHR  Risks  Uterine hyperstimulation  Uterine rupture  Maternal water intoxication  Chorioamnionitis and cesarean flickr.com

7. Induction of Labor bio1152.nicerweb.com

8.  Cervical ripening  Medical methods (PGE2 gel or tablet, misoprostol)  Mechanical methods (Foley Bulb, Laminaria)  Oxytocin administration  IVPB infused at port nearest proximal port to limit amount infused if stopped  Pump necessary for accuracy of titration according to uterine and FHR response  Continuous EFM closely monitored jillstanek.com

9.  Nursing considerations  Baseline EFM and continue because placental blood flow may be compromised (chemical vs natural labor)  Be alert for non-reassuring patterns and hypertonic contraction  Reduce or stop infusion  Increase IV fluids  Keep on left lateral recumbent position  100% O 2 by mask  Be prepared to administer tocolytics prn  Observe mother  VS; I&O for fluid retention  S&S water intoxication: headache, blurred vision, behavioral changes, increased BP and respirations, decreased pulse, rales, wheezing, cough  Monitor contractions and uterine tone

10.  Indications  Maternal: exhaustion, inability to push, heart or lung disease, intra-partum infection  Fetal: prolapsed cord, premature separation of placenta, non- reassuring FHR  Risks  Maternal: lacerations or hematomas of vagina  Fetal: facial or scalp lacerations or abrasions, facial nerve injury, chignon from Vac Ext, cephalohematoma, intracranial hemorrhage http://www.babycenter.com/2_vac uum-and-forceps-during- birth_3656512.bc www.uh.edu www.aafp.org

11.  Nursing implications  May catheterize to provide more room in the pelvis as ordered  Prepare for possible episiotomy  Monitor FHR continuously  After birth, monitor mother and infant for trauma  Apply ice to perineum afterwards  Monitor infant for facial symmetry, skin breaks, neurologic abnormalities, arm movements equally?

12.  Your patient has just had a vacuum extraction assisted vaginal birth. When you give the baby to the mother, she cries, “What’s wrong with my baby? His head looks deformed? What is the most therapeutic answer you can give?

13.  The baby’s skull bones are still soft and moveable. That allows the baby’s head more easily be delivered through the birth canal. Sometimes, the baby’s head swells from all the pressure of your contractions, making it look a little like a cone. Since the midwife had to use the vacuum to help get your baby out. There is a little more swelling present. The swelling will go away and your baby’s head will become rounded.

14.  Indications  Shoulder dystocia  Vaginal breech birth  Operative vaginal births  Birth in OP position  Short perineum  Nursing considerations  May be avoided with upright position during pushing, warm compresses, perineal massage prior to delivery  Monitor for hematoma and hemorrhage after delivery vivature.com http://www.youtube.com/watch?v=TWrfJood2Rc&feature=related

15. A woman who has an episiotomy asks the nurse, “When will I get my stitches taken out? How should the nurse best reply? 1. “It depends on the type of episiotomy.” 2. The stitches will be absorbed on their own. They do not need to be removed.” 3. “The doctor will remove the stitches when the perineum stops hurting.”

16. 2. Sutures used to close an episiotomy will be absorbed by the mother’s body within about 3 weeks. ICE is NICE!!! lilsugar.com diaperswappers.com parentsconnect.com

17.  Indications  Dystocia, CPD, hypertension, maternal diseases (diabetes, HTN), active genital herpes, persistent non- reassuring FHR, prolapsed umbilical cord, fetal malpresentation, hemorrhagic conditions (placenta previa or abruptio placenta)  Contraindications  None are absolute- risks to woman are greater than benefit to her or baby  Not advised with fetal death, fetus that is too immature to survive, or maternal coagulation defects

18.  Mother  Infection, sepsis, UTI  Hemorrhage  Thrombophlebitis  Thromboembolism  Ileus  Atelactasis  Anesthesia complications  Baby  Inadvertent preterm birth  Transient Tachypnea of newborn  Injury, bruising, laceration, other trauma

19.  Accepted way to lower c/s rate  Assoc. with small risk of uterine rupture, increases with number of previous c/s deliveries  Surgical risks also  Dr. to discuss risks and benefits with patient  Greater risk of abnormal placental implantation  ACOG suggests VBAC if:  No more than 2 prior c/s  No previous uterine scars  Adequate pelvis  Availability of anesthesia and personnel  Continuous EFM

22.  Nursing Responsibilities  Labs  Check FHR prior to skin prep in OR  Drugs: antacid reduces gastric acidity, antibiotic, spinal anesthesia  Catheter and shave pubic area  Time out before surgery pregnancy.about.com

23.  Uterine incisions  Low transverse (Pfannenstiel)  Less likely to rupture  Less blood loss  Easier to repair  Less adhesion formation  Low vertical  Can be extended upward  Classic  May be only choice for low implantation of placenta  Transverse lie of large fetus with impacted shoulder in mom’s pelvis

24.  Nursing implications  Provide emotional support  Teach about procedure, sensations to expect (pulling, pressure), attendants  Promote safety  Provide postoperative care  VS, LOC, O2 sats, EKG patterns  Return of sensation after regional blocks  Abdominal dressing/hemorrhage  Uterine firmness and position  Lochia  I&O, IV status  Pain relief