1. Birth Related Procedures Chapter 22 By: Heather Bailey, RN, BSN

2. Version External Cephalic Version-rotation of the fetus from breech/transverse to cephalic presentation by external manipulation Podalic Version-used when the second twin is in breech position to pull the feet through the cervix and precipitate delivery

3. External Version Criteria Equal to or greater than 36 weeks gestation Reactive NST has been obtained Fetal breech is not engaged

4. ECV Contraindications Uterine anomalies Uncontrolled preeclampsia Third trimester bleeding ROM Oligohydramnios Hydramnios Placenta previa Vasa previa Previous Cesarean Prior significant uterine surgery Multiple gestation Non reassuring FHR IUGR Known nuchal cord

5. Care for ECV IV Tocolytic and pain medication Ultrasound at bedside Obtain reactive NST Consent Baseline vital signs Fetal monitoring afterward

6. Amniotomy Artificial Rupture of Membranes Most common invasive procedure in OB Used to speed up or augment labor Allows for internal monitors to be used Allows for assessment of the amniotic fluid

7. AROM Place clean chux under the patient Place the patient supine in bed Ensure FHT is obtained before, during and after the procedure Document the color, consistency, amount, odor and presence of meconium or blood Monitor temp every two hours after Decrease the number of vaginal exams afterward

8. Cervical Ripening Used to soften the cervix Prostaglandin Misoprostol

9. Prostaglandin Prepidil gel or Cervidil Small wafer on a string is placed in the posterior fornix of the cervix It is left for at least 2 hours up to 12 hours Continues fetal monitoring while the insert is in place Must remain flat for 2 hours after placement

10. Misoprostol (Cytotec) Pill inserted into the posterior fornix of the cervix May also be administered orally, most common vaginally Initial dose 25mcg, to be repeated every 4 hours as needed

11. Cytotec Guidelines Use during the 3 rd trimester for ripening or induction 25mcg initial dose Recurrent administration not to exceed intervals of more than 3 to 6 hours Pitocin should not be administered less than 4 hours after the last dose Continuous fetal and uterine monitoring

12. Cytotec Contraindications Uterine contractions 3 times in 10 minutes Significant maternal asthma Previous Cesarean or uterine surgery Bleeding during pregnancy Placenta previa Nonreassuring FHR

13. Cytotec Complications Uterine hyperstimulation Amniotic fluid embolism Uterine rupture Risks for uterine rupture: Previous Cesarean Advanced gestational age Grandmultipara

14. Labor Induction Indications Diabetes mellitus Renal disease Preeclampsia/eclam psia Chronic pulmonary disease PROM Chorioamniotis Postterm Mild abruption with reassuring fetal status IUFD IUGR Alloimunization Oligohydramnios Nonreassuring fetal status Nonreassuring antepartum testing

15. Induction Contraindications Client refusal Placenta previa Vasa previa Transverse fetal lie Prior Cesarean with classical incision Active genital herpes Umbilical cord prolapse Absolute CPD

16. Labor Readiness ACOG recommends confirmed gestational age of at least 39 weeks Cervical readiness: Bishop Score-the higher the score, the greater probability of successful induction of labor

17. Methods of Induction Stripping the membranes Pitocin infusion Cervical ripening Amniotomy Allopathic methods: sexual intercourse, nipple stimulation, mechanical dilation of the cervix, etc.

18. Pitocin Infusion Obtain reactive NST before beginning infusion Assess maternal vital signs During infusion, document vital signs, intake and output every hour and FHR and contraction pattern every fifteen minutes

19. Amnioinfusion Infusion of sterile saline into the uterus via an intrauterine pressure catheter Used to relieve umbilical cord compression Reinfusion of fluid in cases of oligohydramnios Dilutes heavy meconium in utero to decrease the chance of meconium aspiration

20. Episiotomy Surgical incision of the perineum to enlarge the outlet Can increase the risk of 4 th degree perineal lacerations Types: Midline, mediolateral, paramedian Document the type of episiotomy and repair agent used

21. Operative Vaginal Delivery Forceps-instrument used to provide traction or to rotate the fetal head to occiput anterior Vacuum-used to facilitate birth with the use of a soft cup and suction

22. Forcep Categories Outlet-applied when the fetal skull has reached perineum and fetal scalp is visible Low-applied when the presenting part of the fetal skull is +2 station or below Midforceps-applied when the fetal head is engaged

23. Forecp Indications Maternal conditions: heart disease, pulmonary edema, infection and exhaustion Fetal conditions: placental abruption (late), non reassuring fetal status Used to shorted the second stage of labor with poor pushing effort When regional anesthesia has weakened pushing efforts

24. Forcep Criteria Complete dilation Know position and station of fetal head Ruptured membranes Engaged presentation Type of pelvis should be known Empty bladder Adequate anesthesia No CPD Knowledge to perform procedure by physician Adequate staff to perform a Cesarean if indicated including anesthesia staff Maternal consent

25. Risks Newborn: Facial ecchymosis or edema Facial lacerations Brachial plexus injury Cephalohematoma Cerebral hemorrhage Cerebral fracture Brain damage Fetal death Maternal: Lacerations of the vagina and perineum Extension of episiotomy to rectum Increased bleeding Perineal bruising Perineal edema Anal incontinence

26. Vacuum Delivery Cup is applied against the fetal head and traction is used with uterine contractions to facilitate descent Progressive descent should be achieved with the first two pulls, then procedure should be limited to prevent injury

27. Vacuum Risks Cephalohematoma Intracerebral hemorrhage Retinal hemorrhage Jaundice Brain injury Fetal death

28. Cesarean Birth Delivery via surgical incision in the abdomen and uterus C/S rate in US is at all time high at 31.1% Worldwide rate estimated at 12% Increase in rate is related to increase in repeat C/S Also increase primary elective C/S

29. Indications Complete previa CPD Abruption Active genital herpes Cord prolapse Arrest of labor Nonreassuring fetal status Previous classical incision on the uterus More than one previous C/S Tumors obstructing the birth canal Cervical cerclage Cardiac disorders Severe respiratory disease CNS disorders Mechanical vaginal obstruction

30. Indications Continued Several mental illness with altered state of consciousness Breech presentation Previous C/S Major congenital anomalies Severe Rh alloimmunization

31. Risks Increased maternal mortality and morbidity Increased risk of uterine rupture in subsequent pregnancies Increased risk of bleeding problems in subsequent pregnancies Increase in fetal demise Increased risk for respiratory problems in the infant

32. Incisions Skin incisions Pfannenstiel Vertical Uterine incision Transverse Classical Skin incision is not indicative of uterine incision

33. Anesthesia Spinal Epidural Spinal/Epidural combo General Local

34. Preparation for Cesarean Scheduled vs. Unscheduled Support of patient and family NPO Consents IV and lab work Fluid bolus Pepcid/Bictra Abdominal prep Foley catheter

35. Cesarean Recovery Vital signs: q 5 min until stable, q 15 min for an hour then q 30 min until recovery is complete Fundus, bleeding, level of anesthesia and abdominal incision are evaluated q 15 min for an hour then q 30 min until recovery is complete I&O as ordered paying attention to the urine for blood Pain and nausea with each check and PRN Ensure bonding is accomplished

36. Vaginal Birth After Cesarean (VBAC) Used as an alternative to repeat C/S in cases where C/S was indicated but not limited to the following: Umbilical cord prolapse Breech presentation Placenta previa Non reassuring fetal status

37. ACOG VBAC Guidelines One previous C/S with low transverse uterine incision Clinically adequate pelvis Two previous C/S with previous VBAC Must be possible to perform a C/S within 30 minutes Physician, adequate staff, anesthesia and facilities must be readily available to perform C/S if needed A classic or T uterine incision is a contraindication

38. VBAC Risks Hemorrhage Uterine scar separation Uterine rupture Surgical injuries Infant death Infant neurological complications Most risks are associated with uterine rupture

39. VBAC Benefits Lower infection rate Less blood loss Fewer blood transfusion Shorter hospital stay The risks of VBAC complications lowers with each subsequent attempt