Labor Assisted Deliveries

Therapeutic Management of the Problems or Potential Problems in Labor and Delivery 1.

Induction or Augmentation of Labor Induction of labor o Labor is started artificially o Fetus is in danger, risks for the fetus to remain in the utero • Labor does not occur spontaneously and the fetus appears to be at term • Presence of pre-eclampsia • Rh sensitization • Eclampsia • prolonged rupture of membrane • severe hypertension, • intrauterine growth restriction • diabetes • post maturity (pregnancy lasting beyond 42 weeks)

Conditions before beginning induction • The fetus is in a longitudinal lie • The cervix is ripe, or ready for birth • A presenting part is engaged

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There is no CPD The fetus is estimated to be mature by date

Administration of oxytocin initiates contractions Always administered intravenously, so that, if hyperstimulation should occur, it can be quickly discontinued Half life of oxytocin is approximately 3 minutes: effect and level effects falls immediately after discontinuation Induction is begun by:  Dilute administration of IV form of oxytocin (Pitocin)  1L of LR + 10IU • 10IU of oxytocin = 10,000 milliunits (mU) • 1ml = 10mU “piggy back” the oxytocin solution to a maintenance IV solution such as 5% dextrose and water. Always use the infusion port closest to the client. This way, if it is stopped, little remains in the tubing Use an infusion pump – so that it will not change even if the woman changes position Begin infusion rate of .5 to 1 mU/min. If no response, infusion rate is increase every 15 to 60 minutes by small increments of 1 to 2 mU/min until contractions begin. Do not increase the rate to more than 20mU/min w/o checking for further instructions. • Cause titanic contractions

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With 4c cm cervical dilatation • Amniotomy to further induce the labor • Infusion is discontinued, in some it is continued through full dilatation

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Side effect of oxytocin • Peripheral vessel dilatation, that can lead to: o Extreme hypotention 

Excessive stimulation of the uterus o Tonic contractions w/ fetal death o Rupture of uterus

Nsg. Management:  Pulse and BP monitoring q 15mins  Monitor uterine contractions safe limits: • Interval – not < 2 mins

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Intensity – not > 50mmHg Duration – not > 70 seconds Resting pressure – not > 15 mmHg

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Stop IV infusion if beyond this safe limits or if with fetal distress. If hyperstimulation does not stop: • B-adrenergic receptor drug (terbutaline sulfate – Brethine)

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• Magnesium sulfate Watch out for water intoxication • First manifested by headache and vomiting, and can lead to:  Seizures

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Coma, and Death

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↓ myometrial activity

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Monitor I & O

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Test and record specific gravity of urine Limit IV fluid to 150ml/hour (2.5ml/min) Report

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AUGMENTATION OF LABOR  Augmentation o Assisting labor that started spontaneously to be more effective o Hypotonic, too weak or infrequent contractions Active Management of Labor (AMOL) • Includes the aggressive administration of oxytocin o Increases of 6mU/min rather than 1 or 2 mU/min o Maximum dosage of oxytocin used may be as high as 36 to 40mU/min. o Reduces the number of postpartal fevers because of infection and dehydration

FORCEPS DELIVERY • Forceps-assisted birth, instrumental delivery, or operative vaginal delivery

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Obstetrical forceps are steel instruments constructed of two blades that slide together at their shaft to form a handle.

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1..11 Forceps are surgical instruments designed to assist in the birth of a fetus by providing either traction or the means to rotate the fetal head to an occiput anterior position. Maybe used to shorten the second stage of labor Indications: o Woman is unable to push with contractions o Fetus is in distress from cord prolapse in the pelvic division of labor (regional o Heart disease anesthesia, spinal cord injury) o Pulmonary edema o Cessation of descent in the second stage of o Infection labor o Exhaustion o Fetus is in abnormal position or is immature

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Three categories of forceps application: Outlet forceps Low forceps Applied when the fetal skull • Applied when the leading has reached the perineum edge (presenting part) of the Fetal scalp is visible, and fetal skull is at a station of Sagittal suture is not more 2. +2 or more than 45 degrees from the midline

Midforceps Applied when the fetal head is engaged

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Conditions before forceps delivery: o Cervical dilatation is complete and with exact position and station of the fetal head known. o Membranes must be ruptured to allow a firm grasp on the fetal head o Type of pelvis should be known, because certain type of pelvis do not permit rotation o Maternal bladder should be 3. empty and adequate anesthesia given o No degree of CPD can be present

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Maternal risks o Lacerations of the birth canal o Extension of midline episiotomy into the anus o Increased bleeding o Bruising, and o Perineal edema

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Nsg. Care Management o A woman should feel some pressure during procedure but no pain with adequate anesthesia o Breathing techniques that help her prevent from pushing during application of the forceps o Monitors contractions and advises the physician when one is present because traction is only applied with contraction. o With each contraction, the physician provides on traction on the forceps as the woman pushes. o The nurse reinforces to the woman that she needs to push while traction is being applied. Combined efforts help with the birth of the fetus. o Mild and temporary fetal 4. bradycardia is common, this results from head compression o newborn is assessed for : o Woman is assessed for: • facial edema, • perineal swelling • bruising, • bruising • caput succedaneum, • hematoma • cephalhematoma, and • excessive bleeding, and • any sign of cerebral edema. • hemorrhage.

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Fetal Risks o Ecchymosis or edema along side of the face o Facial lacerations o Caput succedaneum or cephalhematoma o Cerebral hemorrhages

VACUUM- ASSISTED BIRTH • used to facilitate the birth of a fetus by applying suction to the fetal head • Composed of soft suction cup attached to a suction bottle (pump) by tubing

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Suction cup is placed against the fetal occiput. Pump is used to create negative pressure (suction) inside the cup. Traction is applied in coordination with uterine contractions Descent occurs and fetal head is born

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There should be progressive descent with the first two pulls and that the procedure should be limited to prevent cephalhematoma

• Chignon (caput) disappears within 2 to 3 days. CESAREAN BIRTH • Is the birth of the infant through an abdominal and uterine incision. • Scheduled CS : o Transverse presentations o Genital herpes o CPD o Avoidance of postprocedure stress 1. incontinence ( no-indicated-risk CS birth) o HIV, Herpes type 2, Hepatitis C •

Emergency CS: o Placenta previa o Abruptio placenta

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Fetal distress Failure to progress in labor

Effects of Surgery on a Woman 1. STRESS RESPONSE • Results in the release of epinephrine and norepinephrine • ↑ heart rate, bronchial dilatation, elevation of blood glucose, ↑ blood pressure o Normally positive responses or ready for action with good heart and lung function and glucose for energy o but may antagonize anesthetic action, which is aimed at minimizing body activity

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May minimize blood supply to the lower extremities that lead to ↑ risk to 2..

thrombophlebitis

2. INTERFERENCE WITH BODY DEFENSES • Strict adherence to aseptic technique 3. INTERFERENCE WITH CIRCULATORY FUNCTION • Increased blood loss because of pelvic vessels are congested with blood waiting to supply the placenta • Extensive blood loss can lead to hypovolemia and lowered blood pressure

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500-1,000ml blood loss in CS

4. INTERFERENCE WITH BODY ORGAN FUNCTION • When a body organ is handled, cut or repaired in surgery, it respond with a temporary disruption in function • Uterus is handled during CS birth o may not contract well – hemorrhage • Urinary bladder is displaced anteriorly o May not sense filling • Intestine is pressured o Paralytic ileus or halt intestinal function • Lower extremity circulation may be compromised because of edema 5. INTERFERENCE WITH SELF-IMAGE OR SELF-ESTEEM PREOPERATIVE TEACHING 1. Deep breathing o Fully aerates the lungs and helps prevent stasis of lund mucus o 5 to 10 deep breaths every hour postoperatively (increase 4. lung o inhale deeply, hold breath for a second or two and exhale deeply 2. incentive Spirometry o purpose is to fully aerates the lung 3. Turning o Prevent both respiratory and circulatory stasis 4. Ambulation

function)

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Early ambulation Stimulates lower extremity circulation 4 hours after surgery (as soon as the effect of the epidural anesthesia has worn off)

Immediate Preoperative Care Measures 1. INFORMED CONSENT o Surgeon’s responsibility 2. OVERALL HYGIENE 3. GI PREPARATION o May order enema o Metoclopramide – to speed stomach emptying o Ranitidine – decrease 5. stomach secretions o Sodium citrate - Oral antacid to neutralize acid stomach secretions 4. BASELINE INTAKE AND OUTPUT DETERMINATIONS o Catheterization 5. HYDRATION o IVF of LRS 6. PREOPERATIVE MEDICATION o Minimum use of preop medication to prevent fetal blood supply compromise o To ensure the fetus is awake at birth an can initiate respirations spontaneously 7. PARTIENT CHART AND PRESURGERY CHECKLIST 8. TRANSPORT TO SURGERY 9. ROLE OF THE SUPPORT PERSON INTRAOPERATIVE CARE MEASURES 1. ADMINISTRATION OF ANESTHESIA o Epidural anesthesia • Usually administered with woman lying on her side o Spinal anesthesia • Usually administered with woman in sitting position 2. SKIN PREPARATIONS

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help in positioning the mother

Reduce the number of 6. bacteria on the skin before surgery From above the umbilicus to below the pubic hair1

OF THE INFANT With complete surgical incision, retractors are slipped into the incision. The uterus is cut, and the child’s head may be born manually or by application of forceps Mouth and nose are suctioned before the remainder or the child is born 7. Oxytocin is administered as the child or placenta is delivered After birth, the uterus is pulled forward onto the abdomen and covered with moist gauze. Internal body of the uterus is inspected, and membranes and placenta are manually removed The uterus, subcutaneous tissues, and skin incisions are closed.

Nsg Care Management: • NPO

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Antacids maybe administered within 8.. 30 mins of surgery With epidural anesthesia 1. Nurse may assist with the procedure 2. Monitor woman’s blood pressure and response 3. Continue EFM 4. Abdominal and perineal prep 5. Indwelling catheter is inserted to prevent bladder 9. distention 6. Intravenous line is started w/ large gauge 7. Pediatrician is notified and preparation made to receive the new baby 8. Ensure the infant warmer and resuscitation equipment is working and available 9. Nurse assist in positioning the woman on the operating table 10. Assess fetal heart rate: before, and during preparation • Fetal 10. hypoxia can result from supine hypotension 11.Operating table is adjusted so it slants slightly to one side, or a hip wedge (folded blanket or towels) is placed under the right hip to tip the uterus slightly and reduce compression of blood vessels  Helps relieves the pressure of heavy uterus on the vena cava  Lessens the incidence of vena cava compression, and  Maternal supine hypotension

12. The suction should be in working order and the uterine collection bag should be positioned under the operating table 13. Continued auscultation or EFM of the fetal heart rate until immediately prior to the procedure

B. Uterine Incisions Lower uterine segment (Transverse Incision (Kerr incision)

Lower uterine segment (vertical incision)

  Most commonly used Advantages

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Lower segment is the thinnest portion of the uterus and involves less blood loss Requires moderate dissection of the bladder from underlying myometrium Easier to repair but takes longer Site is less likely to rupture during subsequent pregnancies. ↓ chance of adherence of bowel or omentum to the incision line

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Takes longer to make a transverse incision limited in size because of the presence of Major vessels on either side of the uterus Greater tendency to extend laterally into the uterine vessels

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Preferred for : o multiple gestation o abnormal presentation o plancenta previa o nonreassuring of fetal status o preterm, and o macrosomic fetuses Disadvantages:

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Incision may extend downward into the cervix More extensive dissection of the bladder is needed to keep the incision in the lower uterine segment Hemostasis and closure are more difficult Higher risk of uterine rupture with subsequent labor. Future births need to be CS

Upper segment of the uterine corpus (Classic Incision)

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Used Infrequently now Made at the upper uterine segment

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Results in more blood loss More difficult to repair ↑ risk of uterine rupture with subsequent pregnancy, labor and birth

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upper portion is most contractile portion of the uterus