Birth Related Procedures
Chapter 22
By: Heather Bailey, RN, BSN
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
External Version Criteria
Equal to or greater than 36 weeks gestation
Reactive NST has been obtained
Fetal breech is not engaged
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
Care for ECV
IV
Tocolytic and pain medication
Ultrasound at bedside
Obtain reactive NST
Consent
Baseline vital signs
Fetal monitoring afterward
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
AROM
Place clean chux under the patientPlace the patient supine in bedEnsure FHT is obtained before, during and after the procedureDocument the color, consistency, amount, odor and presence of meconium or bloodMonitor temp every two hours afterDecrease the number of vaginal exams afterward
Cervical Ripening
Used to soften the cervix
Prostaglandin
Misoprostol
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
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
Cytotec Guidelines
Use during the 3rd trimester for ripening or induction25mcg initial doseRecurrent administration not to exceed intervals of more than 3 to 6 hoursPitocin should not be administered less than 4 hours after the last doseContinuous fetal and uterine monitoring
Cytotec Contraindications
Uterine contractions 3 times in 10 minutes
Significant maternal asthma
Previous Cesarean or uterine surgery
Bleeding during pregnancy
Placenta previa
Nonreassuring FHR
Cytotec Complications
Uterine hyperstimulation
Amniotic fluid embolism
Uterine rupture
Risks for uterine rupture:Previous CesareanAdvanced gestational ageGrandmultipara
Labor Induction Indications
Diabetes mellitusRenal diseasePreeclampsia/eclampsiaChronic pulmonary diseasePROMChorioamniotisPostterm
Mild abruption with reassuring fetal statusIUFDIUGRAlloimunizationOligohydramniosNonreassuring fetal statusNonreassuring antepartum testing
Induction Contraindications
Client refusal
Placenta previa
Vasa previa
Transverse fetal lie
Prior Cesarean with classical incision
Active genital herpes
Umbilical cord prolapse
Absolute CPD
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
Methods of Induction
Stripping the membranes
Pitocin infusion
Cervical ripening
Amniotomy
Allopathic methods: sexual intercourse, nipple stimulation, mechanical dilation of the cervix, etc.
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
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
Episiotomy
Surgical incision of the perineum to enlarge the outletCan increase the risk of 4th degree perineal lacerationsTypes: Midline, mediolateral, paramedianDocument the type of episiotomy and repair agent used
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
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
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
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 CPDKnowledge to perform procedure by physicianAdequate staff to perform a Cesarean if indicated including anesthesia staffMaternal consent
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
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
Vacuum Risks
Cephalohematoma
Intracerebral hemorrhage
Retinal hemorrhage
Jaundice
Brain injury
Fetal death
Cesarean Birth
Delivery via surgical incision in the abdomen and uterusC/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/SAlso increase primary elective C/S
Indications
Complete previaCPDAbruptionActive genital herpesCord prolapseArrest of laborNonreassuring fetal statusPrevious classical incision on the uterus
More than one previous C/STumors obstructing the birth canalCervical cerclageCardiac disordersSevere respiratory diseaseCNS disordersMechanical vaginal obstruction
Indications Continued
Several mental illness with altered state of consciousness
Breech presentation
Previous C/S
Major congenital anomalies
Severe Rh alloimmunization
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
Incisions
Skin incisionsPfannenstielVertical
Uterine incisionTransverseClassical
Skin incision is not indicative of uterine incision
Anesthesia
Spinal
Epidural
Spinal/Epidural combo
General
Local
Preparation for Cesarean
Scheduled vs. UnscheduledSupport of patient and familyNPOConsentsIV and lab workFluid bolusPepcid/BictraAbdominal prepFoley catheter
Cesarean Recovery
Vital signs: q 5 min until stable, q 15 min for an hour then q 30 min until recovery is completeFundus, bleeding, level of anesthesia and abdominal incision are evaluated q 15 min for an hour then q 30 min until recovery is completeI&O as ordered paying attention to the urine for blood Pain and nausea with each check and PRNEnsure bonding is accomplished
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 prolapseBreech presentationPlacenta previaNon reassuring fetal status
ACOG VBAC Guidelines
One previous C/S with low transverse uterine incisionClinically adequate pelvisTwo previous C/S with previous VBACMust be possible to perform a C/S within 30 minutesPhysician, adequate staff, anesthesia and facilities must be readily available to perform C/S if neededA classic or T uterine incision is a contraindication
VBAC Risks
Hemorrhage
Uterine scar separation
Uterine rupture
Surgical injuries
Infant death
Infant neurological complications
Most risks are associated with uterine rupture
VBAC Benefits
Lower infection rate
Less blood loss
Fewer blood transfusion
Shorter hospital stay
The risks of VBAC complications lowers with each subsequent attempt