lecture : nursing care during obstetrical operations...3. uterine inertia: inefficient uterine...

Nursing Care During Obstetrical Operations

تمريض الام والوليد اقدس داود سلمان .د

Lecture : Nursing Care During Obstetrical Operations

Obstetrical Operations Include :

• Forceps

• Version

• Cesarean section c /s

• Episiotomy

• Induction of labor

• Augmentation of labor

• Obstructed Labor

Forceps

• Definition: Forceps extractor may be used to apply traction to the fetal head or to provide

a method of rotating the fetal head during birth

Indications of forceps

a prolonged second stage of labor and include:

1. a distressed FHR pattern,

2. failure of the presenting part to fully rotate and descend in the pelvis

3. limited sensation and inability to push effectively due to the effects of regional

anesthesia.

4. fetal distress.

5. maternal heart disease.

6. acute pulmonary edema.

7. intrapartum infection.



8. maternal fatigue.

Risk from use of forceps

risk of tissue trauma to the mother and the newborn which include:

Maternal trauma may include:

1. lacerations of the cervix, vagina, or perineum; hematoma;

2. extension of the episiotomy incision into the anus;

3. hemorrhage; and infection.

Potential newborn trauma includes:

1. Ecchymoses.

2. facial and scalp lacerations,

3. facial nerve injury,

4. cephalhematoma,

5. caput succedaneum

Nursing intervention for forceps delivery 1. Obtains forceps designated by the physician.

2. Checks, reports, and records the fetal heart rate before forceps are applied.

3. Informs the patient that the forceps blades fit like two tablespoons around an egg.

The blades come over the fetus ears.

4. Rechecks, reports, and records the fetal heart rate again before traction is applied

after application of the forceps. Compression of the cord between the fetal head and

the forceps would cause a drop in fetal heart rate. The physician would then remove

and reapply the forceps.

5. Give support to the patient.

6. Observe for signs and symptoms of complications.

7. Assess the newborn for indications of injury.

8. Reassure the mother that any marks or swelling on the newborn’s head or face will

disappear without treatment within 2 to 3 days after deliver.

9. )Alert the postpartum nursing staff about the use of the technique so that they can

observe for any bleeding or infection related to genital lacerations.

Version

• Definition: Version is the turning of the fetus from one presentation to another. It may

be performed externally or internally by the physician.

• Types: 1. External Cephalic Version

External cephalic version (ECV) is used in an attempt to turn the fetus from a

breech or shoulder presentation to a vertex presentation for birth. It may be attempted in a

labor and birth setting after 37 weeks of gestation. ECV is accomplished by the exertion

of gentle, constant pressure on the abdomen .



Before ECV is attempted, ultrasound scanning is done to:

• Determine the fetal position

• Locate the umbilical cord

• Rule out placenta previa

• Evaluate the adequacy of the maternal pelvis

• Assess the amount of amniotic fluid, the gestational age, and the presence of any

anomalies

• Contraindications to ECV include

o Uterine anomalies

o Third-trimester bleeding

o Multiple gestation

o Oligohydramnios • Evidence of uteroplacental insufficiency

o A nuchal cord (identified by ultrasound)

o Previous cesarean birth or other significant uterine surgery

o Obvious CPD

• Nursing care for ECV

During an attempted ECV,

o the nurse continuously monitors the FHR and pattern, especially for bradycardia

and variable decelerations;

o checks the maternal vital signs;

o and assesses the woman’s level of comfort because the procedure may cause

discomfort.

After the procedure is completed ECV,

o the nurse continues to monitor maternal vital signs and uterine activity and to

assess for vaginal bleeding until the woman’s condition is determined to be

stable.

o FHR and pattern monitoring should continue for at least 1 hour. Women who are

Rh negative should receive Rh immune globulin because the manipulation can

cause fetomaternal bleeding.



2. Internal Version With o internal version, the fetus is turned by the physician, who inserts a hand into the

uterus and changes the presentation to cephalic (head) or podalic (foot).

o Internal version is rarely used, most often in twin gestations to assist with the birth

of the second fetus.

o The safety of this procedure has not been documented; maternal and fetal injury are

possible.

o Cesarean birth is the usual method for managing malpresentation in multifetal

pregnancies.

The nurse’s role in internal version:

monitor the status of the fetus and to provide support to the woman.

Cesarean Section

• Definition: cesarean section C/S is the delivery of the fetus through an incision

in the abdomen and uterus

• Uterine Incisions

o Low transverse (more commend)

Less likely to rupture

Less blood loss

Easier to repair

Less adhesion formation

o Low vertical

Can be extended upward

o Classic

May be only choice for low implantation of placenta

Transverse lie of large fetus with impacted shoulder in mom’s

pelvis



o Indications Of Classical Caesarean Section

o when the lower segment cannot identified due to adhesion.

o when caesarean section is done after motherיs death.

o Cases needs rapid delivery.

o When the fetus lie is transverse and cannot be corrected.

o When hysterectomy will follow caesarean section

o Advantages of the lower segment:

o The wound is extra peritoneal so less risk of infection.

o Healing scar is better.

o The risk of rupture of the scar is less.

o Hemorrhage is less.

o Placenta is away from the incision.

o Disadvantages of the lower segment:

o The operation requires more skill and experience.

o The incision may extend down to the bladder.

o Disadvantages of classical operation:

o More liable to chest infection.

o More liable to intestinal distension.

o The scar is more liable to rupture.

Indications of cesarean section: It is usually performed when a vaginal delivery would put the baby's or mother's life or

health at risk.

The following indications are the most frequent:

1. Extreme degree of contracted pelvic (one or more of the diameters is reduced and

interferes with normal mechanism of labour.

2. Cephalopelvic disproportion: the head of the fetus is too large to come through the pelvis.

3. Uterine Inertia: Inefficient uterine contraction.

4. Placenta abnormalites :

o Placenta previa

o Abruptio placenta

o Placeta accrete

5. Malposition and malpresentation

6. Pre-eclamsia

7. Diabetes

8. Cardiac diseases.

9. Vaginal scaring.

10. Carcinoma of the cervix.

11.Cervical dystoctia (failure of the cervix to dilate in spite of strong contraction of the

uterus).

12.. A previous uterine incision.

13. Prolapse of the umbilical.



14. Fetal distress.

15. Bad post obstetric history (baby habitually dies in the uterus.

16. Failure of labour to progress despite adequate stimulation.

Risks Of Cesarean Delivery

Risk for Mother:

o Longer hospital stay

o Increased blood loss

o Infection

o Injury to bowel, bladder, ureter

o Blood clots

o Anesthesia complications

o Pain

o Admission to the ICU

o Hysterectomy

Risk for Baby

o increased breathing complications

o Less immediate contact with mom

o Longer till breastfeeding is initiated

o Scalpel injury

o Fetal death

Complications Of Cesarean Section:

Cesarean birth is a major surgical procedure with increased risks compared to a vaginal birth. The

client is at risk for complications such as:

o infection,

o hemorrhage,

o aspiration,

o pulmonary embolism,

o urinary tract trauma,

o thrombophlebitis,

o paralytic ileus,

o and atelectasis.

o Fetal injury and transient tachypnea of the newborn also may occur



Nursing Assessment for C/S

o woman’s history for indications associated with cesarean birth

o complete a physical examination.

o Any condition that prevents the safe passage of the fetus through the birth canal

or that seriously compromises.

Nursing Management for C/S

Once the decision has been made to proceed with a cesarean birth nurse should be

oriented about the following:

• assess the woman’s knowledge of the procedure and necessary preparation.

• Assist with obtaining diagnostic tests as ordered. These tests are usually ordered to ensure

the well-being of both parties and may include:

a complete blood count;

urinalysis to rule out infection;

blood type and cross-match

blood is available for transfusion if needed;

an ultrasound to determine fetal position and placental location;

and an amniocentesis to determine fetal lung maturity if needed.

• Although the nurse’s role in a cesarean birth can be very technical and skill oriented at

times, the focus must remain on the woman, not the equipment surrounding the bed.

• Care should be centered on the family, not the surgery:

Provide education and minimize separation of the mother, father, and newborn.

Remember that the client is anxious and concerned about her welfare as well as that of

her child. Use touch, eye contact, therapeutic communication, and genuine caring to

provide couples with a positive birth experience, regardless of the type of delivery.

Providing Preoperative Care

o Provide essential teaching and explanations to reduce the woman’s fears and

anxieties.

o Ascertain the client’s and family’s understanding of the surgical procedure.

o Reinforce the reasons for surgery given by the surgeon.

o Outline the procedure and expectations of the surgical experience.

o Ensure that all diagnostic tests ordered have been completed, and evaluate the

results.

o Explain to the woman and her family about what to expect postoperatively.

o Reassure the woman that pain management will be provided throughout the

procedure and afterward.

o Encourage the woman to report any pain.

o Ask the woman about the time she last had anything to eat or drink.



o Document the time and what was consumed.

o Throughout the preparations, assess maternal and fetal status frequently.

o Provide preoperative teaching to reduce the risk of postoperative complications.

o Demonstrate the use of the incentive spirometer and deep-breathing and leg

exercises.

o Instruct the woman on how to splint her incision.

o Complete the preoperative procedures, which may include:

Preparing the surgical site as ordered

Starting an intravenous infusion for fluid replacement therapy as ordered

Inserting an indwelling (Foley) catheter and informing the client about how long it will

remain in place (usually 24 hours)

Administering any preoperative medications as ordered; documenting the time

administered and the client’s reaction

Providing Postoperative Care of C/S

Postoperative care for the mother who has had a cesarean delivery is similar to that

for one who has had a vaginal birth, with a few additional measures.

o Assess vital signs and lochia flow every 15 minutes for the first hour, then every

30 minutes for the next hour, and then every 4 hours if stable.

o Assist with perineal care and instruct the client in the same. Inspect the

abdominal dressing and document description, including any evidence of

drainage.

o Assess uterine tone to determine fundal firmness.

o Check the patency of the intravenous line, making sure the infusion is flowing at

the correct rate.

o Inspect the infusion site frequently for redness.

o Assess the woman’s level of consciousness if sedative drugs were administered

o Assess for evidence of abdominal distention and auscultate bowel sounds, to

promote peristalsis

o Encourage the woman to cough, perform deep breathing exercises, and use the

incentive spirometer every 2 hours. Administer analgesics as ordered and provide

comfort measures

o Encourage early touching and holding of the newborn to promote bonding



o Allow them to verbalize their feelings and assist them in positive coping

measures.

o Prior to discharge, teach the woman about the need for adequate rest, activity

restrictions such as lifting, and signs and symptoms of infection.

Episiotomy

Definition: Episiotomy is a planned surgical incision made on the

perineum and posterior vaginal wall during late second stage of labour

inorder to widen the introits and straighten the lower end of the birth

canal.

Purposes:

o to prevent damage to the periurethra, perineum, anal sphincter, and rectum from

lacerations during the birth

o to prevent damage to the posterior wall of the vagina

o to prevent jagged tears from lacerations

o to reduce mechanical and metabolic risk to the fetus/newborn

o to protect the maternal bladder

o to prevent future perineal relaxation

Types of Episiotomy The following are the various types of episiotomy

o Mediolateral

o Median

o Lateral

o ‘J’ Shaped



Advantages and Disadvantages of Episiotomy

Advantages:

o Saves perineum from laceration, haematoma and complete perineal tear.

o To cut short second stage of labour.

o To prevent foetal asphyxia.

o ·To prevent postpartum genital prolapse.

Disadvantages:

o Blood loss 100-200 ml.

o from episiotomy wound.

o Increased perineal trauma.

o Vulval haematoma and infection.

o Painful wound

o Dysparuenia due to over stitching

Nursing Care Of Woman With Episiotomy

During episiotomy

o The woman needs to be supported during the episiotomy and the repair because

she may feel some pressure sensations.

o Placing a hand on her shoulder and talking with her can provide comfort and

distraction from the repair process.



o If the woman is having more discomfort than she can comfortably handle, the

nurse needs to act as an advocate in communicating the woman’s needs to the

physician.

o The nurse notes the type of episiotomy on the birth record. This information

should also be included in a report to the postpartum nurse so that adequate

assessments can be made and relief measures can be instituted if necessary.

After episiotomy nurse should educate woman with the following:

o Eat diet high in fiber and fluid to prevent constipation

o Ask woman to walk with thighs apposed

o Not use the squatting position since the wound healing

o Change sanitary pads at least 4 hours to help prevent infection

o Squirt warm tape over the perineum, beginning at the front moving toward the

back

o Sit in a tub of warm water.

o Always wash hand before and after going to bathroom

o Always keep the wound clean and dry after each urination and defecation

Induction of Labor

o Definition: is the chemical or mechanical initiation of uterine

contractions before their spontaneous onset for the purpose of

bringing about birth.

Or

stimulating the uterus to begin labour for the purpose of

accomplishing vaginal birth

o Indication of induction of labor

Induction is indicated when the benefits to either mother or fetus

outweigh those of pregnancy continuation. The more common

indications include:

o membrane rupture without labor.

o gestational hypertension.

o Oligohydramnios.



o nonreassuring fetal status.

o postterm pregnancy, and various maternal medical conditions such as chronic

hypertension and diabetes.

o Contraindication of induction of labor:

The few maternal contraindications are related to prior uterine incision type:

o contracted or distorted pelvic anatomy.

o abnormally implanted placentas.

o uncommon conditions such as active genital. herpes infection or cervical cancer.

o Fetal factors include:

o appreciable macrosomia.

o severe hydrocephalus.

o malpresentation, or nonreassuring fetal status

o Methods of Induction of Labor:

1. Mechanical Methods (Amniotomy)

Amniotomy = artificial rupture of membranes (AROM)

o can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if progress begins to slow.

o Labor usually begins within 12 hours of the rupture. o Amniotomy can decrease the duration of labor by up to 2 hours, even without

oxytocin administration. o However, if amniotomy does not stimulate labor, the resulting prolonged

rupture may lead to intraamniotic infection. o Variable FHR deceleration patterns can occur as a result of cord compression

associated with umbilical cord prolapse or decreased amniotic fluid. o Once an amniotomy is performed, the woman is committed to labor with an

unknown outcome for how and when she will give birth. For this reason, amniotomy often is used in combination with oxytocin induction

Nursing care before procedure:

o Explain to the woman what will be done.



o Assess fetal heart rate (FHR) and pattern before procedure begins to obtain a baseline reading

o Position the woman on a padded bedpan, fracture pan, or rolled-up towel to elevate her hips.

o Assist the health care provider who is performing the procedure by providing sterile gloves and lubricant for the vaginal examination

o assured woman that the actual rupture of the membranes is painless for her and the fetus, although she may experience some discomfort when the Amnihook or other sharp instrument is inserted through the vagina and cervix.

o The presenting part of the fetus should be engaged and well applied to the cervix before the procedure to prevent cord prolapse.

o The woman should also be free of active infection of the genital tract (e.g., herpes) and should be human immunodeficiency virus (HIV) negative or have a viral load low enough that vaginal birth is acceptable.

Nursing care after procedure :

o After rupture, the amniotic fluid is allowed to drain slowly. The color, odor, and consistency of the fluid are assessed (i.e., for the presence or absence of meconium or blood). The time of rupture and characteristics of the fluid are recorded.

o The woman’s temperature should be checked at least every 2 hours after rupture of membranes and more frequently if signs or symptoms of infection are noted. If her temperature is 38° C (100.4° F) or higher, notify the primary health care provider.

o The nurse assesses for other signs and symptoms of infection, such as maternal chills, uterine tenderness on palpation, foul-smelling vaginal drainage, and fetal tachycardia.

o Comfort measures, such as frequently changing the woman’s underpads and perineal cleansing, are implemented



2. Chemical Methods (oxytocin): o Most commonly used induction agent in the US and world o Often used after a cervical ripening (refers to the softening of the cervix that

typically begins prior to the onset of labor contractions and is necessary for cervical dilation and the passage of the fetus agent )

Dosage of oxytocin o The intravenous solution containing oxytocin should be mixed in a

standard concentration. o Concentrations often used are 10 units in 1000 mL of fluid, 20 units in 1000 mL

of fluid, or 30 units in 500 mL of fluid. o Use isotonic intravenous solutions (e.g., 0.9% sodium chloride, lactated Ringer’s

[LR]) to avoid electrolyte imbalance. o Oxytocin is administered intravenously through a secondary line o Begin oxytocin administration at 1 milliunit/min. o Increase the rate by 1 to 2 milliunits/min, no more frequently than every 30 to

60 minutes based on the response of the woman and fetus and the progress of labor.

Action of Oxytocin

Causes uterine contractions that increase in frequency and intensity ((A consistent pattern of one contraction every 2 to 3 minutes, lasting 80 to 90 seconds, and strong to palpation))

Risk of oxytocin o Increases risk of postpartum hemorrhage due to saturation of oxytocin receptors

in the uterus o Potentially highly dangerous drug



Augmentation of labor

Definition: stimulating the uterus during labour to increase the frequency, duration and strength of contractions.

Note: A good labour pattern is established when there are three contractions in 10 minutes, each lasting more than 40 seconds.

Augmentation is usually implemented for the management of hypotonic uterine dysfunction [uterine contractions that are too infrequent or too weak to be effective], resulting in a slowing of the labor process (protracted active phase). Common augmentation methods include oxytocin infusion and amniotomy

Dysfunctional labor [prolonged or arrested progress in cervical dilation during active labor or fetal descent during second stage]

Uterine hypocontractility Similar to induction of labor because an oxytocin infusion is used to stimulate contractions

The difference between induction and augmentation is that with augmentation, labor has already begun and is being stimulated, while induction is used to start labor.

The administration procedure and nursing assessment and care measures for augmenting labor with oxytocin are similar to those used for induction of labor with oxytocin

Contraindications to Augmentation of Labor

• Placenta previa

• Umbilical cord presentation



• Prior classical uterine incision [increased incidence of uterine rupture]

• Active genital herpes infection

• Pelvic structure deformities

• Invasive cervical cancer

Nursing Care with Augmentation of Labor o Client education and ongoing support o Noninvasive methods such as emptying the bladder, ambulation and

position changes, relaxation measures, nourishment and hydration, and hydrotherapy should be attempted before initiating invasive interventions (e.g: oxytocin and aminiotomy)

o Initial and ongoing monitoring of maternal and fetal response to oxytocin

Maternal vital signs Maternal comfort level/coping status Assessment of uterine contractions Assessment of fetal heart rate

o Preparation and administration of oxytocin o Interventions to promote comfort and progress in labor

lecture : nursing care during obstetrical operations...3. uterine inertia: inefficient uterine...

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