Objectives • 1. Identify medical indications for induction of labor. • 2. Explain methods practitioners use to determine labor readiness. • 3. Contrast mechanical methods for hastening cervical readiness with pharmacologic methods. • 4. Describe the procedure for artificial rupture of membranes. • 5. Outline essential steps and possible complications associated with oxytocin induction. • 6. Discuss important issues and considerations associated with episiotomy. • 7. Compare mediolateral and midline episiotomies. • 8. Describe indications, risks, and medical and nursing considerations for vacuum extraction and forceps-assisted delivery. • 9. Name the most common and less common indications for cesarean birth. • 10. Explain maternal and fetal complications of cesarean delivery. • 11. Differentiate between vertical and transverse skin and uterine incisions. • 12. List the responsibilities of each member of the surgical team throughout the perioperative period for a cesarean delivery. • 13. Compare nursing interventions needed to prepare a family for a planned cesarean birth with those for a family who is to undergo emergency cesarean delivery. • 14. Discuss the controversy surrounding vaginal birth after cesarean (VBAC). • 15. Explain important medical and nursing considerations for a woman undergoing attempted VBAC.
Induction of Labor • Elective induction • Where physician and woman choose to induce labor without medical cause • Major cause of increase in number of induced labors • Often result in • More interventions • Longer labors • Higher costs • Possible cesarean birth
Induction of Labor (cont.) • Indications for induced labor • Postdate pregnancy-most common • Premature rupture of membranes (PROM) • Spontaneous rupture of membranes (SROM) without the onset of spontaneous labor • Chorioamnionitis • Pregnancy-induced hypertension • Preeclampsia • Severe intrauterine fetal growth restriction • Maternal medical conditions Learning objective #1
Induction of Labor (cont.) • Contraindications • Maternal contraindications for spontaneous and induced labor • Complete placenta previa • History of a classical uterine incision • Structural abnormalities of the pelvis • Invasive cervical cancer • Medical conditions such as active genital herpes • Fetal contraindications • Certain anomalies, such as hydrocephalus • Certain fetal malpresentations • Fetal compromise
Induction of Labor (cont.) • Labor readiness • Prerequisite for induced labor = “ripe cervix” • Bishop Score often used to determine readiness for labor • 5 factors evaluated-page 239 • Each factor scored 0 to 3 • Score of 8 or greater associated with successful oxytocin-induced labor • Score of 5 or less indicates cervix is not ripe – associated with unsuccessful induction of labor • Learning Objective #2
Induction of Labor (cont.) • Labor readiness (cont.) • Transvaginal ultrasound • Relatively new method • Cervix 27 mm or less is a predictor of successful induction of labor despite Bishop score • Measurement of fetal fibronectinlevels • Newer method • Presence in cervical secretions is associated with labor readiness • More often used as a predictor of preterm labor risk Learning objective #2
Induction of Labor (cont.) • Labor readiness (cont.) • Fetus should be mature • Several ways to assess fetal maturity • At least 38 weeks’ gestation considered mature • Date fetal heart tones first heard • Other pregnancy milestones • Fetal lung maturity is the major point of consideration • Measure L/S ratio by amniocentesis Learning objectives #2
Induction of Labor (cont.) • Methods of cervical ripening • Mechanical methods • Membrane stripping • Inserting a catheter into the cervix and inflating the balloon • Cervical dilators (laminaria) • Pharmacologic methods • Prostaglandin E2 (dinoprostone)-approved by FDA • Prostaglandin E1 (misoprostol)-not FDA approved for cervical ripening Learning objective #3
Induction of Labor (cont.) • Artificial rupture of membranes (AROM) • Also called amniotomy • causes the body to release prostaglandins, which enhances labor • Oxytocin induction • IV oxytocin (Pitocin) most common agent used for labor induction • Infusion pump required • Starting dose usually 1 milliunit/minute • Titrated upward by 1-2 milliunits/minute until adequate contraction pattern established Learning objective #4 & 5
Induction of Labor (cont.) • Oxytocin induction (cont.) • Potential complications • High risk of C-section • Hyperstimulation of uterus • Water intoxication • Hyponatremia • Confusion • Convulsions • Coma Learning objective #5
Induction of Labor (cont.) • Nursing care • The licensed practical/vocational nurse’s (LPN/LVN) role during induction depends upon the procedure • Assist with pelvic exam in mechanical ripening of cervix or amniotomy • Document fetal heart rate before and after amniotomy • Suprapubic or fundal pressure during the procedure if trained • RN responsible for monitoring mother and baby during pharmacologic ripening of cervix
Question Tell whether the following question is true or false. There are two types of prostaglandin approved by the Food and Drug Administration for the induction of labor.
Answer False Rationale: There are two main preparations, but the only substance approved by the United States Food and Drug Administration (FDA) for this purpose is prostaglandin E2 gel or vaginal inserts (dinoprostone). Prostaglandin E1 (misoprostol) is used frequently for cervical ripening, although it is not approved for this use.
Assisted Delivery • Episiotomy • A surgical incision is made into the perineum to enlarge the vaginal opening • Research shows higher incidence of perineal tear into anal sphincter • Methods to minimize the need for episiotomy • Kegel exercises during pregnancy to strengthen perineal muscles • Using natural pushing techniques, particularly in the side-lying position • Patience with the delivery process • Protection of the perineum immediately before birth to avoid uncontrolled delivery of the fetal head Learning objective #6
Assisted delivery cont’d • Mediolateral • Angles to right or left of the perineum • More difficult to repair • Midline • Extends from fourchette straight down into the true perineum • Increases risk for extension into the anal sphincter • Easier to repair than mediolateral • Learning objective #7
Assisted Delivery (cont.) • Vacuum-assisted delivery • A suction cup is placed on the fetus’s head; suction is applied and used to guide the delivery of the infant • Can be hazardous to infant • Scalp trauma • Subgaleal and intracranial hemorrhage • Pressures should not exceed 600 mmHg • Should not be more than 3-4 pop-offs • Vacuum should not be applied for longer than 20 to 30 minutes Learning objective #8
Assisted Delivery (cont.) • Forceps • Instruments with curved, blunted blades are placed around the head of the fetus to facilitate delivery • Low and outlet forceps are more common than are midforceps • Midforceps are most often used to assist the fetus to rotate to an anterior position. • Maternal indications include fatigue certain chronic conditions such as heart or lung disease and a prolonged second stage of labor • Non-reassuring fetal strip Learning objective #8
Assisted Delivery (cont.) • Complications of operative vaginal delivery • Neonatal cephalhematoma, retinal, subdural, and subgaleal hemorrhage occur more frequently with vacuum extraction than with forceps. • Facial bruising, facial nerve injury, skull fractures, and seizures are more common with forceps. • Maternal complications include • Extension of episiotomy into anal sphincter • Uterine rupture, perineal pain, lacerations, hematomas, urinary retention, anemia, and rehospitalization Learning objective #8
Assisted Delivery (cont.) • Nursing care during an assisted delivery • Obtain needed equipment and supplies • Monitor maternal and fetal status before, during, and after the procedure • Assist the birth attendant • Provide support for the woman • Document the type of procedure • Document maternal and fetal response to the procedure
Question An episiotomy is a surgical incision made in the perineum of a laboring woman to assist in the passage of the fetus at birth. What is a possible maternal complication of an episiotomy? a. Loss of bladder control b. Anemia c. Bowel retention d. Shoulder dystocia of the fetus
Answer b. Anemia Rationale: The woman is at higher risk to have episiotomy and for extension of episiotomy into the anal sphincter with operative vaginal delivery. Other maternal complications include uterine rupture, perineal pain, lacerations, hematomas, urinary retention, anemia, and rehospitalization (Ross & Beall, 2007; Wegner & Bernstein, 2007).
Cesarean Birth • Indications • History of previous cesarean birth • Labor dystocia (failure to progress in labor) • Non-reassuring fetal status • Fetal malpresentation • Incidence • 2006 31.1% of births were by cesarean delivery • Highest rate ever reported in the United States Learning objective #9
Cesarean Birth (cont.) • Risks • Major surgery that carries with it all the risks associated with surgery combined with the risks of birth itself • 3 times more likely to die • Normal physiologic changes of pregnancy amplify some surgical risk factors • Inadvertent delivery of a premature fetus • Increases the incidence of neonatal respiratory distress • National goal to decrease the cesarean delivery rate Learning objective #10
Cesarean Birth (cont.) • Maternal complications • Laceration of the uterine artery, bladder, ureter, or bowel • Hemorrhage requiring blood transfusion • Hysterectomy • Infection • Pneumonia • Postpartum hemorrhage, thrombophlebitis, and other surgical-related complications Learning objective #10
Cesarean Birth (cont.) • Fetal complications • Most common is unintended delivery of an immature fetus because of miscalculation of dates and respiratory distress because of retained lung fluid • Depressed fetal respiratory drive, due to anesthesia, makes it difficult for the newborn to take his or her first breath • Fetal injury can occur Learning objective #10
Cesarean Birth (cont.) • Incision types • Abdominal incisions • Vertical approach done in the midline of the lower abdomen • Pfannenstiel’s incision (bikini cut) • Uterine incisions • Classical incision-only in severe emergencies • Low cervical vertical incision • Low cervical transverse incision (preferred method) Learning objective #11
Cesarean Birth (cont.) • Steps in a cesarean delivery • Called perioperative period-once in the OR • Preoperative phase • Team approach, sometimes referred to as collaborative management • Intraoperative phase • LVN/LPN acts as scrub nurse • Postoperative phase • LVN/LPN can assume care of woman after she has sufficiently recovered from anesthesia Learning objective #12
Cesarean Birth (cont.) • Nursing care • Planned cesarean birth • Focus on education to prepare the family for the birth • Emergency cesarean birth • Focus on supportive behaviors • Explaining procedures as they are done • Providing appropriate reassurance • Providing care in immediate postoperative period • Many contributing factors Learning objective #13
Question A cesarean delivery is a major surgery and requires a team approach to caring for the pregnant woman. During the intraoperative period of a cesarean delivery, what is the role of the LVN/LPN? a. Take vital signs every 15 minutes b. Provide reassurance to the mother and significant other c. Act as a scrub nurse if trained appropriately d. Take the infant for assessment at birth
Answer c. Act as a scrub nurse if trained appropriately Rationale: The specially trained LPN/LVN may function as the scrub nurse if a cesarean becomes necessary.
Vaginal Birth After Cesarean • Prerequisites • ACOG Recommendations: • Adequate pelvis • No previous uterine ruptures • Personnel and facilities available to perform an immediate cesarean delivery • No more than one previous, low transverse uterine scar • Signed informed consent that lists benefits and risks • Surgeon, anesthesia provider, and operating room personnel in the hospital • Practitioner who can read and interpret EFM tracings and recognize the signs and symptoms of uterine rupture Learning objective #14
Vaginal Birth After Cesarean (cont.) • Contraindications • Previous classic C-section uterine scar • Placenta previa • History of previous uterine rupture • Lack of facilities or equipment to perform an immediate emergency cesarean Learning objective #15
Vaginal Birth After Cesarean (cont.) • Risksand benefits • Greatest concern is uterine rupture • Risk amplified when prostaglandins are used to ripen the cervix before induction with oxytocin • History of more than one cesarean • Short interval between pregnancies • History of infection with the previous cesarean • Benefit: less chance of uterine rupture or emergency C-section Learning objective #14
Vaginal Birth After Cesarean (cont.) • Signs of uterine rupture • Dramatic onset of fetal bradycardia or deep variable decelerations • Reports by the woman of a “popping” sensation in her abdomen • Excessive maternal pain • Unrelenting uterine contraction followed by a disorganized uterine pattern • Increased fetal station felt upon vaginal examination • Easily palpable fetal parts through the abdominal wall • Signs of maternal shock Learning objective #15
Vaginal Birth After Cesarean (cont.) • Nursing care • Outside the scope of practice for the LPN/LVN to care for a laboring woman who has a history of a previous cesarean delivery • The specially trained LPN/LVN may function as the scrub nurse if a cesarean becomes necessary