Impact of Procedures on Childbearing Woman • Disappointment • Guilt • Conflict between expectation and need for intervention
The decision to bring pregnancy to an end is one of the most drastic ways of intervening in the natural process
Certain specific conditions under which inducing labor has been shown to save lives Serious IUGR Documented placental insufficiency Deteriorating pre-eclampsia
Macrosomia/PROM • Macrosomia has been used as an excuse for induction, but data do not support this • PROM: how long is safe to wait?
Runaway gestational diabetes • According to the Guinness Book of Records the heaviest baby ever born weighed 29 lbs 4 oz. (29.25 lbs). (Historical Note: The birth occurred in Effingham IL in 1939 and due to respiratory problems the baby died two hours later. The heaviest babies to survive weighed 22.5 lbs and were born in 1955 and 1982.)
Supersize Delivery! Woman Gives Birth to 19.2-Pound Baby Friday, September 25, 2009
Big Babies • Babies in developed countries are being born heavier. • In Australia in 2002 report found that there had been a 12% increase since 1993. • In Ireland, researcher at Dublin’s Rotunda maternity hospital looked at birth weights for first-time mothers between 1950 and 200 and found that millenium NBs weighed an average of 7lbs 10oz, about a pound more than they did half a century earlier. • Why such a boost in birth weight in so short a time? Large babies are not the result of evolutionary changes, rather a by-product of rapidly shifting environment and cultural landscape.
“Mums with a diabetic tendency and obese mums tend to be more likely to have bigger babies because there is more fat laid down and more sugar present. The fast food diet also predisposes to increased gestational diabetes, which develops in pregnancy.” Dr. Alen Cameron Consultant OB at Queen Mother’s Hospital Glasgow
Diet advice • 1920-1975 women dieted thruout their pregnancies to make sure they did not gain more than 15-20 lbs. • Late 1970s: docs relaxed • 25-35, based on prepreg BMI • Women now healthier: vits, folic acid, avoid ETOH, tobacco, caffeine • Face the Nation 1971, chairman of Phillip Morris was confronted with evidence that smoking in pregnancy leads to LBW, he famously said “Some women prefer to have small babies.
Postterm • Spontaneous birth between 38 & 42 weeks is perfectly normal variation • Only about 3% of pregnancies go beyond 42 weeks • 1996 study looked at 1800 postdate pregnancies and found no increase in baby deaths as well as no increase in complications compared with babies born “on time” 38-42 weeks • Only about 10% of babies at more than 43 weeks get into trouble
Induction • In about 10% of all births there is a medical indication to induce labor with drugs, and before 1990 10% was the rate of induction in most industrialized countries.
Pitocin Synthetic version of the naturally occurring hormone oxytocin, has been used to induce labor for decades. It is approved by the FDA for this purpose after adequate, careful scientific assessment of its efficacy and risks, and we know a great deal about how best to use it.
Natural approaches to Induction • Sex • Nipple stim • Foods: spicy(capsasins counteract endorphins), chinese, eggplant parmesean(oregano & basil), licorice(glycyrrhizin), pineapple(acidity stimulates prostaglandins) • Herbs: black & blue cohosh, red rasp.leaf tea • Castor oil & evening primrose oil • Acupuncture: webbing between thumb and index finger, above ankle bone, between tip of shoulder & neck
cytotec Given that we already have a well-tested drug, why use cytotec? Pit is administered with IV drip Cytotec requires no IV, easier-pill or vag Cytotec comes in 100 and 200mcg tablets. After a decade of unauthorized experimenting, 25 mcg has emerged as the usual dose for labor induction. Ever try breaking a tablet without a line into quarters?
Pit vs Cytotec • Cytotec is quickly absorbed and stays in the body for hours • Whereas Pit IV has short half life and can be quickly stopped if problems arise • Cytotec costs less than other drugs used for induction (cheap because no research)
Catastrophe • June 1999 2 papers published in AJOG reported alarming rate of uterine rupture when using cytotec on women attempting VBAC • One study 5.6% of VBACs induced with cytotec had a rupture • In another study 3.7%. • This is a 28 fold increase in rate of uterine rupture over having a VBAC without cytotec induction.
Shut the barn door after thousands of horses were gone • ¼ women who had uterine rupture: resulted in death of their babies • Several months later ACOG came out with a position statement that Cytotec not be used for induction with women with previous c/s
Estimates of Risk of Uterine Rupture During Labor Normal (unscarred uterus) 1 in 33,000 births VBAC - no induction 1 in 200 births VBAC – Pit augmentation 1 in 100 births VBAC – Pit induction 1 in 43 births VBAC – Cytotec induction 1 in 20 births Normal unscarred uterus with cytotec induction – unknown Neurological injury or death of baby after uterine rupture-30% Death of woman after uterine rupture 1-2%
Where we are today • According to the CDC, the rate of drug-induced labor induction in U.S. births doubled from 10% to 20% in the 1990s. • An increase almost certainly due to the rampant use of cytotec. • A survey in 2002 showed that 44% of all births are induced with uterine stimulant drugs • Convenience factor is strong motivation to induce labor (God-send to a busy doc, convenient hospital “assembly line.)
Nursing Management of the Client undergoing Induction • Monitor: EFM • VS • Judicious increase of Pit • Terbutaline sc for hyperstimulation
Version • External Cephalic Version (ECV) • Podalic Version (Internal)
External (or cephalic) version of the fetus. A new technique involves applying pressure to the fetal head and buttocks so that the fetus completes a “backward flip” or “forward roll.”
Use of podalic version and extraction of the fetus to assist in the vaginal birth of the second twin. A, The physician reaches into the uterus and grasps a foot. Although a vertex birth is always preferred in a singleton birth, in this instance of assisting in the birth of a second twin it is not possible to grasp any other fetal part. The fetal head would be too large to grasp and pull downward, and grasping the fetal arm would result in a transverse lie and make vaginal birth impossible. B, While applying pressure on the outside of the abdomen to push the baby’s head up toward the top of the uterus with one hand, the physician pulls the baby’s foot down toward the cervix.
Both feet have been pulled through the cervix and vagina. D, The physician now grasps the baby’s trunk and continues to pull downward on the baby to assist the birth.
Nursing Management • Maternal/fetal assessments • NST • Lab studies • Psychological support • Education • Monitor VS
Nursing Management (continued) • EFM • Mediation administration – Beta-mimetics, RhoGAM
Uses of Amniotomy • Labor induction • Labor augmentation • Allow access to fetus and uterus to • Apply an internal fetal heart monitoring scalp electrode • Insert an intrauterine pressure catheter • Obtain a fetal scalp blood sample
Cervical Ripening: Prostaglandin E2 • Advantages • Cervical ripening • Shorter labor • Lower requirements for oxytocin during labor induction • Vaginal birth is achieved within 24 hours for most women • Incidence of cesarean birth is reduced
Cervical Ripening: Prostaglandin E2 (continued) • Risks • Uterine hyperstimulation • Nonreassuring fetal status • Higher incidence of postpartum hemorrhage • Uterine rupture
Labor Induction: Stripping Membranes • Advantages • Labor usually occurs in 24-48 hours • Disadvantages • Can be painful • Uterine contractions • Bloody discharge
Labor Induction: Oxytocin • Risks • Hyperstimulation of the uterus • Uterine rupture • Water intoxication • Nonreassuring fetal heart rate patterns
Labor Induction: Natural Methods • Sexual intercourse/lovemaking • Self or partner stimulation of the woman’s nipples and breasts • Use of herbs • Blue/black cohosh • Evening primrose oil • Red raspberry leaves
Labor Induction: Natural Methods (continued) • Use of homeopathic solutions • Caulophyllum or pulsatilla • Castor oil, enemas • Acupressure/acupuncture • Mechanical dilatation with balloon catheter
Amnioinfusion • Prevent the possibility of variable decelerations • Treat nonperiodic decelerations • Meconium dilution
Episiotomy • Types • Midline • Mediolateral
The two most common types of episiotomies are midline and mediolateral. A, Right mediolateral. B, Midline.
Epis Hartman and colleagues looked at 986 studies on epis conducted over the past 50 years, they found that the 3 main supposed benefits of epis: • Prevention of bad tears • Prevention of long-term damage to the floor of the woman’s pelvis • Protection of the baby from the adverse consequences of an extended labor are NOT supported by the evidence
They found women with epis had: • 26% greater chance of having a tear requiring suturing • 53% greater chance of having pain during sexual intercourse • Twice as likely to suffer fecal incontinence Evidence is clear: routine use of epis is not supported by the research and should stop.
Epis-EBP • 1995 review of best epis research by Cochrane Library found that “when done routinely, the procedure increases the trauma and complication of birth.” • UCSF Hospital (1990s) epis rate dropped from 80% to less than 10%, # of 3rd and 4th degree tears was cut in half, # of women without epis tripled • Mass General: end of 1990s rate fell to between 10 and 15%
Not so EBP • Mayo Clinic rate in 2002 was 60% • A survey of OB practices published in 2002 found nat’l epis rate of 35% • Agency for Healthcare Research and Quality (federal watchdog) found epis performed in 1/3 of all vag births (1 million epis/year) • 70% of all 1st time mothers undergo epis • General consensus among perinatal scientists and OBs that ideal rate is 5-10% of all vag births
Nursing Management • Support • Assist with communication of woman’s needs • Pain relief measures • Assessment • Education
Forceps-Assisted Birth: Maternal Indications • Heart disease • Acute pulmonary edema or pulmonary compromise • Certain neurological conditions • Intrapartal infection • Prolonged second stage • Exhaustion
Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone.