Slide 1		Defined as the stimulation of uterine contractions before spontaneous onset of labor Various reasons: DM, renal problems; Hx of rapid delivery; intraterine fetal demise. Contraindicated : active genital herpes, transverse fetal lie, prior classic uterine incision (vertical incision in upper portion of uterus); patient refusal Labor readiness: Determined by fetal maturity (LMP, EDC, US) Cervical readiness: Bishop’s score, a method of evaluation, scoring 0 – 3 on criteria including cervical dilation, effacement, consistency, position & fetal station. A score of 9 = favorable for induction.
Slide 2		Oxytocin initiates contractions or enhances ineffective contractions (labor augmentation). LR 1000ml with 10 units Pitocin infused at rate of 6 mL/hr; rate can be changed, based on protocol and careful assessment of contractions. Goal: contractions q 2 -3 mins, lasting 40 – 60 secs. Risks: hyperstimulation → hypertonic contractions with inc resting tone, ↓ placental perfusion, fetal distress, uterine rupture, H20 intoxication. Prostaglandin E2 – gel or tablets for cervical ripening (softening & effacing the cervix); Prepidil and Cervidil; vaginal birth within 24 hrs avg. Misoprostol: (Cytotec) synthetic prostaglandin E1 analogue in tablet form. Contraindicated in maternal asthma, Hx of uterine scar or bleeding; non-reassuring FHR tracing. Amniotomy – artificial ROM, most common operative procedure in OB. Amnihook inserted through cervix that is dilated to atleast 2 cm. May induce or augment labor or to insert a fetal internal monitor. Nursing management: observe FHR just before & after amniotomy & compare. Marked changes: cord prolapse. Assess fluid for amount, color, odor, presence of meconium. Cleanse perineum & change underpads. Refer to Drug guide, p 430 – 431. Refer to Clinical Pathways: fFor Induction of Labor pp 432 – 433.
Slide 3		Cover the following:
Slide 4		Amniotomy: explained Episiotomy: surgical incision of perineum to enlarge opening. Just before birth 3 to 4 cm of fetal head visible during contraction; incision made 2 types: midline & mediolateral (45 º ); with regional or local anesthetic. Nursing care: ice pack, frequent assessment for redness, tenderness, hematoma Recognize perineal pain continues for some time, 1 – 8 weeks. Do not discount this pain. Can interfere with breastfeeding
Slide 5		Forceps – surgical instruments for assisting birth by providing traction or the means to rotate the fetal head. Outlet, low, or midforceps Criteria: cervix completely dilated; ROM; known pelvis type, empty maternal bladder; no CPD present Baby can develop edema or ecchymosis, caput succedaneum or cephalhematoma, facial paralysis Adequate regional anesthesia: mother may feel pressure but no pain Figure 20-3, p 437 Vacuum assist: applying suction to the fetal head. Pump provides negative pressure under appropriately sized cup and traction is applied. Limit to 3 pulls, 20 – 30 mins Figure 20 – 4, p 438
Slide 6		Cesarean birth takes place through abdominal incision – 1 of oldest surgical procedures known. Popular during 1970’s, declined in late 80’s d/t costs! Up again; in 1999, 22% of births. Indicated for variety of maternal & fetal conditions: placenta previa or abruption, failure to progress, active genital herpes, cord prolapse, etc. Two types of incisions: transverse (Pfannensteil) in lowest, narrowest part of abdomen; requires more time to make & repair; almost invisible after healing Vertical - between navel & symphysis pubis: quicker; for fetal distress, macrosomia. Uterine incision depends on need for the C-sec. Inc risk for ruptured uterus in subsequent vaginal birth
Slide 7		PP recovery: VS q 5 mins till stable, then q 15 min for 1 hr, then q 30 mins till d/c to PP unit. Gently palpate fundus; IV Oxytocin to promote contractility; Turn, cough, deep breath q 2 hrs 24 hrs; monitor I & O. Observe color of urine: possibly nick bladder during surgery. Care of woman undergoing vaginal birth after Cesarean (VBAC): Trend: trial of labor after C-sec (TOLAC) Considerations: previous 1 -2 low transverse uterine incisions; Classic or T-incision is contraindication; adequate pelvis; anesthesia & surgical team available; physician STAT available
Slide 8		The nurse should develop a variety of means to promote comfort. Back rubs, hydrotherapy, encouragement for some Others: discomfort interferes with breathing & relaxation techniques. Pharmacologic methods may be used to ↓ comfort, ↑ relaxation, & reestablish pt’s sense of control. Cultural considerations: Developing Cultural competencies, p 382 Labor is painful; few can experience natural, painless childbirth. Maternal resp & O2 consumption affects O2 available to fetus. Pain & stress → metabolic acidosis & catecholamine release, → constriction & ↓ O2 to fetus. Couples planning to “go natural” during childbirth classes may be unable to cope with discomfort & feel guilty or inadequate. (C-phone: parking lot). Alternative methods: doula, hynotherapy, acupressure: discuss in class
Slide 9		Systemic analgesia crosses the placenta; must monitor for effects to fetus and potential effects to the newborn May cause labor to progress more rapidly. Narcan may be given. Nursing: monitor labor progress; evaluate effectiveness; SE If Narcan given, pt will indicate a return of pain. Narcan may be given to neonate if CNS depression noted. May demonstrate these effects up to 72 hrs /p delivery
Slide 10		Regional anesthesia: temporary loss of sensation produced by injecting anesthetic agent (local) into direct contact with nervous tissue. Most common types in OB: epidural, spinal, & combined epidural-spinal blocks. Epidurals are used for analgesia during vaginal births and anesthesia in C-sections. Absorption of agents depends on vascularity of area of injection. Usually hydrate woman well. Several types used. Most familiar with opiods used with epidural blocks: morphine, fentanyl, butorphanol, & meperidine. Various combinations are used. Reactions anesthetic agents: palpitations, tinnitus, metallic tase, N&V, itching; severe include hypotension, resp depression, cardiac arrest. Epidural: anesthetic injected into epidural space; usually used continuously; given as soon as active labor established. ADVANTAGES: woman fully awake; discomfort relieved; actively participates. DISADVANTAGES: maternal hypotension; less effective pushing; delay in return of bladder sensation CONTRAINDICATIONS: client refusal, maternal problems with blood coagulation, allergy to drug, hypovolemic shock. Nursing management: enc pt. to empty bladder; start large-bore IV; help woman to position for adequate spinal flexion; monitor for hypotension, HA, return of sensation; pruritis, resp depression
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Slide 12		Epidural narcotic after birth: provides narcotic analgesia for approx 24 hrs after birth. Anesthesiologists injects opioid such as morphine sulfate (Duramorph) into epidural space STAT /p birth. SE: pruritis, N&V, urinary retention. Resolves in 14 – 16 hrs. Drug guide: p 389 Spinal block: local anesthetic is injected into spinal fluid in spinal canal to provide anesthesia for C-sec, rarely for vag. ADVANTAGE: STAT onset of anesthesia, easy to administer, smaller dose, maintenance of muscle tone (+ or -) DISADVANTAGE: high incidence of maternal hypotension, → fetal hypoxia. CONTRAINDICATED in severe hypovolemia, CNS disease; infection over puncture site, + same as epidural Pudendal block – transvaginal administration; provides perineal anesthesia but no relief of contraction discomfort. Easy to administer, absence of maternal hypotension; no need to monitor FHR. May decrease urge to push; may perforate rectum or sciatic nerve Local anesthesia: injecting agent into areas of perineum for episiotomy incision or repair.
Slide 13		General anesthesia (induced unconsciousness) – for C sec or surgical intervention. Usually combination of IV injection & inhalation of anesthetic agents. Primary danger: reaches fetus in 2 mins → fetal resp depression. Causes uterine relaxation. Problem with food/liquids ingested: Gastric juices are highly acidic → chemical pneumonia if aspirated. Nursing mgmt: prophylactic antacid therapy common. Nonparticulate antacid such as Bicitra. Wedge under R hip to displace uterus and prevent vena caval compression. May need to assist: maintain cricoid pressure to occlude esophagus until endotracheal tube is placed by anesthesiologist.
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Slide 18		D.