NU 330 - Exam 2 - PP 5 (Birth-Related Procedures & Pain Management)

Induction

• Stimulate uterine contractions before spontaneous onset of labor

• With or without ruptured membranes

• Indications: Post-dates, risk factors, fetal demise

• All contraindications to anticipated vaginal birth apply

• Fetal malposition, active herpes lesion, placenta previa, et

Augmentation

• Artificial stimulation of uterine contractions

• When spontaneous contractions failed to result in progressive cervical dilation or descent of fetus

Bishop Score

Care of the Woman During Cervical Ripening - Pharmacological Methods = Misoprostol (Cytotec)

• Synthetic prostaglandin E1

• Tablet

• Vaginal, oral, or sublingual

• Guidelines

• Obtain baseline VS and Non-Stress Test

• Fetal heart rate (FHR) and uterine activity (UA) monitored continuously

• Wait 4 hours after last dose of Cytotec to start IV Pitocin

Contraindications

•Nonreassuring FHR tracing

•Frequent moderately strong uterine contractions

•Prior cesarean birth or uterine scar

•Vaginal bleeding of unknown cause

Care of the Woman During Cervical Ripening - Pharmacological Methods = Dinoprostone

• Synthetic prostaglandin E2

• Obtain baseline VS and Non-Stress Test

• FHR and UA monitored continuously

• Cervidil 10mg 12-hour extended release

• Intravaginal insert placed near cervix by provider

• Resembles a fake fingernail with a long string

• Remove prior to 12 hours if: spontaneous rupture of membranes, active

labor onset, non-reassuring FHR, uterine hyperstimulation

Care of the Woman During Cervical Ripening - Pharmacological Methods = prostaglandin

• Advantages of prostaglandin administration

• Cervidil is easily removed

• Can shorten labor

• Lower requirements for oxytocin

• Many patient can achieve vaginal birth within 24 hours after its use

• Risks of prostaglandin administration

– Uterine hyperstimulation

– Nonreassuring fetal status

– Higher incidence of postpartum hemorrhage

– Uterine ruptur

*Care for all patients during cervical ripening and induction: Monitor for uterine tachysystole (hyperstimulation), defined as more than five contractions in 10 minute

Care of the Woman During Cervical Ripening - Mechanical Methods

Foley catheter or Cooks catheter

• 25–80 mL balloon

• Passed through cervical opening by provider

• Inflates balloon(s), pull slight tension and secure to thigh

• Weighted balloon applies pressure on internal os of cervix; assists with

ripening

• Can use with other induction methods (medication)

• Bedrest with bathroom privileges

Stripping amniotic membranes

• Performed by provider at prenatal appointment

Amniotomy (Artificial rupture of membranes--AROM)

• Performed by provider with amnihook during SVE

• Feasible with at least 1.5-2cm cervical dilation

• Fetal assessment and interventions

• Risk for cord prolapse if head not well applied to cervix

• FHR/UA assessed for 30 minutes prior and 30 minutes after and then per order (intermittent vs continuous)

• Maintain bedrest for 30 minute after procedure to ensure fetal head remains against cervix

• Assess fluid color initially and throughout labor

• Absorb fluid; Disposable under pads, towel

*Monitor maternal temp every 2 hours after ROM (due to increased risk of infection

Methods of Inducing or Augmenting Labor-- Pharmacological Methods

• Intravenous oxytocin (Pitocin) infusion procedure

• Effective method of initiating uterine contractions as induction or augmentation

• Assess before starting oxytocin infusion

• Maternal pelvis (provider documents this)

• SVE, fetal station, presentation

• Primary IV infusion of Lactated Ringers or 0.9 Normal Saline (per order)

• Risks

• Tachysystole of uterus (more than 5 contractions in a 10 minute time frame)

• Uterine rupture (higher risk if history of C/section)

Nipple stimulation

• Nipple stim can create contractions

• Stimulates natural release of oxytocin from the pituitary

-Decrease or stop the Pitocin

-Perform intrauterine resuscitation measures

Oxytocin infusion

• 10 or 20 milliunits of oxytocin/mL

• Hang as a primary bag of oxytocin (Pitocin) diluted in isotonic solution

• Must be controlled by IV pump

• Tubing attached to IV extension set (chicken foot) or lowest port

• This allows for quickly stopping the infusion if fetal intolerance or uterine tachysystole requires intrauterine resuscitation

RISKS:

• Prolonged contractions

• Precipitous (fast) delivery

• Lacerations of cervix, vagina or perineum

• Increased risk of PP hemorrhage due to fatigued uterus

• Fetal risks: Hypoxia, rapid molding could cause intracranial hemorrhage, “shocky” baby, increased bruising and petechaie on head and face

Nursing Care During Labor Induction

• For the expectant woman during labor induction

• Close observation (1:1 or 1:2)

• Maternal vital signs and assessments per provider orders and/or protocol

• Electronic fetal monitoring with reactive NST prior to beginning induction, remains reassuring

• Encourage movement and repositioning

• Ambulation

• Shower or tub bath

• Birthing ball, peanut ball

• Patient education

• Understand induction and care process

• Can relate advantages, disadvantages, risks, possible outcomes

• Have opportunity to have questions answered

Episiotomy vs. Laceration

• Enlarging the perineal opening

• Episiotomy; provider cuts perineal tissue

• Expected LGA fetus or fetal intolerance

• Prior to use of vacuum or forceps

• Mediolateral (A) vs. midline (B)

• Often deferred by providers today

• Episiotomies can extend into 3rd and 4th degree lacerations

• Perineal laceration; perineal tissue tears during delivery

• Local anesthetic can be given (1% Lidocaine) prior to episiotomy and/or repair

Episiotomy and Laceration Nursing Care

• During repair

• Provider will repair (stitch) while awaiting delivery of placenta

• If patient feeling discomfort, provide support and education

• Assessment during postpartum course

• Note redness, edema, bruising, possible hematoma (discoloration, firm, painful)

• Differentiate whether bleeding is from a laceration or lochia (laceration = bright red fresh bleeding with a firm uterus)

• Documentation with each assessment

• Pain relief measures

• Peri bottle (cleanse/spray perineum with water after toileting)

• Ice packs (first 24 hours), whirlpool baths, bidets or sitz baths

• Dermoplast spray (numbs the area

Care of the Woman During Vacuum Extraction

• Provider applies suction device to the fetal head to assist with delivery

• Mother must push along with use of vacuum extraction

• Indications

• Nonreassuring fetal heart rate

• Prolonged second stage of labor

• Maternal fatigue or ineffective pushing

• Also used in C/section if surgeon unable to pull head through incision

Nursing Care During Vacuum Extraction

• Continuous EFM

• Empty patient bladder prior to vacuum attempt

• Patient positioning

• RN assists provider by managing amount of suction on device, lowering mmHg between contractions

• If vacuum pops off the fetal head up to three times, the provider must stop using the vacuum

• Be prepared for STAT C/section if vacuum unsuccessful!

• Fetal/neonatal risks

• Lacerations, bruising

• Caput, cephalohematoma

• Measure head circumference frequently (per order/protocol)

• Blood sugar protocol

• Increased jaundice risk

• Maternal risks

• Perineal trauma

• Episiotomy vs. laceration

• Perineal edema

Application of Forceps. During Uterine Contractions, Traction is Applied to the Forceps in a Downward and Outward Direction to Follow the Birth Canal

-Be prepared for STAT C/section if forceps unsuccessful!

-The risks are similar to vacuum extraction, as well as additional risks to both mother and fetus during forceps delivery– refer to the textbook for these

The Nurse’s Role in Pain Relief

• Provide education about options

• Goal to provide attainable pain relief with minimal risk

• Offer alternative therapies if pharmaceuticals not desired

• Support changes in decision, advocate for the patient

• Reassure that accepting medication for pain is not failure

• Understand sources of maternal pain;

-Muscle hypoxia

-Stretching of the tissues

-Pressure of the presenting part

Pain acute:
-encourage relaxation & breathing exercises

-promote relaxation between contractions

-administer pain meds as ordered

-assist with epidural placement

-provide education, support and reassurance

What Patients Need to Know About Pain Relief Medications

Before receiving medications, the patient should understand:

• Type and route of medication administered

• Expected effects of medication

• Implications for fetus/newborn

• Safety measures needed (e.g., remain in bed with side rails up)

• Side effects/complications

• Analgesia: Absence of normal sense of pain (made tolerable, dulled, shortened, or relieved)

• Anesthetic: Partial of complete loss of sensation, with or without loss of consciousness

Common Analgesics Used in Labor

*Opiate Antagonist: Naloxone (Narcan) Maternal dose: IV, IM, or intranasal 0.4 mg IV over 15 second

Administration of Systemic Analgesia

• Given when patient reaches uncomfortable state with well- established labor pattern (cervical change and regular contractions)

• Multiple factors to consider

• Effects on labor contractions; will it space out contractions if given too early?

• Woman's medical status; example-- analgesia given to protect cardiac patient from increased stress

• Labor progress; if progressing quickly, may not be able to receive

• Fetal tolerance to labor; does the medication cross the placenta, and if so, how will it affect the fetus?

• Maternal hydration; hypotension quickly leads to maternal symptoms and decreased placental blood flow= fetal heart rate deceleratio

Administration of Systemic Analgesia

Routes of administration

• Oral not used

• Intravenous (IV) preferred PRIOR to administration, must assess:

• Vital signs

• Sterile vaginal exam (SVE)

• Cervical dilatation

• Cervical effacement

• Fetal presenting part and station

Sedatives for relaxation and/or sleep:

Barbiturates:

• Seconal or Ambien (10mg orally)

• Given at bedtime if hospitalized (antepartum or Cervadil induction)

Benzodiazepines:

• Valium or Versed

• Used for maternal anxiety during cesarean births or manual removal of placenta after vaginal birth

Regional Anesthesia

• Temporary, reversible loss of sensation

• Prevents transmission of nerve impulses

• Types

• Epidural

• Spinal

• Numbing agent added with narcotic agent

• Bupivicaine, Marcaine, or Lidocaine with Fentanyl

• Less risk than general anesthetic

• Requires signed consent

Adverse Maternal Reactions to Anesthetic Agents

• Mild and common side effects

• Itching

• Can impair ability to push

• Moderate reactions

• Hypotension

• Administer fluid bolus and Ephedrine per order

• Severe reactions

• Respiratory depression

• Raise head of bed to allow gravity to pull medicine down toward abdomen

• Allergic reactions

• Malignant hyperthermia (general anesthetic

Labor Epidural

• Injection and infusion of medication into the epidural space

• Complete pain relief obtained by bolus dose and maintained by continuous infusion per epidural catheter and infusion pump

Advantages

• High success rate for pain relief for remainder of labor process

• Patient fully awake with ability to push and deliver

• Epidural medication does not cross the placenta

• Dose of anesthetic agent can be adjusted per infusion pump

• If patient goes to C/section, epidural catheter can be used for dosing of anesthetic to numb abdomen for surgery

Disadvantages

• Anesthesiologist may not be on site, wait for arrival

• Maternal hypotension

• Costly (but can be covered by insurance)

• Onset of full analgesia may take up to 10-20 minutes

• Postdural puncture headaches (spinal HA– slightly common), seizures, meningitis (very rare)

Lumbar Epidural Insertion per Anesthesiologist

Once the needle enters the epidural space, a test dose is given to assess patient tolerance/reaction. The epidural catheter is then threaded through the needle and secured to the patient’s back with large tegaderm to keep it in place for continuous infusion until delivery

Potential side effects

• Maternal hypotension

• Bolus with IV fluid (500-1000mL) prior to procedure to minimize risk

• Common adverse effect within initial hour of administration (due to bolus)

• Patient may be asymptomatic or symptomatic

• Leads to uteroplacental insufficiency (late decelerations)

• Inadequate or unilateral block

• Pruritus

• Urinary retention

• Temperature elevation

Labor Epidural Nursing Care

• Have woman void prior to epidural procedure; then may need to straight cath every 3 hours or place Foley until completely dilated (10cm) and ready to push

• Frequently assess maternal VS and FHR per protocol

• Every 5 minutes after bolus then every 15 minutes

• Reposition patient; at at least every 2 hours to left and right lateral positions with HOB elevated 25 degrees

• Maintain IV infusion and epidural infusion per order

• Assistance with pushing (lifting and moving legs)

• Discontinue infusion and catheter after delivery

• Assess for return of sensation prior to ambulation

• Document

Pudendal Block

• Perineal anesthesia

• Used during second stage of labor, birth, episiotomy repair

• Administered by provider

• Decreases pressure and burning sensation

-The Pudendal Block is a good choice for patients who do not have an epidural. We used this more in the past before epidurals became more commonly used. Pudendals are also beneficial if we anticipate a long second (pushing) stage

Indications for C/section Delivery

• Failure to progress in labor

• Fetal intolerance to labor

• Nonreassuring fetal status

• Cephalopelvic disproportion (CPD)

• Placenta previa

• Placental abruption

• Umbilical cord prolapse

• Active genital herpes

• Malpresentation (breech, shoulder, brow, etc.)

• Multiple gestation (twins if not vertex/vertex)

• Maternal risk/health concern

• Fetal risk/health concern

• Suspected macrosomia (LGA)

• Scheduled repeat

C/section Maternal Mortality and Morbidity

Risks

• Infection (surgical site, uterus)

• Blood clots (DVT, PE), postpartum hemorrhage

• Ureter or bladder injury/laceration

• Wound dehiscence

• Formation of intraabdominal adhesions

• Future pregnancies: Increased risk for uterine rupture, especially if classical incision on uterus

• Risks similar to other abdominal surgical procedures

• Reactions to anesthesia agent

Anesthesia and Surgical Techniques for C/section Delivery

• Spinal Anesthesia

• High incidence of hypotension

• Begin C/section immediately after block achieved

• Greater potential for fetal hypoxia

• General Anesthesia

• Fetal depression

• Uterine relaxation (increased risk for bleeding)

• Potential for chemical pneumonitis

• Decrease in gastrointestinal motility

• Acidic gastric secretions

• Skin incisions

• Transverse

• Vertical

• Uterine incisions

• Lower uterine segment

• Transverse

• Vertical incision

• Classic incision

• Upper uterine segment

• Higher risk for uterine rupture with subsequent pregnancies

Nursing Care Management

• For the woman undergoing a Cesarean birth

• Preparation for cesarean birth

• Encourage all pregnant women, partners to discuss with obstetrician

• Possible preferences

• Participating in choice of anesthesia/pain relief

• Presence of partner during procedure (if patient is awake, not allowed if under general anesthesia)

• Clear sterile drape for parents to see the newborn delivered

• Physical contact or holding newborn while on operating table, recovery room

Nursing Care Management

• Supporting the father/partner/support person

• Must wear PPE (surgical gown, mask, shoe covers)

• Can sit beside woman’s head

• Is allowed in when appropriate spinal anesthetic is achieved, surgery is

already started

• Accompany newborn to the recovery room while surgeon finishes incision repair

• Encourage to call or go to patient room to announce to other family members the newborn’s arrival

Patient Education:

• Preparation for Cesarean birth

• Types of anesthesia

• General, spinal, Duramorph for post-op pain

• Sensations that may be experienced

• Pressure, pulling, nothing sharp or painful

• Interaction with newborn

• Breastfeed as soon as possible in recovery room

• Description of or viewing operating room

• Emergency cesarean birth

• Provide opportunity for further clarification

Care of the Family During Cesarean Birth

• Delivery of neonate through abdominal and uterine incision

• Cesarean birth rate; approximately 30%

• Anesthesia

• Spinal vs. general

• Goals include:

• Safety (what is least risk to both mother and neonate)

• Position supine on O.R. table with wedge under right hip

• Comfort

• Provide warm blanket

• Emotional satisfaction for patient

• Include significant other; can sit at head of patient if awa

Post-Op C/section Nursing Care

After patient returns from the PACU;

• Fundal assessments same as vaginal delivery (still at risk for hemorrhage)

• Palpate fundus: Determine if remaining firm

• Administer IV Pitocin (oxytocin) per order/postpartum dosage

• Assess per orders/protocol:

• Abdominal dressing, perineal pad

• Anesthesia level, pain assessment

• If had general anesthesia, assist with cough, deep breathing

• Same post-operative care as other patients

• SCD’s until able to be up ad lib

• Advance diet as tolerated

• Monitor bowel sounds and urine outp

Care of the Woman Undergoing TOLAC and VBAC

• Trial of labor after cesarean (TOLAC)

• Vaginal birth after cesarean (VBAC)

• American College of Obstetricians and Gynecologists (ACOG) guidelines

• One previous cesarean birth

• Low transverse uterine incision

• Available in-house anesthesia personnel if emergent repeat C/section is warranted

• NPO or minimal clear liquids orally

• Monitor previous incision

• Continuous EFM

Injury, risk for TOLAC

-maintain continous EFM

-be aware of symptoms of uterine rupture

-maintain ongoing uterine assessment

-assess for subjective symptoms of rising uterine tone