Intrrapartum Nursing Care

What is External Cephalic Version (ECV)?

• A procedure used to manually turn a fetus from:

  • Breech

  • Transverse

  • Oblique

• Into a cephalic (head-down) position

• Done to reduce the need for a cesarean birth

When is External Cephalic Version performed?

• After 37 weeks gestation

• Performed in the operating room

• Only when fetal and maternal status are stable

What nursing assessments are required before ECV?

• Nonstress test (NST) to assess fetal well-being

• Confirm gestational age ≥ 37 weeks

• Review maternal history

• Assess psychosocial readiness of the patient

What medications or tools are used during ECV?

• Tocolytic medication → relaxes the uterus

• Ultrasound → guides fetal movement

• Rho(D) immune globulin (RhoGAM) if mother is Rh-negative

What are the major risks of External Cephalic Version?

• Umbilical cord entanglement

• Abruptio placentae

• Mixing of fetal and maternal blood

• Uterine rupture

What conditions contraindicate External Cephalic Version?

• Uterine malformations

• Previous cesarean or vertical uterine incision

• Placenta previa

• Oligohydramnios

• Ruptured membranes

• Nuchal cord

• Multifetal gestation

• Fetal size ≥ 4000 g

• Cephalopelvic disproportion

What is Induction of Labor?

• Artificial initiation of labor

• Used when continuing pregnancy is riskier than delivery

What is Augmentation of Labor?

• Strengthening or speeding up labor that has already started

• Used when contractions are inadequate or ineffective

When is induction or augmentation indicated?

• Gestation > 39 weeks

• Maternal complications

• Fetal complications

What are the risks of induction or augmentation of labor?

• Hypertonic uterine activity (tachysystole)

• Uterine rupture

• Maternal water intoxication

• Chorioamnionitis

• Cesarean birth

What is the Bishop score used for?

• Determines if the cervix is favorable for labor

• Higher score = more favorable cervix

When is cervical ripening required?

• When a patient is being induced

• Bishop score < 8

What is cervical ripening?

• The process of softening, thinning, and dilating the cervix

• Done to improve success of labor induction

What medications are used for pharmacologic cervical ripening?

• Prostaglandins / Misoprostol

• Often used before oxytocin

• May be oral or vaginal

When is misoprostol contraindicated?

• Previous cesarean birth

• Risk of uterine rupture

What must the nurse monitor for during pharmacologic cervical ripening?

• Uterine tachysystole

• Changes in fetal heart rate

What methods are used for mechanical cervical ripening?

• Balloon catheter

• Laminaria

• Membrane stripping

What are the risks of mechanical cervical ripening?

• Increased risk of infection

• Decreased risk of uterine tachysystole

How is oxytocin administered safely?

• Diluted in isotonic solution

• Given as secondary (piggyback) infusion

• Inserted into the lowest (proximal) port

What is the nurse’s FIRST action with uterine tachysystole or nonreassuring FHR while on oxytocin?

• STOP the oxytocin infusion immediately

• Then reposition (sidelying) , give IV bolus, oxygen, and notify provider

What is amniotomy (AROM)?

• Artificial rupture of membranes

• Manual tearing of the amniotic sac

• Performed by a physician or nurse-midwife

Why is an amniotomy performed?

• Induce labor

• Augment labor

• Allow internal fetal monitoring

What tool is used to perform an amniotomy?

• Amnihook

• Used to snag and tear the membranes

What is the MOST serious risk of amniotomy?

• Umbilical cord prolapse

What other risks are associated with amniotomy?

• Infection

• Abruptio placentae

  • Higher risk with polyhydramnios

What nursing assessment is required BEFORE amniotomy?

• Baseline fetal heart rate

• Assessed 20–30 minutes before procedure

What should the nurse assess AFTER amniotomy?

• Amniotic fluid color, amount, and odor

• Normal: clear

• Abnormal: green, purulent, bloody

What nursing actions help prevent infection after amniotomy?

• Pericare

• Monitor maternal temperature at least every 2 hours

What is amnioinfusion?

• Infusion of normal saline or lactated Ringer’s into the uterus

• Used to reduce variable decelerations

What are key nursing considerations for amnioinfusion?

• Membranes must be ruptured

• Use room-temperature fluid

• Monitor FHR and contractions

• Prevent uterine overdistention

• Monitor vaginal fluid output

What is a vacuum-assisted birth?

• Operative vaginal delivery

• Uses a cup-like suction device on the fetal head

• Traction applied during contractions to assist delivery

What conditions MUST be met for vacuum-assisted birth?

• Vertex (cephalic) presentation

• Cervix fully dilated (10 cm)

• No cephalopelvic disproportion (CPD)

• Ruptured membranes (ROM)

When is vacuum-assisted birth indicated?

• Maternal exhaustion

• Ineffective pushing

• Fetal distress in second stage with low station

When is vacuum-assisted birth contraindicated?

• Before 34 weeks gestation

• Risk of intracranial injury

What is a forceps-assisted birth?

• Operative vaginal delivery

• Uses curved spoon-like metal blades

• Traction applied during contractions

What are additional indications for forceps-assisted birth?

• Arrest of rotation

• Abnormal fetal positioning

• Maternal exhaustion

• Fetal distress in second stage

What nursing preparations are needed for vacuum or forceps birth?

• Empty bladder

• Cervix fully dilated & ROM

• Adequate anesthesia

• Continuous fetal monitoring

• Explain procedure to patient

• Request neonatal support

What are neonatal risks of vacuum or forceps delivery?

• Scalp laceration

• Cephalohematoma

• Subdural hematoma

• Facial nerve palsy (forceps)

What is an episiotomy?

• Surgical incision of the perineum

• Posterior aspect of the vulva

• Performed during second stage of labor

What nursing care is needed after an episiotomy?

• Monitor for hematoma and edema

• Ice packs

• Sitz baths

• Pain medication as ordered

• Assist with bowel movements & positioning

What is a cesarean birth?

• Surgical delivery of a fetus through a transabdominal incision

• Performed when vaginal birth is unsafe for mother or fetus

What are the major indications for cesarean birth?

• Malpresentation

• Cephalopelvic disproportion (CPD)

• Nonreassuring fetal status

• Placental abnormalities (previa, abruption)

• Umbilical cord prolapse

• Dystocia

• Multiple gestations

• Congenital malformations

What maternal or fetal conditions may require cesarean birth?

• Risk to fetus

  • HIV+ with high viral load

  • Active genital herpes

• Risk to patient

  • Preeclampsia

  • Diabetes

  • Cardiac disease

What are the maternal risks of cesarean birth?

• Aspiration

• Amniotic fluid embolus

• Wound infection or dehiscence

• Hemorrhage

• Urinary tract trauma/infection

• Thrombophlebitis & thromboembolism

• Bowel or bladder injury

• Paralytic ileus

• Atelectasis

• Anesthesia complications

What are the newborn risks of cesarean birth?

• Inadvertent preterm birth

  • Lung immaturity = greatest risk

• Traumatic injury

What incisions are used in cesarean birth?

• Skin incisions

  • Pfannenstiel (low transverse)

  • Vertical

• Uterine incisions

  • Low transverse (preferred)

  • Low vertical

  • Classical (highest rupture risk)

What are the nursing roles during a cesarean birth?

• Circulator nurse

  • Time out

  • Verify procedure & counts

  • Assist outside sterile field

• Scrub nurse

  • Maintain sterility

  • Assist with counts & surgery

• Baby nurse

  • Receive & resuscitate newborn

  • Promote bonding

What is VBAC (Vaginal Birth After Cesarean)?

• Vaginal delivery after a previous cesarean birth

• Requires strict criteria for safety

Who is an appropriate candidate for VBAC?

• One or two low transverse prior C-sections

• No other uterine scars or rupture history

• Adequate pelvimetry

• No contraindications (LGA, CPD, malpresentation, prior classical C-section)

What are some nursing considerations for VBAC?

• Monitor FHR and contractions

• Assess for uterine rupture

• Provide analgesia as ordered/requested