Exam 2 -- OB Procedures

What is an amniotomy?

What is an amniotomy?

AROM!! When the amniotic sac is ruptured by the provider.

What are indications for an amniotomy?

Starting labor (induce)
Accelerate the process (augmentation)
To apply the FSE (fetal scalp electrode)
Application of IUPC
Assessment of amniotic fluid

What are the risks associated with an amniotomy?

- PROLAPSED CORD! the BOW is no longer keeping the cord free of tension and might slip out.
- INFECTION -- chorioamnionitis (maternal, fetal/neonatal -- infection can be vertically transmitted from mom to fetus)
- Need for C section!

What are the nursing care actions for an amniotomy?

FHR
Document TACO -- time, amount, color, odor
Temp q 2 hrs!!!
Comfort, explain, teach

What is an amnioinfusion?

Infusion of sterile normal saline (NS) or Lactated Ringer's solution warmed to body temperature through an intrauterine catheter into the uterine cavity (adds a BUFFER!!)

What are indications for an amnioinfusion?

Variable decels! (Are caused by cord compression!)
Oligohydramnios (decreased fluid)
Meconium-stained fluid (indicated BM in utero -- danger in the mouth if inhaled, so we want to water it down to decrease the lung irritation -- and might be THICK so we want to dilute it!)

What are nursing care actions for amnioinfusion?

Administer the infusion per orders (WARMED!!)
Maternal assessment of VS and UC's
Continuous EFM!
Comfort measures--can be messy!

What is the difference between induction and augmentation?

Induction is the stimulation of contractions before spontaneous onset of labor, with or without ruptured membranes, for the purpose of accomplishing VAGINAL birth

Augmentation is the stimulation of contractions when spontaneous contractions have already begun, BUT are NOT causing progressive dilation or descent. (we want to make them stronger and more frequent!)

What is LABOR (withdrawl of _____)

a withdrawl of inhibitory mechanisms of pregnancy -- vs. the stimulation of the uterus to cause contractions

Labor initiation -- what is the Parturition cascade's 4 phases?

IMSI !

Phase 0 - INHIBITION of contractions during pregnancy (supression)

Phase 1 - MYOMETRIAL activation (priming as term approaches)

Phase 2 - STIMULATION (by uterotonic agents -- oxy, prostos)

Phase 3 - INVOLUTION (days and weeks following from oxytocin)

What are indications for induction?

Post dates
Pre-E
Premature or prolonged ROM
Chorioamnionitis
Signs of fetal stress -- via non-reactive NST, etc.
IUGR
Fetal demise
Medical problems

Elective inductions ARE HIGHLY DISCOURAGED!!! You need a reason!

What are indications for augmentation?

Labor progression (contractions) have slowed
Labor progression (contractions) have STOPPED
Contraction strength has weakened
---> Dosing often needs less pitocin needed than with induction!

What are contraindications to augmentation or induction?

Don't induce if the delivery should not be vaginal! (Contracindications to spontaneous labor and vaginal birth)

Placenta previa
Vasa previa or velamentous umbilical cord (CORD DOWEN OVER OS, a type of cord without jelly and turned -- respectively)
Certain pelvic abnormalities
Prior classic (vertical) uterine incision
Active genital herpes infection
Some instances of HIV positive status
Abnormal fetal position

What are risks of augementation/induction?

Tachysystole -- fetal distress (6+ UC's in 10 min)
Uterine rupture
Water intoxication from oxytocin
Cesarean delivery -- if induction fails

When are outcomes improved for induction?

OUTCOMES IMPROVED WHEN
- fetal maturity is more than 39 weeks
- Cervical readiness is present via BISHOP SCORE

BISHOP SCORE: how is the scoring set up (categories), what scores are favorable for labor? Favorable score for primips, multips?

Categories all have a score from 0-2 or 0-3, with 3 being the closest to spontaneous labor characteristics.

Categories:
Dilation
Effacement
Fetal station
Cevical consistency
Cervical position

FAVORABLE -- score of 8 (similar to spontaneous labor!)
Favorable FOR PRIMPS -- score of 7
Favorable for MULIPS -- score of 5

BISHOP SCORE BREAKDOWN:
How is dilation scored?

0 = 0cm
1 = 1-2cm
2 = 3-4cm
3 = 5-6cm

BISHOP SCORE BREAKDOWN:
How is effacement scored?

0 = 0-30%
1 = 40-50%
2 = 60-70%
3 = 80+%

BISHOP SCORE BREAKDOWN:
How is fetal station scored?

0 = -3
1 = -2
2 = -1 or 0
3 = +1 or +2

BISHOP SCORE BREAKDOWN:
How is cervical consistency scored? (0-2)

0 - firm
1 - medium
2 - soft

BISHOP SCORE BREAKDOWN:
How is cervical position scored? (0-2)

0 = posterior
1 = middle
2 = anterior

What are some holistic methods of induction/augmentation?

nipple stimulation -- causes oxytocin release
herbs -- black cohash, raspberry tea
intercourse/orgasm -- prostoglandin and oxytocin release
castor oil/enemas -- diarrhea
acupuncture

What are the drugs that cause cervical ripening?

Cervical ripening = PROSTOGLANDIN DRUGS!
- Dinoprostone (includes prepidil and cervadil)
- Misoprostone (Cytotec)

How do the drugs for cervical ripening differ?

- Dinoprostone (includes prepidil and cervadil)
---> PREPIDIL: a gel placed vaginally hard to remove, patient must lay for 30 min
---> CERVADIL: vaginal insert with controlled release, patient must lay for 2 hours, easy to remove, but very expensive
- Misoprostone (Cytotec): Tablets placed vaginally, also given orally or sublingual. Least expensive, most common, and can be used for PPH or as a uterotonic.

What are nursing care actions when giving cervical ripening agents?

- Continuous FHR and UC monitoring
- Prostoglandins contraindicated for women who have had a prior C-section (TOLAC -- we do not want to strengthen the force of contractions, TOLAC women just lead to let nature go!)
- Potential side effects?
--- tachysystole
--- Category II or III FHR
--- Diarrhea

What are mechanical methods of cervical ripening? What are their side effects?

Devices placed into the cervix to help it dilate and cause prostoglandin release!

-- Foley cath balloon --left in place for 6-12 hours to cause pressure on the cervix and the lower uterine segment

-- Laminaria, Lamicil, Dilipan
--> Laminaria is seaweed that can has stem expand 5x the width (dilate/expand the cervix)

Pitocin is considered a _____________ medication! What is it used for? What are adverse reactions?

High-alert medication

USED FOR:
induction
augmentation
prevent PPH
treat PPH

ADEs:
Tachysystole or excessive uterine activity
Maternal fluid retention, water intoxication (already puff and get puffier!)

What are the typical concentrations of oxytocin and their infusion rates?

10 units of oxytocin in 1000 mL LR!
- Infuse at 1mU/min or 6 mL/hr

20 units of oxytocin in 1000 mL LF
- infuse at 1mU/min or 3 mL/hr

What are the typical dosing ranges for induction and augmentation with oxytocin?

Induction is a low dose, and augmentation is even lower!

1-20 mU/min titrated to 3 UC's in 10 min, with 40-60 sec durations
-- start low 1-2mU/min then slowly increase 3-6 mL/hr

Start low, go slow, this can kill the fetus

What is the typical dosing of oxytocin for PPH?

HIGHER DOSES AND CONC!

10-40 UNITS in 1000ml LR
Can run around 125 ml/hr
IV or IM!

What are nursing care actions for oxytocin? What is the goal for UC's?

GOAL: 3 contractions within 10 min lasting 40-60 seconds, but avoid tachysystole 6+!!

- oxytocin piggybacked into a main line for induction and augmentation -- always using an INFUSION PUMP!
- Low doses, careful titration, this is a huge area of liability
- Continuous FHR monitoring, and UC's measurement
- Monitor the resting tone of the uterus (should be 5-15 mmHg)
- Monitor labor progression with SVE for dilation, effacement, and fetal descent
- assess I and O -- watch for fluid retention as an antidiuretic
- assess pain/provide pain mgmt

What counts as tachysystole? What are nursing care actions for tachysystole?

6 or more contractions in 10 min, averaged over 30 min
Contractions lasting greater than 2 min
Uterine resting tone more than 20 mmHg

INTERVENTIONS:
**Discontinue pitocin!!!
Reposition
IV fluid bolus
O2 per mask
Notify provider
Maybe give terbutaline (as ordered) (tocolytic)

What are the indications for episiotomy?

Shoulder dystocia
Breech presentation
Forceps or vacuum extraction
OP position

What are risks associated with episiotomy?

3rd or 4th degree laceration
increased blood loss
infection
PP pain
Dyspareunia (pain with intercourse)

What are nursing care actions for an episiotomy?

SAME AS FOR A LACERATION!
- advocacy, pain control, support, assess
- prevention: positioning, natural pushing, perineal massage, warm compresses, counter pressure, mineral oil
- comfort measures: ice pack, pain meds, analgesic spray, pericare, sitz bath after 24 hrs, kegal exercises!

What is a vacuum assisted birth? What is a forceps assisted birth?

Vacuum = cup to fetal head creates negative pressure, 15% of the time causes cephalohematoma, can rip head

Forceps = traction to pull out or rotate to OA
can be OUTLET FORCEPS (help when scalp is visible) or can be LOW FORCEPS (help when baby is still pretty far in there)

What are the indications for both vacuum and forceps?

- Maternal conditions (Heart disease, pulmonary edema, infection, exhaustion, regional anesthesia, elective)
- Prolonged second stage of labor
- Fetal conditions (fetal malpresentation -- OP, fetal distress, premature placental separation)

What are the risks for both vacuum and foreceps?

MATERNAL:
- lacerations of birth canal -- 3rd or 4th degree
- increased bleeding
- bruising, edema

FETAL:
- eccymosis/edema/marks on face
- caput seccedaneum or cephalohemalatoma leading to hyperbilirubinemia (vacuum)
- transient facial paralysis (forceps)

MAX pop-off's = 3 can cause intracranial hemorrhage

What is the ideal incision method for C-sections, what is not?

ideal = horizontal, low
Not ideal but needed in emergencies? vertical, low or higher up

What are indications for C-section?

Labor arrest (1/3 of the time!)
Nonreassuring fetal tracing
Malpresentation
Multiple gestation
Maternal-fetal
Macrosomia
Pre-E
Maternal request
Repeat C-section
Others!

What are the risks associated with a C-section?

This is major abdominal surgery!
- maternal mortality
- maternal morbidity
----> respiratory comp, infections, blood clots, bleeding (PPH), anesthetic reactions
- feelings of failure
- neonatal respiratory issues (don't get the squeeze!)
- placental implantation issues in future pregnancies

What are nursing care actions for a C-section? (NOT in the OR)

informed consent and NPO, labs should be ordered and baseline vitals should be known...
There should be a baseline FHR nonstress test
IV fluid preload
Chlorhexidine bath prior and after
Abdominal prep/vaginal prep
Apply SCDs
Give meds as ordered, antacids, antibiotics just prior to surgery (prevent endometritis -- infection of the uterus)

Read box 19.2 in slides

What are nursing care actions in the OR?

Teach/reassure, complete surgical checklists, time out called before procedure begins, Peds/NICU team should be notified and in attendance, ID bands placed on the newborn, allow parents to see, touch, and hold newborn (skin to skin)

VBAC and TOLAC -- what do we worry about? What type of incision is used? What do we give/not give?

VBAC and TOLAC -- we worry about the high risk for UTERINE RUPTURE!
- <1% uterine scar tear or ruture (but still sometimes not worth it)
- rates of VBAC have declines

Requires: LOW transverse uterine incision (horizontal)

Bishops score is the best predictor of its success, surgical team should be able to perform C/S if needed tho.

WE do NOT give PROSTAGLANDINS to ripen the cervix!

What is the external version procedure? What criteria must be met for it to be done?

When the fetus is changed from a breech or transverse lie to a cephalic presentation by external manipulation of the maternal abdomen.
- Best at term (37+) but can be 34-36 (early) weeks gestation--however they might end of flipping back...
- Baseline NST must be reactive, healthy
- Can be Fetal breech, but not engaged into the pelvis
- Must be adequate amniotic fluid

What is needed for an external version procedure?

IV line!
Terbutaline SQ given -- tocolytic bc we don't want to start contactions when we try to move baby...
FHR monitoring
Ultrasound monitoring
Epidural? Pain control of some sort.

A patient is having an amniotomy to induce labor. The nurse recognizes that the priority intervention after the amniotomy is to __________

assess FHR!

When inducing labor, how many contractions do we want in a period of time?

3/10 min period, 40-60 sec. duration while titrating from 1-20mU/min