PPN 301 wk 6: Labour at risk

Labour and Birth at risk

• Complications during labour increases  perinatal morbidity and mortality risks

• Complications may be anticipated or arises unexpectedly or due to unforeseen factors 

Caring for high risk clients require nurses to: (Labour at risk)

• Understand the normal birth process.

• Prevent and detect deviations from normal labour and birth.

• Implement nursing measures if complications arise.

Preterm labour

• cervical changes with uterine contraction occurring between 20-37 weeks

• Rate is higher among patients younger than 18 years of age or older than 35 years

Preterm Birth

• Any birth occurring before 37 weeks completion of pregnancy regardless of the weight of the infant (discuss in week 8 the preterm baby)

Risk factors for preterm labour

• History of previous spontaneous preterm birth between 16 and 36 weeks of gestation

• Family history of preterm labour

• African descent

• Genital tract infection

• Uterine anomaly

• Use of assisted human reproduction

• Cigarette smoking, substance misuse

• Periodontal disease

• Multifetal gestation

• Bleeding of uncertain origin in pregnancy

• Low prepregnancy weight

• Low socioeconomic status

• Lack of access to prenatal care

• High levels of personal stress in one or more domains of life

Causes of preterm labour

• Infections

• Vaginal bleeding

• Hormone changes

• Stretching of the uterus.

Signs and symptoms of Preterm labour

• Uterine activity

• Discomfort

• Vaginal discharge

Uterine activity (Signs and symptoms of preterm labour)

• Uterine contractions more frequent than every 10 minutes, persisting for 1 hour or more

• Uterine contractions painful or painless

Discomfort (Signs and symptoms of preterm labour)

• Lower abdominal cramping similar to gas pains; may be accompanied by diarrhea

• Dull, intermittent low back pain (below the waist)

• Painful, menstrual-like cramps

• Suprapubic pain or pressure

• Pelvic pressure or heaviness; feeling that “baby is pushing down”

• Urinary frequency

Vaginal discharge (Signs and symptoms of preterm labour)

• Change in character and amount of usual discharge: thicker (mucoid) or thinner (watery), bloody, brown or colourless, increased amount, odour

Nursing care (preterm labour)

• Early recognition and diagnosis is based on three major diagnostic criteria:

  • Gestational age between 20 and 36 6/7 weeks

  • Regular uterine activity, accompanied by a cervical change

  • Initial presentation with regular contractions and cervical dilation of 2 cm or greater

• Goal of is prevention- Preconception counselling 

• Prenatal-addressing of risk factors and health promoting activities  (good nutrition, exercise, stress management)

• Administration of prophylactic progesterone-daily vaginal suppositories or creams and weekly intramuscular injections to decrease the rate of preterm labour and birth 

Preterm interdisciplinary care

Early recognition and diagnosis is based on three major diagnostic criteria:

• Gestational age between 20 and 36 6/7 weeks

• Regular uterine activity, accompanied by a cervical change

• Initial presentation with regular contractions and cervical dilation of 2 cm or greater

Suppression of uterine activity

• Tocolytics –used suppress labour –(no specific medication approved in Canada)

Promotion of fetal lung maturity

• Antenatal glucocorticoids

  • to accelerate fetal lung maturity by stimulating fetal surfactant production.

Management of inevitable preterm birth

• Magnesium sulphate may be administered to reduce or prevent newborn neurological morbidity 

  • Nifedipine, indomethacin, magnesium sulphate

Educate patient about early symptoms of preterm labour.

• Stop what you are doing.

• Empty your bladder.

• Drink two to three glasses of water or juice.

• Lie down on your side for 1 hour.

• Palpate for contractions.

• If symptoms continue, call your health care provider or go to the hospital.

• If symptoms go away, resume light activity but not what you were doing when the symptoms began.

• If symptoms return, call your health care provider or go to the hospital.

• If any of the following symptoms occur, call your health care provider or go to the hospital immediately:

• Uterine contractions every 10 minutes or less for 1 hour or more

• Vaginal bleeding

• Fluid leaking from the vagina

Preterm premature rupture membranes

•  PROM-Is the spontaneous rupture of the amniotic sac and leakage of amniotic fluid beginning before the onset of labour at any gestational age.

• preterm PROM or pPROM - is the rupture of membranes before the completion of 37 weeks of gestation

  • associated with approximately 10% of all preterm births

Risk factors (Preterm premature rupture of membrance)

• History of prior preterm birth, especially if associated with preterm PROM

• History of cervical surgery or cerclage (suture to keep cervix closed)

• Urinary or genital tract infection

• Short (<25 mm) cervical length in the second trimester identified by transvaginal

• Ultrasound

• Preterm labour or symptomatic contractions in the current pregnancy

• Uterine overdistension

• Second- and third-trimester bleeding

• Pulmonary disease

• Connective tissue disorders

• Low socioeconomic status

• Low body mass index

• Nutritional deficiencies (copper and ascorbic acid)

• Cigarette smoking

Preterm premature rupture of membrane interdisciplinary care

• Based on estimated risk of maternal, fetal, and newborn complications

• Term pregnancy- induction if labour begin spontaneously

• 34-36 conservative management if there is low risk of intrauterine infection 

• Before 32 weeks-expectant or conservative allow fetal lung maturity and complication associated with preterm birth

  • Not recommended if is there intrauterine infection, significant vaginal bleeding, placental abruption, advanced labour, or atypical or abnormal fetal assessment

• Nonstress test (NST) and biophysical profile (BPP) to determine fetal health status and estimate amniotic fluid volume 

• Antenatal corticosteroid administered to patients at 24 to 34 + 6 weeks gestation 

• 7-day course of broad-spectrum antibiotics (e.g., ampicillin/amoxicillin and erythromycin) 

• magnesium sulphate is given for fetal neuroprotection in preterm PROM less than 34 weeks of gestation

Nursing care (Preterm premature rupture of membrane)

• support of the patient and family is critical at this time due to anxious about the health of the baby and fear they be responsible in some way for the membrane rupture.

• Encouraging expression of feelings and concerns, and providing information

• Inform patient to count fetal movements daily, because a slowing of fetal movement is a precursor to severe fetal compromise. 

• Patients should feel six movements in 2 hours; if they do not, further antenatal testing (NST, BPP, or both) is required 

• Monitor and educate signs of infection is a major part of nursing care and patient education after preterm PROM

  • ever, foul-smelling vaginal discharge, maternal and fetal tachycardia) should be reported immediately to the primary health care provide

• Educate patient to keep the genital area clean and that nothing should be introduced into the vagina.

Maternal complications of PROM

• Chorioamnionitis-bacterial infection of the amniotic cavity

  • is the most common maternal complication of preterm PROM

Associated with: (Chorioamnionitis Maternal complications of PROM)

• prolonged membrane rupture

• multiple vaginal examinations

• use of internal FHR and contraction monitoring modes

• young maternal age

• low socioeconomic status (which may be associated with no or minimal prenatal care), 

• Nulliparity

• Pre-existing infections of the lower genital tract 

Management (Chorioamnionitis Maternal complications of PROM)

• intravenous (IV) broad-spectrum antibiotics (ampicillin or penicillin and gentamicin) 

  Plus clindamycin or metronidazole (Flagyl)(kills bacteria) after c-section

  • Placental abruption

  • Retained placenta and hemorrhage Sepsis and death. 

Fetal complications (Complications of Premature rupture of membranes

• intrauterine infection

  Cord prolapse and umbilical cord compression associated with oligohydramnios

Post term or postdate pregnancy  

• Pregnancy that goes beyond the end of week 42 of gestation, or more than 294 days from the first day of the last menstrual period (LMP).

Risk factors (Post term or postdate pregnancy)

• first pregnancy, prior post-term

• pregnancy, a male fetus, obesity

• genetic predisposition 

Maternal risks (Post term or postdate pregnancy)

• Labour dystocia 

• severe perineal injuries

• Chorioamnionitis

• Endomyometritis

• postpartum hemorrhage

• Caesarean birth

• Anxiety 

These are associated with a significant risk for morbidity during the intrapartum period

Fetal risks (Post term or postdate pregnancy)

• Macrosomia or small for gestational age 

  • Shoulder dystocia

• Birth trauma 

• Asphyxia

• Oligohydramnios-common

  • Cord compression → affects the blood supply

    • Abnormal FHR

• Risk compromise fetal due “aging” placenta

  • Still birth 

• meconium-stained amniotic fluid, meconium aspiration, 

• Low Apgar scores

• Convulsions in the newborn 

• Monitor the count of baby movements (5-6 movement in 2 hr)

(Post term or postdate pregnancy)

• Antepartum fetal assessment beginning at 41 weeks of gestation

  • daily fetal movement counts, NSTs, AFV assessments, contraction stress tests, BPPs, and Doppler flow measurements

• Patient teaching 

  • Perform daily fetal movement counts.

  • Assess for signs of labour.

  • Call your primary health care provider if your membranes rupture or if you perceive a decrease in or no fetal movement. 

  • Keep appointments for fetal assessment tests or cervical checks.

  • Go to the hospital soon after labour begins

• Birth is recommended after 42 weeks and by 42 + 6 weeks of gestation to decrease the risk for perinatal morbidity and mortality 

Dystocia

• Abnormally slow progress of labour

  • Greater than 4 hours of less than 0.5 cm per hour of cervical dilation in active labour OR

  • Greater than 1 hour of active pushing with no descent

Causes (Dystocia)-Five P’s of labour

• Ineffective uterine contractions or bearing-down efforts (the powers); the most common cause of dystocia

• Alterations in the pelvic structure, including abnormalities of the labouring patient’s bony pelvis or soft-tissue abnormalities of the reproductive tract (the passageway)

• Fetal causes, including abnormal presentation or position, anomalies, excessive size, and number of fetuses (the passenger)

• Position of patient during labour and birth

• Psychological responses of the patient to labour that are related to past experiences, preparation, culture and heritage, and support system

Complications of labour dystocia

• Fetal distress

• Risk of maternal and neonatal infection

• Postpartum hemorrhage

• Uterine rupture

• Increased risk of pelvic floor, genital, perineal trauma

• Increased risk of uterine or pelvic organ prolapse

• Increased risk obstetric fistula(hole) (vesico-vaginal of rectovaginal fistula) and incontinence

• Sacroiliac joint dislocation

Supportive care by a nurse is important:(Nursing Care for Dystocia)

• Health care team approach

• Electronic fetal monitoring (EFM)

• Ultrasonography-to identify potential labour complications related to the fetus (e.g., abnormal fetal position) or pelvis of the pregnant patient.

• Risk assessment is a continuous process to identify dysfunctional labour

• Prevention

Interventions is based on assessment and may include (Nursing Care for Dystocia)

• External cephalic version – if it doesnt work then if has to be removed through a c-section

• Cervical ripening

• Induction or augmentation of labour

• Operative procedures [forceps- or vacuum-assisted birth]

• Caesarean birth

Methods of Induction: Cervical ripening agents

• Chemical agents (prostaglandins E2): ripens the cervix, making it softer and causing it to begin to dilate and efface; it stimulates uterine contractions

• Cervidil  insert-placed transvaginally into the posterior fornix of the vagina. removed after 12 hours or at the onset of active labour or abnormal fetal heart rate and patterns occur.

• Prepidil Gel-administered through a syringe into the vaginal canal just below the internal cervical os.

Nursing care (Methods of Induction: Cervical ripening agents)

• Explain the procedure to the patient and family and obtain informed consent 

• Assess the patient and fetus before each insertion and during treatment

• Bring the Prepidil gel to room temperature just before administration avoid force with hot water or microwave 

• Keep the Cervidil insert frozen until just before insertion and warming is needed.

• Have the patient void before insertion.

• Assist the patient in maintaining a supine position with lateral tilt for at least 30 minutes after insertion of gel or for 2 hours after placement of insert.

• Allow the patient to ambulate after a recommended period of bed rest and observation

• Prepare to pull the string to remove the insert if significant adverse effects occur. Delay initiation of oxytocin for induction of labour for 6 hours after last instillation of gel or at least 30 to 60 minutes after removal of the insert

• Follow agency protocol for induction if ripening has occurred 

Methods of Induction: Mechanical

• Using mechanical dilators to ripen the cervix by stimulating the release of endogenous prostaglandins

• Balloon catheters (e.g., Foley catheter) is inserted through the intracervical canal

• Hydroscopic dilators-substances that absorb fluid from surrounding tissues and enlarge

Contraindications (Mechanical induction)

•  ( don’t put foley catheter in if…)

  • Low-lying placenta 

  • antepartum hemorrhage

  • rupture of membranes

  • evidence of lower tract genital infection

Balloon catheters (mechanical induction)

• is inserted through the intracervical canal

  • catheter balloon is inflated above the internal cervical os with 30 to 50 mL of sterile water. 

  • resulting pressure and stretching of the lower uterine segment and the cervix, stimulating the release of endogenous prostaglandins.

  • balloon will fall out when cervical dilation reaches approximately 3 cm or is removed after 24 hours have elapsed.

Hydroscopic dilators (Mechanical induction)

• substances that absorb fluid from surrounding tissues and enlarge

  • Laminaria tents (natural cervical dilators made from desiccated seaweed)  

  • Lamicel synthetic dilators containing magnesium sulphate 

    • inserted into the endocervix without rupturing the membranes

    • expand as fluid is absorb, causing cervical dilation and the release of endogenous prostaglandins. 

Management of cord prolapse

• Goal-relieving the pressure on the cord by elevation of the fetal presenting part.

• knee-to-chest position to relieve the pressure on the umbilical cord

• Manual decompression by the healthcare by gently elevation of the presenting part off the umbilical cord. 

• Placing client in a Trendelenburg or knee-chest position to aid in cord decompression. 

• Tocolytic - slow down uterine contractions to relieve pressure on the umbilical vessels and to improve placental perfusion

• protruding should be kept warm and moist prevent vasospasm of the umbilical arteries, contributing to fetal hypoxia

• Continuous fetal monitoring

• Caesarean section if cervix is not fully dilated or risk of fetal compromise is high 

Patients should be counseled to recognize cord prolapse

• Sudden gush of fluid followed by the feeling of vaginal pressure or fullness. 

• Seek immediate care

• assume a knee-chest position while waiting for help to arrive

 

Shoulder dystocia

• Is a condition in which the head is born but the anterior shoulder cannot pass under the pubic arch. 

• Fetopelvic disproportion caused by excessive fetal size (greater than 4 000 g) 

  •  macrosomia

• pelvic abnormalities

• prolonged second stage of labour

• history of shoulder dystocia with a previous birth

Collaborative care- first line interventions (Shoulder dystocia)

• McRoberts maneuver-legs are hyperflexed on the abdomen.

• Suprapubic pressure-applied over the anterior shoulder

  • Fundal pressure should be avoided 

• Gaskin manoeuvre (placing patient in all position with hands-and-knees position)

Complications (collaborative care- Shoulder dystocia)

• brachial plexus (Erb palsy) occurs in 10 to 20% and phrenic nerve injuries 

• fracture of the humerus or clavicle.

• Asphyxia 

Amniotic fluid embolism (AFE) or anaphylactoid syndrome of pregnancy 

• Introduction of amniotic fluid into the circulation of the labouring patient during labour, during birth, or within 30 minutes after birth.

• Respiratory distress

  • Restlessness

  • Dyspnea

  • Cyanosis

  • Pulmonary edema

  • Respiratory arrest

• Circulatory collapse

  • Hypotension

  • Tachycardia

  • Shock

  • Cardiac arrest

• Hemorrhage

  • Coagulation failure

  • Uterine atony

• mortality rate is 61% or higher

Risk factors (Amniotic fluid embolism (AFE) or anaphylactoid syndrome of pregnancy)

• advanced age, non-White race, placenta previa, pre-eclampsia, and forceps-assisted or Caesarean birth.

Interventions (Amniotic fluid embolism (AFE) or anaphylactoid syndrome of pregnancy)

• Oxygenate.

  • Administer oxygen by nonrebreather face mask (10 L/min) or resuscitation bag delivering 100% oxygen.

  • Prepare for intubation and mechanical ventilation.

  • Initiate or assist with cardiopulmonary resuscitation. Tilt pregnant patient 30 degrees to side to displace uterus.

• Maintain cardiac output and replace fluid losses.

  • Position patient on their side.

  • Administer IV fluids.

  • Administer blood: packed cells, fresh frozen plasma.

  • Insert in-dwelling catheter and measure hourly urine output.

• Correct coagulation failure.

• Monitor fetal and maternal status.

• Prepare for emergency birth once patient’s condition has stabilized.

• Provide emotional support to the patient, partner, and family.

Induction of Labour

Chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about the birth

High priority indications (Induction of labour)

• Pre-eclampsia > 37 weeks

• Significant maternal disease not responding to treatment

• Significant but stable antepartum hemorrhage

• Chorioamnionitis

• Suspected fetal compromise

• Term prelabour rupture of membranes (PROM) with maternal group B streptococcus (GBS) colonization

Other indications (Induction of labour)

• Postdates (> 41 + 0 weeks) or post-term (> 42 + 0 weeks) pregnancy

• Uncomplicated twin pregnancy > 38 weeks

• Diabetes mellitus (glucose control may dictate urgency)

• Alloimmune disease at or near term

• Intrauterine growth restriction

• Oligohydramnios

• Gestational hypertension > 38 weeks

• Intrauterine fetal death

• PROM near or at term (GBS negative)

• Logistical issues (history of fast labour, distance from the hospital)

• Intrauterine demise in previous pregnancy (to allay anxiety)

Contraindications (induction of labour)

• Suspected fetal macrosomia

• Absence of fetal or maternal indication

• Caregiver or patient convenience

Methods of Induction:Mechanical and physical methods

• sexual intercourse (prostaglandins in the semen and stimulation of contractions with orgasm)

• nipple stimulation (release of endogenous oxytocin from the pituitary gland)

• ambulation/walking (gravity applies pressure to the cervix, which stimulates the secretion of endogenous oxytocin)

Amniotomy (Methods of Induction: Alternative and Amniotomy)

• artificial rupture of membranes [AROM]

  • Initiated when the:

    • the presenting part of the fetus should be engaged and well applied to the cervix. 

    • there is no active infection of the genital tract (e.g., herpes) 

    • HIV status is negative or viral load is low 

  • Labour usually begins within 12 hours of the rupture. 

  • Difficulty to predict outcome of labour and time of birth after amniotomy

  • For this reason, amniotomy often is used in combination with oxytocin induction and timing 

  Amniotic fluid assess

  • colour, odour, amount, and consistency  meconium or blood

Alternative (Methods of Induction: Alternative and Amniotomy)

• Blue cohosh and castor oil for labour-stimulation effects 

• Black cohosh and evening primrose oil to ripen the cervix. 

• effects of these alternative methods are not well researched,

Amniotomy complications (Methods of Induction: Alternative and Amniotomy)

• Chorioamnionitis resulting from prolonged rupture without labor. 

• Variable FHR deceleration patterns may due occur due to cord compression resulting from umbilical cord prolapse or decreased amniotic fluid.

Oxytocin

• Stimulates uterine contractions

  Used for induction or augmentation of labour

  • Administered IV in saline or lactated Ringers via a pump 

  • rate of oxytocin infusion should be continually titrated to the lowest dose that achieves acceptable labour progress. Usually the oxytocin dose can be decreased or discontinued after rupture of membranes and in the active phase of first-stage labour

  • goal of oxytocin administration is to produce acceptable uterine contractions as evidenced by a consistent pattern of three to five contractions every 10 minutes.

Indications for oxytocin

• Suspected fetal jeopardy (e.g., intrauterine growth restriction)

• Inadequate uterine contractions; dystocia

• Prelabour rupture of membranes

• Post-term pregnancy

• Chorioamnionitis

• Medical concerns in pregnant patient (e.g., severe Rh isoimmunization, inadequately controlled diabetes, chronic renal disease, or chronic pulmonary disease)

• Gestational hypertension (e.g., pre-eclampsia, eclampsia)

• Fetal death

Contraindications for oxytocin

• Abnormal fetal heart rate

• Cephalopelvic disproportion, prolapsed cord, transverse lie

• Placenta previa or vasa previa

• Prior classic uterine incision or other uterine surgery

• Active genital herpes infection

• Invasive cancer of the cervix

• Previous uterine rupture

Reportable condition (immediate) (administering oxytocin)

• Uterine tachysystole (with or without FHR changes)

• Abnormal fetal heart rate and pattern (absent baseline variability and any of the following: 

  • recurrent late decelerations,

  • recurrent variable decelerations

  • bradycardia

  • prolonged decelerations

• Suspected uterine rupture

• Inadequate uterine response at 30 mU/min

Nursing Care during oxytocin administration

• Assess level of the labouring patient’s discomfort and pain and the effectiveness of pain management.

• Monitor fetal status using electronic fetal monitoring and evaluate tracing 

• Monitor the contraction pattern and uterine resting tone 

• every 15 minutes and with every change in dose during the first stage of labour and every 5 minutes during the second stage of labour.

• Monitor blood pressure, pulse, and respirations every 30 to 60 minutes and with every change in dose.

• Assess intake and output; limit IV intake to 1 000 mL in 8 hours; urine output should be 120 mL or more every 4 hours.

• Monitor for adverse effects, including nausea, vomiting, headache, and hypotension.

• Observe emotional responses of labouring patient and their partner.

Measures if any reportable conditions should occur (Oxytocin administration)

• Discontinue use of oxytocin per hospital protocol and notify primary care provider immediately:

• Turn patient onto lateral position (side).

• Give IV bolus if patient is hypovolemic or hypotensive.

• If there is evidence of hypoxia or hypovolemia in the patient, administer oxygen by nonrebreather face mask at 8 to 10 units/min or per protocol or primary health care provider’s order. Oxygen is reserved for maternal resuscitation in the presence of maternal hypoxia or hypovolemia, NOT for fetal resuscitation.

• Prepare to administer nitroglycerine, if ordered, to decrease uterine activity.

• Continue monitoring fetal heart rate and pattern and uterine activity.

Augmentation of Labour

Stimulation of uterine contractions after labour has started spontaneously but progress is unsatisfactory.

• Implemented for management of hypotonic uterine dysfunction

• Common augmentation methods

  • Oxytocin infusion

  • Amniotomy

  • Noninvasive methods-emptying the bladder, ambulation, position changes, relaxation measures, nourishment, hydration, and hydrotherapy

• Active management of labour

External cephalic version (ECV)

Manual turning of at fetus from breech or transverse to vertex

Contraindications

• Multiple fetus e.g. twin

• Non-assuring fetal status 

• Placenta previa

Complications (External cephalic version-ECV)

• Prelabor rupture of membranes

• Changes in the fetus's heart rate

• Placental abruption

• Placenta previa

• Preterm labor

• PROM 

• Cord prolapse

• Multiple gestation

• Oligohydramnios

• uteroplacental insufficiency

• fetomaternal hemorrhage

• CPD

• Nuchal cord

• spontaneous conversion back to breech

• High rate of cesarean delivery—up to 64% 

Required assessment before External cephalic version (ECV)

• Determine the fetal position

• Locate the umbilical cord

• Rule out placenta previa

• Detect multiple gestation, oligohydramnios, or fetal abnormalities

• Measure fetal dimensions

Maternal indications (Operative Vaginal Births: Forceps-assisted birth)

• Prolonged second stage of labour or need to shorten the second stage of labour for maternal reasons (e.g., exhaustion or cardiopulmonary or cerebrovascular disease)

Fetal indications (Operative Vaginal Births: Forceps-assisted birth)

• Abnormal FHR tracing, abnormal presentation

• Arrest of rotation

• Delivery of head in a breech presentation

Key considerations (Operative Vaginal Births: Forceps-assisted birth)

• Membranes must be ruptured

• Assessment of adequacy of pelvis relation fetal head circumference 

• fully dilated cervix with head engaged 

• Empty bladder

Nursing care (Operative Vaginal Births: Forceps-assisted birth)

Postpartum and newborn assessment

• assessed for vaginal and cervical lacerations

• bleeding due to lacerations

• urinary retention due to bladder injuries or urethral injuries; hematoma formation in the pelvic soft tissues

• assessed newborn for bruising or abrasions at the site of the blade applications

• facial palsy resulting from pressure of the blades on the facial nerve (cranial nerve VII)

• subdural hematoma.

Operative Vaginal Births: Vacuum Assisted Birth 

• Attachment of vacuum cup to fetal head, using negative pressure to assist birth of head

• Indications-similar to forceps delivery

• Risk to newborn: cephalhematoma,    scalp lacerations, subdural hematoma

Nursing care (Operative Vaginal Births: Vacuum Assisted Birth)

• FHR monitoring 

• Newborn assessment for signs of trauma, infection and cerebral irritation (seizures, lethargy, increased irritability or poor feeding)

Caesarean Birth

• Birth of a fetus through a transabdominal incision of the uterus

• Cuts

  • vertical through the skin

  • horizonta through the skin (first skin crease under hairline)

• incidence of Caesarean births has increased, from 17.6% in 1993 to 28.8% in 2017–2018

  • Elective

  • Scheduled

  • Unplanned

  • Forced

Elective cesarean birth

•  primary Caesarean birth without medical or obstetrical indication

Scheduled cesarean birth

• Labour and vaginal birth are contraindicated

Unplanned cesarean birth

• changes in labouring patient’s and family expectations

Forced cesarean birth

•  to protect the well-being of both the labouring patient and the fetus

Maternal indications (cesarean birth)

• specific cardiac disease

• specific respiratory disease

• conditions with intercranial pressure

• mechanical obstructions history of 2 or more c/s

• elective caesarean birth

Fetal indications (cesarean birth)

• abnormal fetal heart rate or patterns

• malpresentation

• active maternal herpes lesions

• maternal HIV

• congenital abnormalities

Maternal-Fetal indications (cesarean birth)

• dysfunctional labour (cephalopelvic disproportion)

• placental abruption

• placenta previa

Trial of labour after caesarean : TOLAC

• A patient who has had a previous low-segment Caesarean birth may be a candidate for a TOLAC

• Contributes to successful vaginal birth after Caesarean (VBAC) of approximately 60 to 80%. 

Indications for  primary Caesarean birth (Trial of labour after caesarean)

• Dystocia

• breech presentation

• abnormal FHR pattern often are nonrecurring.

Contraindications (Trial of labour after caesarean-TOLAC)

• Previous or suspected classical uterine incision

• Previous inverted T or low vertical uterine incision

• Previous uterine rupture

• Previous major uterine surgery

• Patient requests repeat Caesarean birth

• Inability to perform an emergency Caesarean birth if necessary

Nursing care (Trial of labour after caesarean-TOLAC)

• Be alert for signs of potential complications

• Provide for psychological and physical needs of patient

• Review preoperative and post operative care