Chapter 15: Therapeutic Procedures to Assist With Labor and Delivery

What is an external cephalic version (ECV)?

An ultrasound-guided procedure that manually turns a breech or transverse fetus into a cephalic position.

When is an external cephalic version (ECV) typically performed?

At 37-38 weeks of gestation.

What are the indications for an external cephalic version (ECV)?

A breech or transverse fetal presentation near term.

What are contraindications to an external cephalic version (ECV)?

Placenta previa, nonreassuring fetal status, uterine anomalies, or any condition where vaginal birth is contraindicated.

What assessments are performed before an external cephalic version?

Ultrasound, nonstress test, fetal position, placental location, amniotic fluid amount, and fetal well-being.

What medication is commonly given before an external cephalic version?

Terbutaline to relax the uterus.

What should the nurse continuously monitor during and after an external cephalic version?

Fetal heart rate.

Which Rh medication should be administered after an external cephalic version to an Rh-negative client?

Rho(D) immune globulin.

What is the purpose of the Bishop score?

To determine whether the cervix is favorable for labor induction.

What five components make up the Bishop score?

Dilation, effacement, cervical consistency, cervical position, and fetal station.

What Bishop score indicates the cervix is favorable for induction?

8 or greater.

What is cervical ripening?

Softening, thinning, and dilating the cervix before labor induction.

What mechanical methods are used for cervical ripening?

Balloon catheter, membrane stripping, and amniotomy.

Which medications are used for cervical ripening?

Misoprostol and dinoprostone.

What should be done before administering cervical-ripening agents?

Obtain informed consent, baseline maternal/fetal assessment, and have the client void.

What position should a client remain in after placement of a vaginal prostaglandin insert?

Side-lying or recumbent for 30 minutes to 2 hours.

What should be removed before starting oxytocin induction?

Vaginal prostaglandin inserts.

What adverse effects can prostaglandins cause?

Nausea, vomiting, diarrhea, fever, and uterine tachysystole.

What medication treats uterine tachysystole caused by prostaglandins?

Subcutaneous terbutaline.

What nursing interventions are appropriate for nonreassuring fetal status?

Left lateral position, increase IV fluids, oxygen if indicated, and notify the provider.

What is the purpose of oxytocin induction?

To stimulate uterine contractions before spontaneous labor begins.

What is the earliest gestational age for elective induction?

39 weeks.

What are common indications for oxytocin induction?

Postterm pregnancy, PROM, IUGR, diabetes, hypertension, fetal demise, infection, and Rh isoimmunization.

How should oxytocin be administered?

As a secondary IV infusion using an infusion pump.

How often should fetal heart rate be monitored during oxytocin induction in the first stage of labor?

Every 15 minutes.

How often should fetal heart rate be monitored during the second stage while receiving oxytocin?

Every 5 minutes.

What is the desired contraction pattern with oxytocin?

Every 2-3 minutes, lasting 40-70 seconds, with soft resting tone between contractions.

When should oxytocin be discontinued?

If uterine tachysystole or nonreassuring fetal heart rate occurs.

What findings indicate uterine tachysystole?

More than 5 contractions in 10 minutes, contractions longer than 90 seconds, or no uterine relaxation.

What are the nursing interventions for uterine tachysystole?

Stop oxytocin, reposition to side-lying, increase IV fluids, administer oxygen if indicated, notify provider, and give terbutaline if ordered.

What are signs of nonreassuring fetal heart rate?

Baseline less than 110 or greater than 160 bpm, decreased variability, and late or prolonged decelerations.

What is augmentation of labor?

Stimulating contractions after spontaneous labor has started but is progressing inadequately.

What is an amniotomy?

Artificial rupture of membranes (AROM).

What must occur before an amniotomy?

The fetal head must be engaged.

Why is fetal engagement important before an amniotomy?

To reduce the risk of umbilical cord prolapse.

What should the nurse assess immediately before and after an amniotomy?

Fetal heart rate.

What should the nurse document after an amniotomy?

Time of rupture and characteristics of amniotic fluid.

How often should maternal temperature be monitored after an amniotomy?

At least every 2 hours.

What is an amnioinfusion?

Infusion of warmed normal saline or lactated Ringer's into the uterus through an intrauterine catheter.

What is the purpose of an amnioinfusion?

To relieve umbilical cord compression and reduce variable decelerations.

What is the major indication for amnioinfusion?

Variable decelerations caused by umbilical cord compression.

What must be true before an amnioinfusion can be performed?

The membranes must be ruptured.

What should the nurse monitor during an amnioinfusion?

FHR, uterine tone, contractions, and fluid return.

When can a vacuum-assisted birth be performed?

Second stage of labor with complete dilation and ruptured membranes.

What are indications for vacuum-assisted birth?

Maternal exhaustion, ineffective pushing, or nonreassuring fetal heart rate.

What newborn complications are associated with vacuum extraction?

Cephalohematoma, scalp lacerations, caput succedaneum, and subdural hematoma.

What maternal complications are associated with vacuum extraction?

Cervical, vaginal, or perineal lacerations.

What conditions must be present before forceps are used?

Complete dilation, ruptured membranes, and engaged fetal head.

What newborn complications are associated with forceps?

Facial bruising, facial nerve palsy, and subdural hematoma.

What maternal complications are associated with forceps?

Cervical, vaginal, bladder, or perineal injury.

What is a first-degree laceration?

Involves only the skin.

What is a second-degree laceration?

Involves skin and perineal muscles.

What is a third-degree laceration?

Extends into the anal sphincter.

What is a fourth-degree laceration?

Extends into the rectal wall.

Why is an episiotomy performed?

To enlarge the vaginal opening and facilitate birth.

Which type of episiotomy is most commonly performed?

Median (midline).

Which episiotomy has a greater risk for third- and fourth-degree tears?

Median (midline).

Which episiotomy causes more pain and blood loss?

Mediolateral.

What are common indications for cesarean birth?

Placenta previa, abruptio placentae, breech, cephalopelvic disproportion, fetal distress, prolapsed cord, previous cesarean, active genital herpes, and multiple gestation.

What nursing actions are performed before a cesarean birth?

Obtain consent, start IV, insert Foley catheter, monitor FHR, apply SCDs, prepare the surgical site, and maintain NPO status if ordered.

What postoperative assessments are priorities after a cesarean birth?

Incision, fundus, lochia, infection, urinary output, thrombophlebitis, and pain.

What nursing interventions help prevent postoperative complications after a cesarean birth?

Ambulation, coughing and deep breathing, splinting the incision, SCDs, and pain management.

What maternal complications can occur after a cesarean birth?

Hemorrhage, infection, thrombophlebitis, UTI, wound dehiscence, bowel or bladder injury, and anesthesia complications.

What does TOLAC stand for?

Trial of labor after cesarean.

What does VBAC stand for?

Vaginal birth after cesarean.

Who is a good candidate for VBAC?

A client with one or two previous low-transverse cesarean incisions, no uterine rupture history, an adequate pelvis, and no contraindications to vaginal birth.

What is the major complication of a trial of labor after cesarean?

Uterine rupture.

What should the nurse monitor closely during a VBAC?

Fetal heart rate, contraction pattern, and signs of uterine rupture.