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Birth-Related Procedures

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Birth-Related Procedures Impact of Procedures on Childbearing Woman Disappointment Guilt Conflict between expectation and need for intervention Macrosomia/PROM ... – PowerPoint PPT presentation

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Title: Birth-Related Procedures


1
Birth-Related Procedures
2
Impact of Procedures on Childbearing Woman
  • Disappointment
  • Guilt
  • Conflict between expectation and need for
    intervention

3
Spontaneous Labor
4
The decision to induce labor is not one to be
taken lightly
5
The decision to bring pregnancy to an end is one
of the most drastic ways of intervening in the
natural process
6
Certain specific conditions under which inducing
labor has been shown to save lives
  • Serious IUGR
  • Documented placental insufficiency
  • Deteriorating pre-eclampsia

7
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8
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9
Macrosomia/PROM
  • Macrosomia has been used as an excuse for
    induction, but data do not support this
  • PROM how long is safe to wait?

10
Postterm
  • Spontaneous birth between 38 42 weeks is
    perfectly normal variation
  • Only about 3 of pregnancies go beyond 42 weeks
  • 1996 study looked at 1800 postdate pregnancies
    and found no increase in baby deaths as well as
    no increase in complications compared with babies
    born on time 38-42 weeks
  • Only about 10 of babies at more than 43 weeks
    get into trouble

11
Induction
  • In about 10 of all births there is a medical
    indication to induce labor with drugs, and before
    1990 10 was the rate of induction in most
    industrialized countries.

12
Pitocin
  • Synthetic version of the naturally occurring
    hormone oxytocin, has been used to induce labor
    for decades.
  • It is approved by the FDA for this purpose after
    adequate, careful scientific assessment of its
    efficacy and risks, and we know a great deal
    about how best to use it.

13
Natural approaches to Induction
  • Sex
  • Nipple stim
  • Foods spicy(capsasins counteract endorphins),
    chinese, eggplant parmesean(oregano basil),
    licorice(glycyrrhizin), pineapple(acidity
    stimulates prostaglandins)
  • Herbs black blue cohosh, red rasp.leaf tea
  • Castor oil evening primrose oil
  • Acupuncture webbing between thumb and index
    finger, above ankle bone, between tip of shoulder
    neck

14
Bishops Score
15
cytotec
  • Given that we already have a well-tested drug,
    why use cytotec?
  • Pit is administered with IV drip
  • Cytotec requires no IV, easier-pill or vag
  • Cytotec comes in 100 and 200mcg tablets. After a
    decade of unauthorized experimenting, 25 mcg has
    emerged as the usual dose for labor induction.
  • Ever try breaking a tablet without a line into
    quarters?

16
Pit vs Cytotec
  • Cytotec is quickly absorbed and stays in the body
    for hours
  • Whereas Pit IV has short half life and can be
    quickly stopped if problems arise
  • Cytotec costs less than other drugs used for
    induction (cheap because no research)

17
Catastrophe
  • June 1999 2 papers published in AJOG reported
    alarming rate of uterine rupture when using
    cytotec on women attempting VBAC
  • One study 5.6 of VBACs induced with cytotec had
    a rupture
  • In another study 3.7.
  • This is a 28 fold increase in rate of uterine
    rupture over having a VBAC without cytotec
    induction.

18
Shut the barn door after thousands of horses were
gone
  • ¼ women who had uterine rupture resulted in
    death of their babies
  • Several months later ACOG came out with a
    position statement that Cytotec not be used for
    induction with women with previous c/s

19
Estimates of Risk of Uterine Rupture During Labor
  • Normal (unscarred uterus) 1 in 33,000 births
  • VBAC - no induction 1 in 200 births
  • VBAC Pit augmentation 1 in 100 births
  • VBAC Pit induction 1 in 43 births
  • VBAC Cytotec induction 1 in 20 births
  • Normal unscarred uterus with cytotec induction
    unknown
  • Neurological injury or death of baby after
    uterine rupture-30
  • Death of woman after uterine rupture 1-2

20
VBAC Complications
21
Where we are today
  • According to the CDC, the rate of drug-induced
    labor induction in U.S. births doubled from 10
    to 20 in the 1990s.
  • An increase almost certainly due to the rampant
    use of cytotec.
  • A survey in 2002 showed that 44 of all births
    are induced with uterine stimulant drugs
  • Convenience factor is strong motivation to induce
    labor

22
Nursing Management of the Client undergoing
Induction
  • Monitor EFM
  • VS
  • Judicious increase of Pit
  • Terbutaline sc for hyperstimulation

23
Version
  • External Cephalic Version (ECV)
  • Podalic Version (Internal)

24
External (or cephalic) version of the fetus. A
new technique involves applying pressure to the
fetal head and buttocks so that the fetus
completes a backward flip or forward roll.
25
Use of podalic version and extraction of the
fetus to assist in the vaginal birth of the
second twin. A, The physician reaches into the
uterus and grasps a foot. Although a vertex birth
is always preferred in a singleton birth, in this
instance of assisting in the birth of a second
twin it is not possible to grasp any other fetal
part. The fetal head would be too large to grasp
and pull downward, and grasping the fetal arm
would result in a transverse lie and make vaginal
birth impossible. B, While applying pressure on
the outside of the abdomen to push the babys
head up toward the top of the uterus with one
hand, the physician pulls the babys foot down
toward the cervix.
26
Both feet have been pulled through the cervix and
vagina. D, The physician now grasps the babys
trunk and continues to pull downward on the baby
to assist the birth.
27
Nursing Management
  • Maternal/fetal assessments
  • NST
  • Lab studies
  • Psychological support
  • Education
  • Monitor VS

28
Nursing Management (continued)
  • EFM
  • Mediation administration Beta-mimetics, RhoGAM

29
Uses of Amniotomy
  • Labor induction
  • Labor augmentation
  • Allow access to fetus and uterus to
  • Apply an internal fetal heart monitoring scalp
    electrode
  • Insert an intrauterine pressure catheter
  • Obtain a fetal scalp blood sample

30
Cervical Ripening Prostaglandin E2
  • Advantages
  • Cervical ripening
  • Shorter labor
  • Lower requirements for oxytocin during labor
    induction
  • Vaginal birth is achieved within 24 hours for
    most women
  • Incidence of cesarean birth is reduced

31
Cervical Ripening Prostaglandin E2 (continued)
  • Risks
  • Uterine hyperstimulation
  • Nonreassuring fetal status
  • Higher incidence of postpartum hemorrhage
  • Uterine rupture

32
Labor Induction Stripping Membranes
  • Advantages
  • Labor usually occurs in 24-48 hours
  • Disadvantages
  • Can be painful
  • Uterine contractions
  • Bloody discharge

33
Labor Induction Oxytocin
  • Risks
  • Hyperstimulation of the uterus
  • Uterine rupture
  • Water intoxication
  • Nonreassuring fetal heart rate patterns

34
Labor Induction Natural Methods
  • Sexual intercourse/lovemaking
  • Self or partner stimulation of the womans
    nipples and breasts
  • Use of herbs
  • Blue/black cohosh
  • Evening primrose oil
  • Red raspberry leaves

35
Labor Induction Natural Methods (continued)
  • Use of homeopathic solutions
  • Caulophyllum or pulsatilla
  • Castor oil, enemas
  • Acupressure/acupuncture
  • Mechanical dilatation with balloon catheter

36
Amnioinfusion
  • Prevent the possibility of variable decelerations
  • Treat nonperiodic decelerations
  • Meconium dilution

37
Episiotomy
  • Types
  • Midline
  • Mediolateral

38
The two most common types of episiotomies are
midline and mediolateral. A, Right mediolateral.
B, Midline.
39
Epis
  • Hartman and colleagues looked at 986
    studies on epis conducted over the past 50 years,
    they found that the 3 main supposed benefits of
    epis
  • Prevention of bad tears
  • Prevention of long-term damage to the floor of
    the womans pelvis
  • Protection of the baby from the adverse
    consequences of an extended labor
  • are NOT supported by the evidence

40
They found women with epis had
  • 26 greater chance of having a tear requiring
    suturing
  • 53 greater chance of having pain during sexual
    intercourse
  • Twice as likely to suffer fecal incontinence
  • Evidence is clear routine use of epis is not
    supported by the research and should stop.

41
Epis-EBP
  • 1995 review of best epis research by Cochrane
    Library found that when done routinely, the
    procedure increases the trauma and complication
    of birth.
  • UCSF Hospital (1990s) epis rate dropped from 80
    to less than 10, of 3rd and 4th degree tears
    was cut in half, of women without epis tripled
  • Mass General end of 1990s rate fell to between
    10 and 15

42
Not so EBP
  • Mayo Clinic rate in 2002 was 60
  • A survey of OB practices published in 2002 found
    natl epis rate of 35
  • Agency for Healthcare Research and Quality
    (federal watchdog) found epis performed in 1/3 of
    all vag births (1 million epis/year)
  • 70 of all 1st time mothers undergo epis
  • General consensus among perinatal scientists and
    OBs that ideal rate is 5-10 of all vag births

43
Nursing Management
  • Support
  • Assist with communication of womans needs
  • Pain relief measures
  • Assessment
  • Education

44
Forceps-Assisted Birth Maternal Indications
  • Heart disease
  • Acute pulmonary edema or pulmonary compromise
  • Certain neurological conditions
  • Intrapartal infection
  • Prolonged second stage
  • Exhaustion

45
Application of forceps in occiput-anterior (OA)
position. A, The left blade is inserted along the
left side wall of the pelvis over the parietal
bone.
46
The right blade is inserted along the right side
wall of the pelvis over the parietal bone.
47
With correct placement of the blades, the handles
lock easily. During uterine contractions,
traction is applied to the forceps in a downward
and outward direction to follow the birth canal.
48
Forceps-Assisted Birth Fetal Indications
  • Premature placental separation
  • Prolapsed umbilical cord
  • Nonreassuring fetal status

49
Types of Forceps
  • Outlet forceps
  • Midforceps
  • Breech forceps

50
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51
Fetal Risks
  • Ecchymosis, edema, or both along the sides of the
    face
  • Caput succedaneum or cephalhematoma
  • Transient facial paralysis
  • Low Apgar scores
  • Retinal hemorrhage
  • Corneal abrasions

52
Fetal Risks (continued)
  • Ocular trauma
  • Other trauma (Erbs palsy, fractured clavicle)
  • Elevated neonatal bilirubin levels
  • Prolonged infant hospital stay

53
Maternal Risks
  • Lacerations of the birth canal
  • Periurethral lacerations
  • Extension of a median episiotomy into the anus
  • More likely to have a third- or fourth-degree
    laceration
  • Report more perineal pain and sexual problems in
    the postpartum period
  • Postpartum infections

54
Maternal Risks (continued)
  • Cervical lacerations
  • Prolonged hospital stay
  • Urinary and rectal incontinence
  • Anal sphincter injury
  • Postpartum metritis

55
Nursing Management
  • Explains procedure to woman
  • Monitors contractions
  • Informs physician/CNM of contraction
  • Encourages woman to avoid pushing during
    contraction
  • Assessment of mother and her newborn
  • Reassurance

56
Indications for Vacuum Extraction
  • Prolonged second stage of labor
  • Nonreassuring heart rate pattern
  • Used to relieve the woman of pushing effort
  • When analgesia or fatigue interfere with ability
    to push effectively
  • Borderline CPD

57
Vacuum Extraction Procedure
  • Procedure
  • Suction cup placed on fetal occiput
  • Pump is used to create suction
  • Traction is applied
  • Fetal head should descend with each contraction

58
The cup is placed on the fetal occiput, creating
suction. Traction is applied in a downward and
outward direction.
59
Traction continues in a downward direction as the
fetal head begins to emerge from the vagina.
60
Traction is maintained to lift the fetal head out
of the vagina
61
Nursing Management
  • Inform woman about procedure
  • Pumps the vacuum
  • Supports the woman
  • Assesses the mother and neonate for complications

62
Neonatal Risks with Vacuum Extraction
  • Scalp lacerations and bruising
  • Shoulder dystocia
  • Subgaleal hematomas
  • Cephalhematomas
  • Intracranial hemorrhages
  • Subconjunctival hemorrhages

63
Neonatal Risks with Vacuum Extraction (continued)
  • Neonatal jaundice
  • Fractured clavicle
  • Erbs palsy
  • Damage to the sixth and seventh cranial nerves
  • Retinal hemorrhage
  • Fetal death

64
Maternal Risks with Vacuum Extraction
  • Perineal trauma
  • Edema
  • Third- and fourth-degree lacerations
  • Postpartum pain
  • Infection
  • More sexual difficulties in the postpartum period

65
Cesarean Birth
66
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67
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68
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69
c/s
  • More common than tonsillectomy or appendectomy
  • Risks
  • Baby nicked by scapel
  • Increased liklihood of difficulty with initail BF
    attempts
  • Pain can supress mild production
  • Mom more prone to PPD, infertility and placenta
    abnormalities in future pregnancies
  • Previa, acreta and abruption can lead to
    hemorrhage

70
Julius?
71
Indications for Cesarean Birth
  • Complete placenta previa
  • CPD
  • Placental abruption
  • Active genital herpes
  • Umbilical cord prolapse
  • Failure to progress in labor

72
Indications for Cesarean Birth (continued)
  • Proven nonreassuring fetal status
  • Benign and malignant tumors that obstruct the
    birth canal
  • Breech presentation
  • Previous cesarean birth
  • Major congenital anomalies
  • Cervical cerclage

73
Indications for Cesarean Birth (continued)
  • Severe Rh isoimmunization
  • Maternal preference for cesarean birth

74
This transverse incision in the lower uterine
segment is called a Kerr incision.
75
The Sellheim incision is a vertical incision in
the lower uterine segment.
76
This view illustrates the classic uterine
incision that is done in the body (corpus) of the
uterus. The classic incision was commonly done in
the past and is associated with increased risk of
uterine rupture in subsequent pregnancies and
labor.
77
Impact on the Family
  • Stress and anxiety
  • Sense of loss of vaginal birth experience
  • Fear
  • Relief

78
Preparation for Cesarean Birth
  • Preoperative teaching
  • Coughing and deep breathing
  • Splinting
  • What to expect

79
Nursing Management Before Cesarean Birth
  • Assisting with the epidural
  • Monitoring maternal vital signs and fetal heart
    rate
  • Inserting an indwelling urinary catheter
  • Preparing the abdomen and perineum
  • Making sure that all necessary personnel and
    equipment are present
  • Positioning the woman on the operating table

80
Risks
  • Even with elective c/s, no emergency, 2.84 fold
    greater chance than vag birth of resulting in the
    womans death
  • Estimated that 12 American women die every year
    because of unnecessary elective c/s
  • Anesthesia, hemorrhage, infection, adhesions
  • Infertility, ectopics, unexplained stillbirth,
    placenta problem
  • 2-6 of the time cut into baby

81
Nursing Management Before Cesarean Birth
(continued)
  • Supporting the couple
  • Instrument count

82
Nursing Management After Cesarean Birth
  • Normal newborn post-delivery care
  • Monitoring vital signs
  • Checking the surgical dressing
  • Palpating the fundus and checking lochia
  • Monitoring intake and output
  • Administration of oxytocin and pain management

83
Vaginal Birth After Cesarean (VBAC) Criteria
  • One previous cesarean birth and a low transverse
    uterine incision
  • An adequate pelvis
  • No other uterine scars or previous uterine
    rupture
  • An available physician who is able to do a
    cesarean
  • In-house anesthesia personnel

84
Vaginal Birth After Cesarean (VBAC) Risks
  • Uterine rupture
  • Stillbirths
  • Hypoxia

85
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