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Birth-Related Procedures

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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
Runaway gestational diabetes
  • According to the Guinness Book of Records the
    heaviest baby ever born weighed 29 lbs 4 oz.
    (29.25 lbs). (Historical Note The birth occurred
    in Effingham IL in 1939 and due to respiratory
    problems the baby died two hours later. The
    heaviest babies to survive weighed 22.5 lbs and
    were born in 1955 and 1982.)

11
Supersize Delivery! Woman Gives Birth to
19.2-Pound Baby Friday, September 25, 2009
12
Big Babies
  • Babies in developed countries are being born
    heavier.
  • In Australia in 2002 report found that there had
    been a 12 increase since 1993.
  • In Ireland, researcher at Dublins Rotunda
    maternity hospital looked at birth weights for
    first-time mothers between 1950 and 200 and found
    that millenium NBs weighed an average of 7lbs
    10oz, about a pound more than they did half a
    century earlier.
  • Why such a boost in birth weight in so short a
    time? Large babies are not the result of
    evolutionary changes, rather a by-product of
    rapidly shifting environment and cultural
    landscape.

13
  • Mums with a diabetic tendency and obese mums
    tend to be more likely to have bigger babies
    because there is more fat laid down and more
    sugar present. The fast food diet also
    predisposes to increased gestational diabetes,
    which develops in pregnancy.
  • Dr. Alen
    Cameron
  • Consultant OB at Queen Mothers Hospital
  • Glasgow

14
Diet advice
  • 1920-1975 women dieted thruout their pregnancies
    to make sure they did not gain more than 15-20
    lbs.
  • Late 1970s docs relaxed
  • 25-35, based on prepreg BMI
  • Women now healthier vits, folic acid, avoid
    ETOH, tobacco, caffeine
  • Face the Nation 1971, chairman of Phillip Morris
    was confronted with evidence that smoking in
    pregnancy leads to LBW, he famously said Some
    women prefer to have small babies.

15
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

16
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.

17
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.

18
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

19
Bishops Score
20
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?

21
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)

22
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.

23
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

24
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

25
VBAC Complications
26
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 (God-send to a busy doc, convenient
    hospital assembly line.)

27
Nursing Management of the Client undergoing
Induction
  • Monitor EFM
  • VS
  • Judicious increase of Pit
  • Terbutaline sc for hyperstimulation

28
Version
  • External Cephalic Version (ECV)
  • Podalic Version (Internal)

29
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.
30
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.
31
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.
32
Nursing Management
  • Maternal/fetal assessments
  • NST
  • Lab studies
  • Psychological support
  • Education
  • Monitor VS

33
Nursing Management (continued)
  • EFM
  • Mediation administration Beta-mimetics, RhoGAM

34
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

35
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

36
Cervical Ripening Prostaglandin E2 (continued)
  • Risks
  • Uterine hyperstimulation
  • Nonreassuring fetal status
  • Higher incidence of postpartum hemorrhage
  • Uterine rupture

37
Labor Induction Stripping Membranes
  • Advantages
  • Labor usually occurs in 24-48 hours
  • Disadvantages
  • Can be painful
  • Uterine contractions
  • Bloody discharge

38
Labor Induction Oxytocin
  • Risks
  • Hyperstimulation of the uterus
  • Uterine rupture
  • Water intoxication
  • Nonreassuring fetal heart rate patterns

39
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

40
Labor Induction Natural Methods (continued)
  • Use of homeopathic solutions
  • Caulophyllum or pulsatilla
  • Castor oil, enemas
  • Acupressure/acupuncture
  • Mechanical dilatation with balloon catheter

41
Amnioinfusion
  • Prevent the possibility of variable decelerations
  • Treat nonperiodic decelerations
  • Meconium dilution

42
Episiotomy
  • Types
  • Midline
  • Mediolateral

43
The two most common types of episiotomies are
midline and mediolateral. A, Right mediolateral.
B, Midline.
44
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

45
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.

46
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

47
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

48
Nursing Management
  • Support
  • Assist with communication of womans needs
  • Pain relief measures
  • Assessment
  • Education

49
Forceps-Assisted Birth Maternal Indications
  • Heart disease
  • Acute pulmonary edema or pulmonary compromise
  • Certain neurological conditions
  • Intrapartal infection
  • Prolonged second stage
  • Exhaustion

50
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.
51
The right blade is inserted along the right side
wall of the pelvis over the parietal bone.
52
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.
53
Forceps-Assisted Birth Fetal Indications
  • Premature placental separation
  • Prolapsed umbilical cord
  • Nonreassuring fetal status

54
Types of Forceps
  • Outlet forceps
  • Midforceps
  • Breech forceps

55
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56
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

57
Fetal Risks (continued)
  • Ocular trauma
  • Other trauma (Erbs palsy, fractured clavicle)
  • Elevated neonatal bilirubin levels
  • Prolonged infant hospital stay

58
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

59
Maternal Risks (continued)
  • Cervical lacerations
  • Prolonged hospital stay
  • Urinary and rectal incontinence
  • Anal sphincter injury
  • Postpartum metritis

60
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

61
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

62
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

63
The cup is placed on the fetal occiput, creating
suction. Traction is applied in a downward and
outward direction.
64
Traction continues in a downward direction as the
fetal head begins to emerge from the vagina.
65
Traction is maintained to lift the fetal head out
of the vagina
66
Nursing Management
  • Inform woman about procedure
  • Pumps the vacuum
  • Supports the woman
  • Assesses the mother and neonate for complications

67
Neonatal Risks with Vacuum Extraction
  • Scalp lacerations and bruising
  • Shoulder dystocia
  • Subgaleal hematomas
  • Cephalhematomas
  • Intracranial hemorrhages
  • Subconjunctival hemorrhages

68
Neonatal Risks with Vacuum Extraction (continued)
  • Neonatal jaundice
  • Fractured clavicle
  • Erbs palsy
  • Damage to the sixth and seventh cranial nerves
  • Retinal hemorrhage
  • Fetal death

69
Maternal Risks with Vacuum Extraction
  • Perineal trauma
  • Edema
  • Third- and fourth-degree lacerations
  • Postpartum pain
  • Infection
  • More sexual difficulties in the postpartum period

70
Cesarean Birth
71
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74
c/s
  • More common than tonsillectomy or appendectomy
  • Risks
  • Baby nicked by scapel
  • Increased liklihood of difficulty with initial BF
    attempts
  • Pain can suppress mild production
  • Mom more prone to PPD, infertility and placenta
    abnormalities in future pregnancies
  • Previa, acreta and abruption can lead to
    hemorrhage

75
Julius?
76
Indications for Cesarean Birth
  • Complete placenta previa
  • CPD
  • Placental abruption
  • Active genital herpes
  • Umbilical cord prolapse
  • Failure to progress in labor

77
Indications for Cesarean Birth (continued)
  • Proven non-reassuring fetal status
  • Benign and malignant tumors that obstruct the
    birth canal
  • Breech presentation
  • Previous cesarean birth
  • Major congenital anomalies
  • Cervical cerclage

78
Indications for Cesarean Birth (continued)
  • Severe Rh isoimmunization
  • Maternal preference for cesarean birth

79
This transverse incision in the lower uterine
segment is called a Kerr incision.
80
The Sellheim incision is a vertical incision in
the lower uterine segment.
81
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.
82
Impact on the Family
  • Stress and anxiety
  • Sense of loss of vaginal birth experience
  • Fear
  • Relief

83
Preparation for Cesarean Birth
  • Preoperative teaching
  • Coughing and deep breathing
  • Splinting
  • What to expect

84
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

85
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

86
Nursing Management Before Cesarean Birth
(continued)
  • Supporting the couple
  • Instrument count

87
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

88
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

89
C/S A jaded view on the most performed surgery
  • http//www.xtranormal.com/watch/7000271/

90
Vaginal Birth After Cesarean (VBAC) Risks
  • Uterine rupture
  • Stillbirths
  • Hypoxia

91
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