Birth Related Procedures

Chapter 22

By: Heather Bailey, RN, BSN

Version

External Cephalic Version-rotation of the fetus from breech/transverse to cephalic presentation by external manipulation

Podalic Version-used when the second twin is in breech position to pull the feet through the cervix and precipitate delivery

External Version Criteria

Equal to or greater than 36 weeks gestation

Reactive NST has been obtained

Fetal breech is not engaged

ECV Contraindications

Uterine anomalies

Uncontrolled preeclampsia

Third trimester bleeding

ROM

Oligohydramnios

Hydramnios

Placenta previa

Vasa previa

Previous Cesarean

Prior significant uterine surgery

Multiple gestation

Non reassuring FHR

IUGR

Known nuchal cord

Care for ECV

IV

Tocolytic and pain medication

Ultrasound at bedside

Obtain reactive NST

Consent

Baseline vital signs

Fetal monitoring afterward

Amniotomy

Artificial Rupture of Membranes

Most common invasive procedure in OB

Used to speed up or augment labor

Allows for internal monitors to be used

Allows for assessment of the amniotic fluid

AROM

Place clean chux under the patientPlace the patient supine in bedEnsure FHT is obtained before, during and after the procedureDocument the color, consistency, amount, odor and presence of meconium or bloodMonitor temp every two hours afterDecrease the number of vaginal exams afterward

Cervical Ripening

Used to soften the cervix

Prostaglandin

Misoprostol

Prostaglandin

Prepidil gel or Cervidil

Small wafer on a string is placed in the posterior fornix of the cervix

It is left for at least 2 hours up to 12 hours

Continues fetal monitoring while the insert is in place

Must remain flat for 2 hours after placement

Misoprostol (Cytotec)

Pill inserted into the posterior fornix of the cervix

May also be administered orally, most common vaginally

Initial dose 25mcg, to be repeated every 4 hours as needed

Cytotec Guidelines

Use during the 3rd trimester for ripening or induction25mcg initial doseRecurrent administration not to exceed intervals of more than 3 to 6 hoursPitocin should not be administered less than 4 hours after the last doseContinuous fetal and uterine monitoring

Cytotec Contraindications

Uterine contractions 3 times in 10 minutes

Significant maternal asthma

Previous Cesarean or uterine surgery

Bleeding during pregnancy

Placenta previa

Nonreassuring FHR

Cytotec Complications

Uterine hyperstimulation

Amniotic fluid embolism

Uterine rupture

Risks for uterine rupture:Previous CesareanAdvanced gestational ageGrandmultipara

Labor Induction Indications

Diabetes mellitusRenal diseasePreeclampsia/eclampsiaChronic pulmonary diseasePROMChorioamniotisPostterm

Mild abruption with reassuring fetal statusIUFDIUGRAlloimunizationOligohydramniosNonreassuring fetal statusNonreassuring antepartum testing

Induction Contraindications

Client refusal

Placenta previa

Vasa previa

Transverse fetal lie

Prior Cesarean with classical incision

Active genital herpes

Umbilical cord prolapse

Absolute CPD

Labor Readiness

ACOG recommends confirmed gestational age of at least 39 weeks

Cervical readiness: Bishop Score-the higher the score, the greater probability of successful induction of labor

Methods of Induction

Stripping the membranes

Pitocin infusion

Cervical ripening

Amniotomy

Allopathic methods: sexual intercourse, nipple stimulation, mechanical dilation of the cervix, etc.

Pitocin Infusion

Obtain reactive NST before beginning infusion

Assess maternal vital signs

During infusion, document vital signs, intake and output every hour and FHR and contraction pattern every fifteen minutes

Amnioinfusion

Infusion of sterile saline into the uterus via an intrauterine pressure catheter

Used to relieve umbilical cord compression

Reinfusion of fluid in cases of oligohydramnios

Dilutes heavy meconium in utero to decrease the chance of meconium aspiration

Episiotomy

Surgical incision of the perineum to enlarge the outletCan increase the risk of 4th degree perineal lacerationsTypes: Midline, mediolateral, paramedianDocument the type of episiotomy and repair agent used

Operative Vaginal Delivery

Forceps-instrument used to provide traction or to rotate the fetal head to occiput anterior

Vacuum-used to facilitate birth with the use of a soft cup and suction

Forcep Categories

Outlet-applied when the fetal skull has reached perineum and fetal scalp is visible

Low-applied when the presenting part of the fetal skull is +2 station or below

Midforceps-applied when the fetal head is engaged

Forecp Indications

Maternal conditions: heart disease, pulmonary edema, infection and exhaustion

Fetal conditions: placental abruption (late), non reassuring fetal status

Used to shorted the second stage of labor with poor pushing effort

When regional anesthesia has weakened pushing efforts

Forcep Criteria

Complete dilation

Know position and station of fetal head

Ruptured membranes

Engaged presentation

Type of pelvis should be known

Empty bladder

Adequate anesthesia

No CPDKnowledge to perform procedure by physicianAdequate staff to perform a Cesarean if indicated including anesthesia staffMaternal consent

Risks

Newborn: Facial ecchymosis or

edema Facial lacerations Brachial plexus injury Cephalohematoma Cerebral hemorrhage Cerebral fracture Brain damage Fetal death

Maternal: Lacerations of the

vagina and perineum Extension of

episiotomy to rectum Increased bleeding Perineal bruising Perineal edema Anal incontinence

Vacuum Delivery

Cup is applied against the fetal head and traction is used with uterine contractions to facilitate descent

Progressive descent should be achieved with the first two pulls, then procedure should be limited to prevent injury

Vacuum Risks

Cephalohematoma

Intracerebral hemorrhage

Retinal hemorrhage

Jaundice

Brain injury

Fetal death

Cesarean Birth

Delivery via surgical incision in the abdomen and uterusC/S rate in US is at all time high at 31.1%Worldwide rate estimated at 12%Increase in rate is related to increase in repeat C/SAlso increase primary elective C/S

Indications

Complete previaCPDAbruptionActive genital herpesCord prolapseArrest of laborNonreassuring fetal statusPrevious classical incision on the uterus

More than one previous C/STumors obstructing the birth canalCervical cerclageCardiac disordersSevere respiratory diseaseCNS disordersMechanical vaginal obstruction

Indications Continued

Several mental illness with altered state of consciousness

Breech presentation

Previous C/S

Major congenital anomalies

Severe Rh alloimmunization

Risks

Increased maternal mortality and morbidity

Increased risk of uterine rupture in subsequent pregnancies

Increased risk of bleeding problems in subsequent pregnancies

Increase in fetal demise

Increased risk for respiratory problems in the infant

Incisions

Skin incisionsPfannenstielVertical

Uterine incisionTransverseClassical

Skin incision is not indicative of uterine incision

Anesthesia

Spinal

Epidural

Spinal/Epidural combo

General

Local

Preparation for Cesarean

Scheduled vs. UnscheduledSupport of patient and familyNPOConsentsIV and lab workFluid bolusPepcid/BictraAbdominal prepFoley catheter

Cesarean Recovery

Vital signs: q 5 min until stable, q 15 min for an hour then q 30 min until recovery is completeFundus, bleeding, level of anesthesia and abdominal incision are evaluated q 15 min for an hour then q 30 min until recovery is completeI&O as ordered paying attention to the urine for blood Pain and nausea with each check and PRNEnsure bonding is accomplished

Vaginal Birth After Cesarean (VBAC)

Used as an alternative to repeat C/S in cases where C/S was indicated but not limited to the following:Umbilical cord prolapseBreech presentationPlacenta previaNon reassuring fetal status

ACOG VBAC Guidelines

One previous C/S with low transverse uterine incisionClinically adequate pelvisTwo previous C/S with previous VBACMust be possible to perform a C/S within 30 minutesPhysician, adequate staff, anesthesia and facilities must be readily available to perform C/S if neededA classic or T uterine incision is a contraindication

VBAC Risks

Hemorrhage

Uterine scar separation

Uterine rupture

Surgical injuries

Infant death

Infant neurological complications

Most risks are associated with uterine rupture

VBAC Benefits

Lower infection rate

Less blood loss

Fewer blood transfusion

Shorter hospital stay

The risks of VBAC complications lowers with each subsequent attempt