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

Birth-Related Procedures

Impact of Procedures on Childbearing Woman

• Disappointment

• Guilt

• Conflict between expectation and need for intervention

Spontaneous Labor

The decision to induce labor is not one to be taken lightly

The decision to bring pregnancy to an end is one of the most drastic ways of intervening

in the natural process

Certain specific conditions under which inducing labor has been shown to save lives

• Serious IUGR• Documented

placental insufficiency• Deteriorating pre-

eclampsia

Macrosomia/PROM

• Macrosomia has been used as an excuse for induction, but data do not support this

• PROM: how long is safe to wait?

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

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.

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.

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

Bishop’s Score

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?

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)

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.

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

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%

VBAC Complications

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

Nursing Management of the Client undergoing Induction

• Monitor: EFM

• VS

• Judicious increase of Pit

• Terbutaline sc for hyperstimulation

Version

• External Cephalic Version (ECV)

• Podalic Version (Internal)

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.”

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 baby’s head up toward the top

of the uterus with one hand, the physician pulls the baby’s foot down toward the cervix.

Both feet have been pulled through the cervix and vagina. D, The physician now grasps the baby’s trunk and

continues to pull downward on the baby to assist the birth.

Nursing Management

• Maternal/fetal assessments

• NST

• Lab studies

• Psychological support

• Education

• Monitor VS

Nursing Management (continued)

• EFM

• Mediation administration – Beta-mimetics, RhoGAM

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

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

Cervical Ripening: Prostaglandin E2 (continued)

• Risks – Uterine hyperstimulation– Nonreassuring fetal status– Higher incidence of postpartum hemorrhage– Uterine rupture

Labor Induction: Stripping Membranes

• Advantages– Labor usually occurs in 24-48 hours

• Disadvantages– Can be painful– Uterine contractions– Bloody discharge

Labor Induction: Oxytocin

• Risks– Hyperstimulation of the uterus – Uterine rupture– Water intoxication– Nonreassuring fetal heart rate patterns

Labor Induction: Natural Methods

• Sexual intercourse/lovemaking

• Self or partner stimulation of the woman’s nipples and breasts

• Use of herbs– Blue/black cohosh– Evening primrose oil– Red raspberry leaves

Labor Induction: Natural Methods (continued)

• Use of homeopathic solutions– Caulophyllum or pulsatilla– Castor oil, enemas– Acupressure/acupuncture

• Mechanical dilatation with balloon catheter

Amnioinfusion

• Prevent the possibility of variable decelerations

• Treat nonperiodic decelerations

• Meconium dilution

Episiotomy

• Types– Midline– Mediolateral

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

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:

1. Prevention of bad tears2. Prevention of long-term damage to the floor of

the woman’s pelvis 3. Protection of the baby from the adverse

consequences of an extended labor

are NOT supported by the evidence

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.

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%

Not so EBP

• Mayo Clinic rate in 2002 was 60%• A survey of OB practices published in 2002

found nat’l 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

Nursing Management

• Support

• Assist with communication of woman’s needs

• Pain relief measures

• Assessment

• Education

Forceps-Assisted Birth: Maternal Indications

• Heart disease

• Acute pulmonary edema or pulmonary compromise

• Certain neurological conditions

• Intrapartal infection

• Prolonged second stage

• Exhaustion

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.

The right blade is inserted along the right side wall of the pelvis over the parietal bone.

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.

Forceps-Assisted Birth: Fetal Indications

• Premature placental separation

• Prolapsed umbilical cord

• Nonreassuring fetal status

Types of Forceps

• Outlet forceps

• Midforceps

• Breech forceps

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

Fetal Risks (continued)

• Ocular trauma

• Other trauma (Erb’s palsy, fractured clavicle)

• Elevated neonatal bilirubin levels

• Prolonged infant hospital stay

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

Maternal Risks (continued)

• Cervical lacerations

• Prolonged hospital stay

• Urinary and rectal incontinence

• Anal sphincter injury

• Postpartum metritis

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

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

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

The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction.

Traction continues in a downward direction as the fetal head begins to emerge from the vagina.

Traction is maintained to lift the fetal head out of the vagina

Nursing Management

• Inform woman about procedure

• Pumps the vacuum

• Supports the woman

• Assesses the mother and neonate for complications

Neonatal Risks with Vacuum Extraction

• Scalp lacerations and bruising

• Shoulder dystocia

• Subgaleal hematomas

• Cephalhematomas

• Intracranial hemorrhages

• Subconjunctival hemorrhages

Neonatal Risks with Vacuum Extraction (continued)

• Neonatal jaundice

• Fractured clavicle

• Erb’s palsy

• Damage to the sixth and seventh cranial nerves

• Retinal hemorrhage

• Fetal death

Maternal Risks with Vacuum Extraction

• Perineal trauma

• Edema

• Third- and fourth-degree lacerations

• Postpartum pain

• Infection

• More sexual difficulties in the postpartum period

Cesarean Birth

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

Julius?

Indications for Cesarean Birth

• Complete placenta previa

• CPD

• Placental abruption

• Active genital herpes

• Umbilical cord prolapse

• Failure to progress in labor

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

Indications for Cesarean Birth (continued)

• Severe Rh isoimmunization

• Maternal preference for cesarean birth

This transverse incision in the lower uterine segment is called a Kerr incision.

The Sellheim incision is a vertical incision in the lower uterine segment.

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.

Impact on the Family

• Stress and anxiety

• Sense of loss of vaginal birth experience

• Fear

• Relief

Preparation for Cesarean Birth

• Preoperative teaching– Coughing and deep breathing– Splinting– What to expect

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

Risks

• Even with elective c/s, no emergency, 2.84 fold greater chance than vag birth of resulting in the woman’s 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

Nursing Management Before Cesarean Birth (continued)

• Supporting the couple

• Instrument count

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

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

Vaginal Birth After Cesarean (VBAC): Risks

• Uterine rupture

• Stillbirths

• Hypoxia