Chapter 16: Nursing Care During Obstetric Procedures Flashcards
(110 cards)
1
Q
What are some indications for an amniotomy?
A
- To induce/augment labor
2. For placement of IUPC or fetal scalp electrode (which requires ruptured membranes)
2
Q
Amniotomy
A
Artificial rupture of amniotic sac.
3
Q
How is an amniotomy performed?
A
- Performed with amniohook of FSE.**
- Hook is passed through cervical opening, snagging membranes.
- Opening in membranes is enlarged with finger, allowing fluid to drain.
4
Q
An amniotomy is deferred if
A
- If fetal presenting part is high or presentation is NOT cephalic.
- Head must be engaged at 0 station.**
5
Q
What is the priority when an amniotomy is performed?**
A
Fetal heart tone which can come down quickly.
6
Q
What are the risks associated with amniotomy?
A
- Prolapse of umbilical cord
- Infection
- Abruptio placentae
7
Q
Risks of Amniotomy: Prolapse of umbilical cord
A
Primary risk is that the umbilical cord with slip down in gush of fluid -> reduce in fetal gas exchange.
8
Q
Risks of Amniotomy: Infection
A
- When there is an interruption of the membrane barrier, vaginal organisms have access to the uterine cavity.
- Can cause chorioamnioitis.
- Risk is low but as interval between membrane rupture & birth increases, so does the risk for infection.
9
Q
Chorioamnioitis
A
inflammation of amniotic sac; bacterial and viral.
10
Q
Within what time frame would birth be desired after membrane is ruptured?
A
Within 24 hours of membrane rupture.
11
Q
Risks of Amniotomy: Abruptio Placentae
A
- Occurs when uterus is distended w/ excessive amniotic fluid.
- As uterus collapses w/ discharge of amniotic fluid, area of placental attachment shrinks.
- This causes it to partially separate from uterus.
12
Q
Why is abruptio placentae important?
A
It reduces fetal oxygenation, nutrition, and waste disposal.
13
Q
What are some assessments that should be performed prior to amniotomy?
A
o FHR is assessed with electronic monitor or auscultation to verify reassuring rate and pattern.
o 20-30 min needed for adequate fetal baseline evaluation.
o NON-BALLOTABLE → if ballotable small for their size, rapid labor.
14
Q
Safety and Nursing Considerations Prior to Amniotomy
A
- Place 2-3 underpads under buttocks; towel too
- Explain that amniotomy is no more painful that vaginal exam
- Gather disposable plastic hook, sterile gloves for birth and packet of sterile lubricant.
15
Q
Nursing Care After Amniotomy
A
- FHR assessed at least 1 full minute after. **
- Chart quantity, odor and color of fluid.
- Assess temperature at least every 2-4 hours after membrane rupture.**
- Regularly change underpads to keep her dry and reduce moist environment (favors bacteria growth)
16
Q
What FHR suggests possible cord compression after amniotomy?
A
< 100 bpm
17
Q
What should the amniotic fluid look like after an amniotomy?
A
Should be clear (often with bits of vernix) and mild odor.
18
Q
What are some abnormal characteristics of amniotic fluid to make note of?
A
- Large amt of vernix which suggests preterm fetus
- Greenish, meconium-stained fluid seen in posterm or placental insufficiency
- Foul strong odor, cloudy appearance, yellow which suggests chorioamnioitis
• Hydramnios → fetal abnormalities - Oligo → placental insufficiency/fetal renal tract abnormalities
19
Q
What characteristics precede maternal fever?**
A
A rising FHR and fetal tachycardia precede maternal fever.
20
Q
How often should vital signs be checked after an Amniotomy?
A
2-4 hours**
21
Q
Induction and augmentation of labor
A
- Artificial method to stimulate contractions.
- Want to mimic natural labor as much as possible.
- Techniques/care are the same for both.
22
Q
When is an induction performed?
A
Performed when a continued pregnancy may jeopardize the health of the woman or fetus and labor and vaginal birth are considered safe.
23
Q
Augmentation of labor
A
is considered with oxytocin when labor begun spontaneously but progress
has slowed or stopped, even if contraction seem to be adequate.
24
Q
Nonpharm augmentation
A
Nipple stimulation in shower, whirlpool.
25
Why is amniotomy considered a method of surgical induction and augmentation?
Because rupturing membranes stimulates uterine contraction.
26
What are drugs used for augmentation and induction of labor?
- Prostaglandins (augmentation)
| - IV oxytocin (Pitocin)
27
Indications for induction and augmentation of labor
1. IUFGR, blood incompatibility: intrauterine environment is hostile to fetal well being.
2. Spontaneous rupture of membranes at or near term without onset of labor.
3. Postterm pregnancy
4. Chorioamnionitis
5. HTN associated with pregnancy, chronic HTN: reduce placental blood flow.
6. Abruptio placentae**
7. Maternal medical conditions that worsen continuation of pregnancy (i.e diabetes, HTN, renal disease, etc.)
8. Fetal death
28
Why is elective induction and augmentation not recommended?
o Unless factors as having rapid labor and living long distance from hospital.
o Make sure reassurance of fetal lung maturity.
29
What are contraindications to augmentation and induction of labor?
o If fetus has to be delivered more quickly → C/S instead.
o Placenta previa: results in hemorrhage during labor
o Vasa previa
o Umbilical cord prolapse, immediate c/s would be needed.
o Abnormal fetal presentation: vaginal birth is often more hazardous
o Fetal presenting part above pelvic inlet
o **Previous surgery in upper uterus, C/S history or extensive surgery for uterine fibroids.
30
Fetal presenting part above pelvic inlet may be associated with
cephalopelvic disproportion (fetal head TOO BIG) or preterm fetus
31
Vasa previa
fetal umbilical cord vessels branch over amniotic sac rather than inserting into placenta; fetal hemorrhage possible if membrane rupture.
32
What are the risks associated with induction and augmentation of labor?
1. Hypertonic uterine activity
2. Uterine rupture
3. Maternal water intoxication
4. Increased risk for chorioamnionitis and c-section.
5. Newborn respiratory problems
6. Tachysystole
33
Maternal water intoxication is likely during augmentation and induction of labor if
Hypertonic IV solution to dilute oxytocin has a rate greater than 20 milliunits/minute.
34
Steps for starting oxytocin for induction and augmentation of labor
- Placed in piggyback with isotonic solution
- Oxytocin line is inserted into primary IV line as close as possible to venipuncture site to limit amount of drug infused after changing to nonadditive fluid.
- Start slowly, increase gradually, regulate with infusion pump
35
Assessment before using oxytocin in augmentation and induction of labor
-Monitor uterine activity, FHR and fetal heart patterns.
36
When can the rate of oxytocin be reduced?
- Rate of oxytocin may be gradually reduced when she is in the active phase of labor (5 – 6 cm dilation) because the uterus is more sensitive to oxytocin.
- May be stopped or the rate reduced after her membrane rupture
37
How does the uterus react to oxytocin as labor progresses?
It becomes more sensitive to oxytocin as labor progresses.
38
Labor augmented with oxytocin
Lower total dose is needed to achieve adequate contractions.
39
Nursing responsibilities during oxytocin infusion for augmentation and labor
-Nurse must decide when to start, change, and stop an oxytocin infusion using the facility’s protocols and medical orders.
-Facility policies related to oxytocin must clearly support correct nursing and med action.
40
Assessing fetal response to augmentation or induction of labor using oxytocin
- Observe for tachysystole.
- Monitor for persistent bradycardia or tachycardia.
- Observe for late decelerations and decreased FHR variability.
41
Tachysystole Characteristics
* Contraction duration longer than 90 to 120 seconds
* Contractions occurring less than 2 minutes apart or relaxation of less than 30 seconds between contractions
* Uterine resting tone higher than 20 mm Hg (with intrauterine pressure catheter)
* Peak pressure higher than 90 mm Hg during first-stage labor (with intrauterine pressure catheter)
* Montevideo units (unit of measure for uterine contraction intensity) exceeding 400
* A fetal heart rate pattern of late decelerations accompanying hypertonic uterine activity
42
How often is FHR charted in labor record during the first and second stage while using oxytocin to induce labor?
At least every 15 minutes during 1st stage of labor and every 5 minutes during 2nd stage.**
43
Reduced placental exchange can be caused by
- Excess uterine activity
- Maternal hypotension
- Maternal DM
44
Interventions for non reassuring patterns OR tachysystole during augmentation or induction of labor using oxytocin.
- Reduce/stop oxytocin infusion and ↑ rate of primary nonadditive infusion**
- Keep woman in a NONSUPINE position (side-lying)
- Give 100% oxygen by facemask at 8-10 liters per minute to increase woman’s oxygen saturation, making more oxygen available for fetus.
- Terbutaline or magnesium sulfate may be ordered to reduce uterine activity
45
Assessment of maternal response during augmentation and induction of labor using oxytocin.
-Assess uterus for hypertonia
-Assess contractions for frequency, duration, intensity.
-V/S: Temperature, pulse, BP
-Pain
-I&O
-Postpartum hemorrhage after birth -> Hypovolemic shock
-
46
Why should you assess for hypertonia during oxytocin infusion?
May reduce fetal oxygenation and contribute to uterine rupture.
47
Uterine resting tone is assessed for
Relaxation of at least 30 seconds between contractions.
48
When oxytocin is decreased for 40 minutes,
-The drug that was in the woman’s system has been metabolized. -Therefore, it should be restarted at the beginning dose ordered and advanced more slowly to prevent a recurrence of uterine hyperstimulation and nonreassuring FHR patterns.
49
When restarting oxytocin, it should be**
- Should be restarted at the beginning dose ordered
| - Advanced more slowly to prevent recurrence of uterine hyperstimulation and nonreassuring FHR Patterns.
50
How often should blood pressure and pulse be taken when given oxytocin for augmentation or induction of labor?**
Taken every 30 minutes or with each oxytocin dose increase
51
Why is it important to record I&O during oxytocin infusion?
To identify fluid retention preceding water intoxication.
52
What are signs and symptoms of water intoxication?
- Headache, blurred vision, behavioral changes.
- Increase BP and respiration.
- Decreased pulse rate.
- Rales, wheezing and coughing.
53
Prolonged oxytocin can increase the risk for
Uterine atony.
54
What are indications for cervical ripening?
Ripen cervix and make it more likely to dilate w/ forces of labor are common adjuncts to induction.
55
When is cervical induction usually done?
Most are done the day before scheduled induction. **
56
What is used for cervical ripening?
-Prostaglandin E2 via Intra vagina looks gel, vertical and a timed-released vaginal insert.
57
Misoprostol (Cytotec)
A prostaglandin E1 given for gastric ulcer, used for both cervical ripening and induction of labor.
58
Misoprostol (Cytotec) is contraindicated if
History of c-section, which increases the risk for uterine stimulation/rupture
59
Normal dose of Cytotec for cervical ripening
100 milligrams
60
Nursing indications for cervical ripening with prostaglandin
- Woman should lie flat for 15-20 minutes after gel form of prostaglandin is inserted. **
- FHR should be monitored for at least 30 minutes for changes.
- Assess uterus for excessive contractions.
61
Servadil little gel
Prostaglandin agents, body produces to enhance labor progress.
62
What are precautions when using prostaglandins?
- Significant asthma**
- Need to ask if they have ever been intubated or admitted for asthma.
- It may cause exacerbation.
63
At what point is an episiotomy done?
done when the fetal presenting part has crowned to a diameter of about 3 to 4 cm**
64
What is another reason to get episiotomy?
Preterm fetus. Head is not developed and crowning puts a lot of pressure on preterm head and puts them at risk for intraventricular hemorrhage.
65
What are the types of episiotomies?
1. Median or Midline
| 2. Mediolateral
66
Median or Midline Episiotomy
- Minimal blood loss, neat healing, less pain
- Can extend to rectum and can limit enlargement of vaginal opening. 4th to 3rd degree.
- Most common.
67
Mediolateral Episiotomy
- More enlargement of vaginal opening, no risk to anus.
| - More blood loss, ↑ pain, scarring and prolonged painful intercourse (painful intercourse).
68
Indications for Episiotomy
o Incision of the perineum just before birth..
o Rapid resolution of fetal shoulder dystocia (shoulder of fetus becomes lodged under mother’s symphysis during birth)
o Vacuum extractor-assisted or forceps-assisted births
o Births w/ fetus in occiput posterior (face-up) position
o Birth of a small preterm fetus to reduce pressure on head.
69
Nursing care after episiotomy: Assessment
- Monitor risk for infection and perineal pain
| - Observe perineum for hematoma and edema. REEDA
70
Nursing care after Episiotomy: Interventions
- Encourage patient to sit upright position while pushing to promote stretching of perineum.
- Push with open glottis technique rather than prolonged breath-holding when pushing.**
- Daily perineal massage and stretching by woman from 36 weeks until birth has been shown to decrease risk for perineal trauma during birth.
- Cold application for at least 12 hours followed by heat after 12 hours with forced delivery. **
- Pain management, perineal care
71
Why should you push with open glottis technique rather than prolonged breath-holding when pushing?
Promotes gradual perineal stretching
72
24 hours after an episiotomy, you could offer
Sitz bath alternated with ice to promote healing.
73
Vacuum Extractor
Uses suction to grasp fetal head, while traction is applied.
74
Contraindications for forceps or vacuum extractor use
- If breech or face position.
| - < 34 weeks gestation (less gestation can injury head, scalp and intracranial vessels)
75
Indications for forceps or vacuum extractor
- Big baby
- Inability to push
- Occipital posterior position
- Macrosomia
76
What is a must when using instruments during delivery?
Head must be crowning in order for instrumentation use**
77
What is the most important rule for use of vacuum extractor or forceps?
Only do 3 pop offs! No more. No forceps after either.
78
C-section is preferred over operative vaginal births if
- Situation mandates a more rapid birth that can be accompanied with forceps or vacuum extraction and if procedure would be too traumatic.
- Examples of these conditions are severe fetal compromise, acute maternal conditions such as congestive heart failure and pulmonary edema, a high fetal station, and disproportion between the size of the fetus and maternal pelvis.
79
Indications for c-section include
* Dystocia (prolonged labor)**
* Cephalopelvic disproportion
* HTN
* Maternal DM, heart disease, cervical cancer if labor is not advisable
* Active genital herpes
* Previous uterine surgical procedures, c/s or fibroid removal
* Persistent nonreassuring FHR patterns
* Prolapsed umbilical cord**
* Fetal malrepresentation such as breech or transverse lie.
* Hemorrhagic conditions such as abruptio placentae or placenta previa.
80
Instrumentation to provide traction or to assist to rotate to OA position (Not sure, wording was weird on notes so read more about it in book)
- Done by physician during birth to aid in expulsion efforts
- Both techniques assist descent only, or assist both descent and rotation of fetal head from occiput posterior or occiput transverse position to occiput anterior posterior.
81
Occiput posterior
Abnormal fetal positioning.
82
Maternal-fetal risks for occiput posterior position
Prolonged labor -> dysfunctional labor -> prevent cardinal movement from occurring naturally.
83
Complications of occiput posterior position
Instrumentation
C/S
4th degree perineal laceration
Intense leg/back pain
84
How can you manage occiput posterior position?
- Counter pressure on back during contraction; ↓ maternal discomfort by reducing pressure on of fetal head on sacrum
- Change position: hands and knees (w/ rocking), side lying, lunge, squatting, sitting/kneeling, standing while leaning forward
85
Outlet operative vaginal delivery
Crowing required.
86
Conditions (ABC) for Operative Vaginal Births
1. Anesthesia
2. Bladder
3. Cephalic
*Not exactly sure what this means, so look up in book.
87
Conditions: Anesthesia
Needs regional block such as epidural.
88
Conditions: Bladder
Bladder must be empty!
89
Conditions: Cephalic
Must be head down!
90
Medical indication for operative vaginal birth includes
- Exhaustion
- Inability to push effectively
- Cardiac and pulmonary disease
91
Anesthetic indication for operative vaginal birth
Loses sensation to push.
| No urge.
92
Fetal indication for operative vaginal birth
- Nonreassuring FHR patterns
- Failure of fetal presenting part to fully rotate and descend into pelvis
- Partial separation of placenta
- Nonreassuring FHR patterns near time of birth
- Macrosmonia
- Occipital Posterior position
- Weak pushing
- Lung disease
93
What are the maternal risks for operative vaginal births?
1. Perineal complications: trauma to maternal and fetal tissues.
2. Laceration and hematoma of vagina
3. Fetus may have ecchymosis, facial and scalp lacerations/abrasion, nerve injury, cephalhematoma, subgaleal hemorrhage, intracranial hemorrhage.
4. Chignon: vacuum causing edema on scalp.
94
C-section incision
One made in abdominal wall (skin incision) and other made in the uterine wall
95
What are the two types of skin incisions used during a c-section?
* Midline vertical incision
| * Low transverse incision
96
What are the types of uterine incisions used during a c-section?
* Low transverse
* Low vertical
* Classic
97
Low Transverse Uterine Incision**
* Preferred, low risk for rupture
| * Not for large baby. T may be done.
98
Low Vertical Uterine Incision
•Likely to rupture
99
Classic Uterine Incision
* Done if other 2 not possible like in placenta previa
* Likely to rupture during later pregnancies
* NO MORE VBAC WITH THIS
100
What are the maternal risks for c-section?
* Infection**
* Hemorrhage**
* Urinary tract trauma or infection
* Thrombophlebitis, thromboembolism
* Paralytic ileus
* Atelectasis
* Anesthesia complications
101
Newborn risks for c-section
* Inadvertent preterm birth
* Transient tachypnea** d/t delayed absorption of lung fluids
* Persistent pulmonary HTN of newborn
* Injury such as laceration, bruising, fractures or other trauma.
102
C-Section: Medications given before procedure
- Epidural or combined Spinal-epi common.
- Famotidine (Pepcid) or sodium citrate (Bicitria) given to reduce gastric acidity before surgery. For general anesthesia makes sense.
- IV dose ampicillin or cephalosporin AFTER cord is clamped
103
Nursing assessment prior to c-section
- Get fetal heart tones for 20 wks by fetoscope or 30 wks by Doppler
- CBC, blood type, clotting factors.
- Fetal surveillance just prior
104
Nursing duties prior to c-section
- Place wedge under her to prevent hypotension.
- Indwelling catheter inserted after regional block is established.
- Sterile abdominal skin preparation
- Provide emotional support
- Do teaching -> cath and IV lines stay for only 24 hours.
- Verify proper functioning of equipment (suction, monitor, ectrocautery)
105
C-section: Post-op assessment
* Temp assessed in admission to PACU
* Vital signs, respiratory character, and oxygen saturation
* Return of motion and sensation if regional block given
* LOC
* Abdominal dressing
* Bowel sounds**
* Uterine firmness and position (midline or deviated to one side)
* Lochia (color, quantity, presence and size of any clots)
* Urine output (quantity, color, other characteristics)
* IV infusion (fluid, rate, condition of IV site)
* Pain relief needs
* Function of the SCD
106
How often should assessments be done after c-section?
- Q15min during first 1-2 hours**
| - 30 minutes to 1 hour until she is transferred to postpartum
107
Nursing management after c-section
- Provide pillow to support incision
- Assess fundus d/t risk for uterine atony
- Ensure emptying of bladder
- Provide pain relief (NSAIDs provides long acting analgesia, PCA pump)
108
When assessing the fundus, have woman
- Flex knees and take slow deep breaths for fundus checks
| - Vertical has more pain that pfannenstiel skin incision.
109
Bishop score
used to estimate cervical readiness for labor with five factors: cervical dilation, effacement, consistency, position, and fetal station
110
Vaginal birth is more likely to result if a Bishop score is
higher than 8
