Chapter 16: Obstetric Procedures Flashcards
1
Q
explain an amniotomy
what are the indications?
A
- it is an artificial rupture of membranes w/ amnihook (disposable plastic membrane perforator)
- indications:
- induce labor
- augment labor
- allow internal monitoring
2
Q
risks of an amniotomy
A
- umbilical cord prolapse
- defer rupture if presenting part is high OR if presentation is not cephalic
- infection
- placental abruption
- can occur w/ polyhydramnios
3
Q
amniotomy: nursing care before
A
- obtaining baseline information: FHR for 20-30 min prior to procedure
- assisting w/ amniotomy:
- place absorbent pads under mother
- gater equipment
- no more painful than a vaginal exam
- make sure to wear goggle–universal precautions
4
Q
amniotomy: nursing care after
A
- PRIORITY: monitor FHR immediately after AROM
- assess amniotic fluid
- assess maternal V/S
- assess temp Q4h before ROM, then assess Q2h after AROM, but if mom spikes a fever, assess Q1h
- promote comfort
5
Q
what are possible observations to make with amniotic fluid?
A
- what to assess:
- T: time
- A: amount
- C: color (clear, bloody, yellow, green)
- O: odor
- problem observations:
- polyhydramnios: more than 2000 mL
- oligohydramnios: less than 500 mL
- large amount of vernix (preterm)
- greenish (meconium b/c post term or placental insufficiency)
- odor (chorioamniotis)
6
Q
why does oligohydramnios occur?
A
- maternal HTN
7
Q
what is the difference b/w induction and augmentation?
A
- induction: artificial initiation of labor
- augmentation: artificial stimulation of ineffective uterine contractions
8
Q
what are the 2 chemical methods used for cervical ripening?
A
- Dinoprostone (Cervidil)–Prostaglandin E2
- Misoprostol (Cytotec)–Prostaglandin E1
- used for cervical ripening and induction
- inserted into the posterior vaginal fornix (25 mcg)
- not given to woman who had previous C/S
9
Q
what are possible ADRs when trying to induce/augment labor?
A
- uterine hyperstimulation
- uterine rupture
- maternal water intoxication
- watch for: HA and vomiting
- neonatal jaundice
- inc risk of chorioamnionitis and C/S
10
Q
what are medical indications for induction?
A
- hostile intrauterine environment
- premature ROM (PROM)–mom has ruptured, but no contractions, so have to give oxytocin
- chorioamnionitis
- HTN–main reason for induction
- placental abruption
- maternal medical conditions: (G)DM, lupus
- fetal death
11
Q
what are other possible reasons that a mom may choose to induce labor?
A
- hx of rapid labors
- living a long way from hospital
- maternity leave
- change in insurance
- fetal anomaly
12
Q
what is the Bishop Score?
A
- used to determine successful induction
- ACOG: vaginal delivery more likely if higher than 8 out of 12
- nullipara most successful when 7 or more
- multipara most successful when 5 or more
- looks at position of cervix, consistency of cervix, effacement, dilation, baby’s station
13
Q
what are the mechanical methods used for cervical ripening?
A
- used infrequently
- moisture attracting inserts are placed in the cervical canal–absorb H2O and swell
- Dilapan: synthetic material
- Lamicel: sponge with MgSO4
- Laminaria: dried seawee
- foley bulb
14
Q
Oxytocin Administration for Induction
A
- dilute oxytocin in isotonic fluid
- secondary infusion via PUMP
- insert oxytocin line close to venipuncture site
- assess uterine activity, FHR, maternal BP and HR
- start slow and inc infusion rate gradually
- nurse decides when to start, change, and stop oxytocin by hospital protocol and Dr.’s orders
- inc by 1-2 milliunits/min
- monitor uterine activity and FHR frequently
15
Q
what is important to recognize during induction or augmentation?
A
- tachysystole/hypertonus
16
Q
how to recognize tachysystole (hypertonus)?
A
- duration longer than 90-120 sec
- frequency <2 min
- relaxation <30 sec
- resting tone >20 mmHg
- peak pressure >90 mmHg
17
Q
what are nursing actions to do for tachysystole?
A
- reduce or stop Pitocin & increase primary fluids
- non-supine, lateral position
- O2 by face mask at 8-10 L/min
- notify doctor
18
Q
what to observe for with induction/augmentation of labor?
A
- assess blood pressure and pulse frequently
- record I&O
- observe for signs of water intoxication
- pain management
- assess for uterine atony in postpartum period
- assess for jaundice in newborn
19
Q
risks of induction and augmentation
A
- uterine hyperstimulation
- uterine rupture
- maternal water intoxication
- greater risk of chorioamnionitis and C/S
20
Q
what are S/S of maternal water intoxication?
A
- HA
- blurred vision
- behavior change
- inc BP and RR
21
Q
indications for version
A
- external version: change fetal position to cephalic position to inc chance of vaginal birth
- attempted after 37 weeks
- internal version: vaginal birth of twins
22
Q
nursing considerations and promoting fetal and maternal health with an external version
A
- provide information and reduce anxiety
- assess NST or BPP for fetal well being
- assess maternal V/S
- monitor FHR for baseline and reassuring pattern
- IV line
- administer tocolytic: terbutaline 0.25 mg subQ (may inc HR)
- observe for complications:
- nonreassuring FHR
- persistent pain: suggests placental abruption
- regular contractions
23
Q
Nursing Care after an External Version
A
- monitor for 1 hour
- perform NST
- monitor for U/Cs, bleeding, ROM, decreased fetal movement
- if Rh negative, check Kleinhauer Betke test
- checks for presence of fetal blood in maternal circulation
- V/S: pulse should NOT be greater than 120
24
Q
amnioinfusion
A
- a volume of LR or sterile NS is introduced into the uterus through an IUPC
25
amnioinfusion: indications
* cord compression is suspected (d/t variable decels)
* meconium stained fluid (usually medium or heavy amounts)
* preterm labor with PROM
26
amnioinfusion: nursing considerations
* monitor maternal V/S
* monitor FHR
* keep mom and partner informed
* comfort measures: ie. dry pads
* positioning
* return of fluid
27
what is used during assisted or operative vaginal births?
* forceps (occasionally used)
* vacuum extractor:
* if 2nd stage needs to be shortened
* maternal exhaustion/inability to push
* cardiac & pulmonary dz
28
forceps: technique
* 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 combined with maternal pushing efforts.
29
vacuum extractor: technique
* The cup is placed on the fetal occiput and suction is created.
* Traction is applied in a downward and outward direction with maternal pushing efforts.
30
risks for mom with a operative vaginal birth
* lacerations and hematomas of the vagina
31
risks for fetus with an operative vaginal birth
* **ecchymosis**
* facial/scalp lacerations and abrasions
* **cephalohematomas**: collection of blood; does NOT cross suture lines
* intracranial or subgaleal bleeds
32
what is an episiotomy? what are the types?
* surgical incision of the perineum
* types:
* ML: midline
* RML or LML: right or left medial lateral
33
advantages of an episiotomy
* allows more room
* dec pressure on the head
34
disadvantages of an episiotomy
* inc postpartum pain
* more scarring
* prolonged dysparunia
* inc risk of infection
* may extend to rectum
35
episiotomy: indications
* to prevent pressure on fetal head
* control direction of vagina opening
* clean incision simpler to repair than a laceration
36
How to Prevent an Episiotomy
* upright position for pushing
* open glottis pushing
* no arbitrary length of time for 2nd stage
* daily perineal massage and stretching after 36 weeks
37
types of lacerations
* 1st degree: skin and mucosa
* 2nd degree: muscle
* 3rd degree: involves the anal sphincter, anterior wall of rectum
* 4th degree: through the rectal mucosa to the lumen of the rectum
38
how to provide pain relief for lacerations or episiotomy
* ice pack first 24 hours
* analgesic spray or ointment as prescribed
* sitz baths after 24 hours (not regularly used)
39
how to prevent infection with lacerations and episiotomies
* perineal care with each void
* dry perineal area from front to back
* blot rather than wipe
* shower rather than tub bath
* apply peri pad front to back
* don't touch inside of pad
* report any bleeding or discharge to physician
40
what are the fetal risks of cesarean birth?
* inadvertent premature birth
* transient tachypnea
* persistent pulmonary HTN of the newborn
* traumatic injury
41
C/S pre-op nursing responsibilities
* informed consent
* patient education and family support
* additional interventions:
* clip hair
* insert bladder catheter
* T&C
* grounding pad
* instrument & sponge counts
* pre-op meds: anti-emetics, antibiotics
42
vertical skin incision with C/S
* advantages:
* quicker
* better visualization
* can extend upward
* better for obese women
* disadvantages:
* visible when healed
* greater chance of dehiscence and hernia
* w/ classic: inc risk of uterine rupture in subsequent pregnancies/labor
43
Pfannenstiel skin incision with C/S
* preferred
* advantages:
* less visible
* less dehiscence and hernia risk
* disadvantages:
* less visualization of uterus
* takes more time and can't be easily extended
* subsequent births take more time
44
low transverse uterine incision w/ C/S
* advantages:
* unlikely to rupture in subsequent births
* makes VBAC possible w/ next birth
* less blood loss
* easier repair
* less adhesion formation
* disadvantage:
* limited ability to extend
45
low vertical uterine incision w/ C/S
* advantage:
* can be extended upward
* disadvantage:
* slightly more likely to rupture in subsequent births
* tear may extend incision down to cervix
46
classic uterine incision w/ C/S
* advantage:
* may be the only choice if:
* implantation of placenta previa on lower anterior uterine wall
* presence of dense adhesions
* transverse lie of large fetus
* disadvantage:
* most likely to rupture in subsequent births
* eliminates VBAC as an option
47
C/S intra-op nursing responsibilities
* circulator
* maintaining counts at cavity closures
* extra supplies
* recording data
* observing sterile field
48
recovery room care after C/S
* postpartum assessment:
* fundus, lochia, dressing, V/S
* urine output
* pain: assess need for analgesia
* assess for return of sensation
* turn frequently prior to its return
* SCD
* promote bonding w/ infant
* airway protection if general anesthesia
49
VBAC
* vaginal birth after C/S
* physician's responsibility to discuss during prenatal care
* reinforce explanations:
* advantages of a vaginal birth
* present in a positive way
* acknowledge that a cesarean delivery may be needed
