Transcript Birth-Related Procedures

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 preeclampsia
Macrosomia/PROM
• Macrosomia has been used as an excuse
for induction, but data do not support this
• PROM: how long is safe to wait?
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.)
Supersize Delivery! Woman Gives Birth to
19.2-Pound Baby
Friday, September 25, 2009
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 Dublin’s 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.
“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 Mother’s Hospital
Glasgow
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.
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, easierpill 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 rupture30%
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 (God-send to a busy doc,
convenient hospital “assembly line.)
Nursing Management of the Client
undergoing Induction
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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
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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 tears
2. 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 fourthdegree laceration
• Report more perineal pain and sexual
problems in the postpartum period
• Postpartum infections
Maternal Risks (continued)
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Cervical lacerations
Prolonged hospital stay
Urinary and rectal incontinence
Anal sphincter injury
Postpartum metritis
Nursing Management
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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
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Inform woman about procedure
Pumps the vacuum
Supports the woman
Assesses the mother and neonate for
complications
Neonatal Risks with
Vacuum Extraction
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Scalp lacerations and bruising
Shoulder dystocia
Subgaleal hematomas
Cephalhematomas
Intracranial hemorrhages
Subconjunctival hemorrhages
Neonatal Risks with
Vacuum Extraction (continued)
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Neonatal jaundice
Fractured clavicle
Erb’s palsy
Damage to the sixth and seventh cranial
nerves
• Retinal hemorrhage
• Fetal death
Maternal Risks with
Vacuum Extraction
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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 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
Julius?
Indications for
Cesarean Birth
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Complete placenta previa
CPD
Placental abruption
Active genital herpes
Umbilical cord prolapse
Failure to progress in labor
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
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
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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
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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
C/S: A jaded view on the most
performed surgery
• http://www.xtranormal.com/watch/7000271
/
Vaginal Birth After Cesarean
(VBAC): Risks
• Uterine rupture
• Stillbirths
• Hypoxia