OB procedures

• Amniotomy (AROM)

  • Rupture of amniotic sac
  • Indications: starting labor (inducing), accelerating progress (augmenting), application of FSE, application of IUPC, and assessment of amniotic fluid
  • Risks: prolapsed cord!, chorioamnionitis and cesarean delivery
• Nursing care (amniotomy)

  • Explain procedure
  • FHR
  • Document fluid quality -TACO
  • Comfort measures
  • Temp q 2 hours
  • Minimal vag exams
  • Teach
• Amnioinfusion

  • Infusion of sterile normal saline or LR solution warmed to body temp through an intrauterine catheter into the uterine cavity
  • Indications: variable decelerations (cord compression), oligohydramnios and meconium-stained fluid
  • Nursing care: VS, UCs, EFM and comfort measures
• Induction

  • Stimulation of contractions before spontaneous onset of labor, with or without ruptured membranes, for the purpose of accomplishing a vaginal birth
• Augmentation

  • Stimulation of contractions when spontaneous contractions have already begin but are not causing progressive dilation or descent
• Labor

  • Withdrawal of inhibitory mechanisms of pregnancy
• Parturition cascade

  • Phase O: Inhibition of contractions during pregnancy: progesterone, prostaglandins and relaxin
  • Phase 1: myometrial activation (priming): progesterone levels decrease, estrogen levels increase
  • Phase 2: Stimulating uterotonic agonists: oxytocin and stimulatory prostaglandins causes uterus to contract
  • Phase 3: Involution: oxytocin
• Indications for inductions

  • Post dates
  • Preeclampsia
  • Premature and or prolonged ROM
  • Chorioamnionitis
  • Signs of fetal stress: non-reactive NST
  • IUGR
  • Fetal demise
  • Diabetes, heart disease
• Indications for augmentation

  • Labor contractions have slowed/stopped
  • Contraction strength has weakened
• Contraindications for induction/augmentation:

  • Placenta previa
  • Vasa previa or velamentous umbilical cord
  • Certain pelvic abnormalities
  • Prior vertical uterine incision
  • Active genital herpes infection
  • HIV + status
  • Abnormal fetal position
• Risks for induction/augmentation:

  • Outcomes improved when: fetal maturity of 39 weeks or greater and cervical readiness
  • Risks: tachysystole, uterine rupture, water intoxication from oxytocin and cesarean delivery
• Bishop Score:

  • Favorable: 8= similar to spontaneous labor, 7= primips, and 5= multips
  • 5 categories: Dilation, Effacement, Fetal station, Cervical consistency and Cervical position
• Medical interventions

  • Synthetic prostaglandins: Soften or ripen cervix, ex. Misoprostol/Dinoprostone, and stimulate contractions
  • Pitocin (oxytocin) for induction and augmentation: stimulates contractions
  • AROM-Amniotomy: releases prostaglandins
  • Stripping of the membranes: releases prostaglandins
• Holistic methods

  • Nipple stimulation: oxytocin release
  • Intercourse/orgasm: prostaglandin and oxytocin release
  • Herbs: black cohash and raspberry tea
  • Castor oil/enemas: diarrhea
  • Acupuncture
• Cervical ripening:

  • Prepidil (dino): gel placed vaginally q 6 hrs, pt. recumbent for 30 min but difficult to remove
  • Cervidil (dino): vag insert-controlled release, pt. recumbent for 2 hrs, easily removed but very expensive
  • Cytotec (miso): tablets vag, PO or sublingual, uterotonic & PPH and least expensive
• Nursing care with cervical ripening agents:

  • Continuous FHR and UC monitoring
  • Prostaglandins contraindicated for women who had a prior C-section (TOLAC)
  • Potential side effects: tachysystole, category II or III FHR and diarrhea
• Cervical ripening (mechanical methods)

  • Devices inserted into the cervix to cause dilation and prostaglandin release
  • Potential side effects: less tachysystole, increased risk for infection and PROM
  • Ballon (foley) catheter: causes pressure on cervix & lower uterine segments and left in place for 6-12 hours
  • Laminaria (seaweed), Lamicil and Dilipan: expand/dilate cervix like a tampon
• Oxytocin (Pitocin)

  • Adverse reactions: tachysystole or excessive uterine activity, maternal fluid retention and water intoxication
  • Used for: induction, augmentation, prevent/treat PPH
  • Dose is much HIGHER for PPH (10-40 units) compared to 1-20 mU for induction/augmentation
  • Nursing care: Goal (3 contractions/10 minutes lasting 40-60 seconds), tachysystole (6 or more cx in 10 min), careful titration of dose!!!!!, continuous FHR, VS every 2 hr, resting tone of uterus, watch for fluid retention
• Nursing care for tachysystole

  • 6 or more contractions in 10 minutes
  • Contractions lasting greater than 2 minutes
  • Uterine resting tone greater than 20 mmHg
  • Interventions: decrease OR discontinue Pitocin, reposition, IV fluid bolus, O2, notify, and administer terbutaline
• Episiotomy

  -Surgical incision of the perineal body to enlarge the outlet

  -Indications:

  Shoulder dystocia, breech presentation, forceps or vacuum extraction, OP

  -Risks:

  3rd or 4th degree laceration, increased blood loss, infection, postpartum pain and dyspareunia

  -Nursing care:

  Pain control, position, natural pushing, perineal massage, warm compress, counter pressure, mineral oil, ice pack, analgesic spray, pericare, sitz baths after 24 hrs and Kegel exercises.
• Instrument assisted (operative vaginal) deliveries:

  -Indications:

  Maternal (heart disease, pulmonary edema, infection, exhaustion, regional anesthesia, elective), prolonged 2nd stage, and Fetal (OP, distress/non-reassuring fetal testing and premature placental separation)

  -Risks:

  Maternal (lacerations 3rd or 4th, bleeding, bruising, and perineal edema) & Fetal (ecchymosis/edema/marks, caput succedaneum/cephalhematoma/hyperbilirubienmia-vacuum and transient facial paralysis- forceps)
• C-section

  Risks:

  -Atelectasis/pneumonia, wound/endometritis, DVT/pulmonary emboli, PPH

  Nursing care:

  -NPO, Foley, IV fluid pre-load, VS, SCDs and antibiotics prior to surgery
• Vaginal Birth After Cesarean (VBAC)

  • Risk for uterine rupture
  • Requires low transverse uterine incision
  • Prostaglandins are not used to ripen cervix