Nursing Care During Obstetric Procedures

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NURS 1102 - Chapter 16 Foundations of Maternal-Newborn and Women's Health Nursing, 5th Edition. Vocabulary, Check Your Reading & Summary Concepts

abruptio placentae

Premature separation of a normally implanted placenta.

amniotomy

Artificial rupture of the amniotic sac (fetal membranes).

augmentation of labor

Artificial stimulation of uterine contractions that have become ineffective.

cephalopelvic disproportion

Fetal head size that is too large to fit through the maternal pelvis at birth (also called fetopelvic disproportion).

cesarean birth

Surgical birth of the fetus through an incision in the abdominal wall and uterus.

chignon

Newborn scalp edema created by a vacuum extractor.

chorioamnionitis

Inflammation of the amniotic sac (fetal membranes); usually caused by bacterial and viral infections (also called amnionitis).

dystocia

Difficult or prolonged labor; often associated with abnormal uterine activity and cephalopelvic disproportion.

episiotomy

Surgical incision of the perineum to enlarge the vaginal opening.

hydramnios

Excessive volume of amniotic fluid, more than about 2000 mL at term (also called polyhydramnios).

iatrogenic

Term used to describe an adverse condition resulting from treatment.

induction of labor

Artificial initiation of labor.

Montevideo unit

A unit of measure expressing the intensity of uterine contractions in millimeters of mercury as measured with an intrauterine pressure catheter; the contraction intensity minus the resting tone multiplied by the number of contractions in 10 minutes.

nuchal cord

Umbilical cord around the fetal neck.

oligohydramnios

Abnormally small quantity of amniotic fluid, less than about 500 mL at term.

placenta previa

Abnormal implantation of the placenta in the lower uterus.

premature rupture of the membranes

Spontaneous rupture of the membranes before the onset of labor (term, preterm, or postterm gestation).

version

Turning the fetus from one presentation to another before birth, usually from breech to cephalic.

What are three risks associated with amniotomy?

Three major risks of amniotomy are prolapsed umbilical cord, infection, and abruptio placentae.

Why is the FHR assessed before and after the membranes rupture?

The FHR is assessed before the membranes rupture to identify whether the fetus has a normal rate and pattern and establish a baseline. It is checked after the membranes rupture to identify patterns that suggest umbilical cord compression and other problems.

What is the significance of green amniotic fluid?

Green amniotic fluid contains meconium, passed from the fetal intestines. It may be seen in post-term gestation or placental insufficiency.

What maternal and fetal signs are associated with chorioamnionitis?

Signs of chorioamnionitis include fetal tachycardia (often the first sign), elevated maternal temperature, and amniotic fluid that has a foul or strong odor or a cloudy or yellowish appearance.

What precautions are taken to enhance the safety of oxytocin administration for the woman and fetus?

Five precautions that promote safe oxytocin induction or augmentation of labor include the following:
a. Dilution of the oxytocin in an isotonic solution
b. Piggybacking the oxytocin solution into the port of the primary nonadditive (maintenance) IV line that is nearest the venipuncture site
c. Starting the oxytocin infusion slowly
d. Increasing the rate of infusion gradually
e. Monitoring uterine contractions and FHR

How may oxytocin administration differ if labor is being augmented rather than induced?

Labor may be augmented if it stops or contractions become ineffective. The woman whose labor is augmented with oxytocin usually needs less of the drug than the woman whose labor is being induced, because her uterus is more sensitive to its effects.

What signs may indicate a nonreassuring fetal response to oxytocin stimulation?

The fetus may have an adverse reaction to oxytocin, manifested by nonreassuring FHR patterns such as bradycardia, tachycardia, late decelerations, or decreased FHR variability.

What are the signs of hypertonic uterine activity?

Signs of hypertonic uterine activity include incomplete relaxation of the uterus between contractions or a rest period shorter than 30 seconds or Montevideo units exceeding 400, which may result in inadequate placental blood flow and a fall in fetal oxygenation. Nonreassuring FHR patterns may occur even if these signs of hypertonic uterine activity are absent.

How can induction of labor with oxytocin contribute to postpartum hemorrhage?

Administration of oxytocin for a prolonged time may lead to postpartum hemorrhage because the fatigued uterus cannot contract properly to compress bleeding vessels at the placenta site (uterine atony).

Why is observing the FHR important before, during, and after ECV?

The FHR should be monitored before external version to identify nonreassuring patterns that would preclude the procedure and to establish a baseline. It should be monitored (by Doppler or real-time ultrasound) as much as possible during and after external version to detect cord compression that can occur if the umbilical cord becomes entangled during change of the fetal presentation. FHR assessment will continue if induction is started after a successful induction.

Why should the uterine activity be monitored after ECV?

Uterine activity should be observed after external version for possible onset of labor because this procedure may cause uterine irritability or possible abruptio placentae; therefore the procedure is done near term.

What are the similarities in the uses of forceps and vacuum extractors? What are the differences? Do limits exist for the number of attempts with these instruments?

Forceps and vacuum extraction are used to provide traction to assist the mother in rotation, expulsion, or both, of the fetal head. Special forceps (Piper) can be used to deliver the head of the fetus in a breech presentation, but a vacuum extractor can be used only with a cephalic presentation. Forceps may cause fetal injury such as facial bruising and nerve injury. The vacuum extractor may create an artificial caput called a chignon. No more than 3 "pop-offs" should be done and these should not be followed by forceps attempts at vaginal birth.

Why should the nurse add a urinary catheter to the instrument table if a vacuum extractor- or forceps-assisted birth is expected?

Catheterization before forceps are used eliminates a full bladder, which would reduce available room in the pelvis. Emptying the bladder also reduces the risk of bladder injury.

A woman has a forceps birth with a median episiotomy. What nursing interventions can make her more comfortable?

Use of cold immediately (for the first 12 hours) after episiotomy reduces pain, edema, and formation of hematomas. The nurse should also observe for continuous, bright red bleeding that suggests a vaginal wall laceration. Warmth after at least 12 hours of cold application promotes resolution of the edema and hematoma.

What injury is suggested by an asymmetric facial appearance when the infant cries?

The infant with an asymmetric facial appearance when crying may have facial nerve injury, usually a temporary condition that sometimes occurs when forceps are used to assist birth.

Why is the low transverse uterine incision preferred for cesarean birth?

The low transverse uterine incision is less likely to rupture during another pregnancy than either of the two vertical incisions. There are, however, valid reasons for the use of vertical incisions.

What should a woman who expects a cesarean birth be taught about the operating room? The recovery room?

The woman expecting a cesarean birth should be taught the following about the operating room and recovery area:
a. Preoperative procedures, such as skin preparation and insertion of an indwelling catheter
b. Personnel who will be present and their functions
c. The narrow table, safety strap, and positioning measures
d. When her partner or support person can come in
e. If a regional anesthetic is planned, that she will be awake and feel pulling and pressure sensations but should not expect pain. If a general anesthetic is planned, that all preparations will be made before anesthesia is induced but that the surgery will not begin before she is asleep and she will not awaken during it.
f. In the recovery area, use of oxygen, pulse oximeter, and automatic blood pressure cuff for vital signs; checking of her fundus, incision, lochia, and pain-relief needs

How should the nurse modify recovery room care of the mother who had a cesarean birth from that of the mother who had a vaginal delivery?

The woman who has cesarean birth needs care similar to that of the woman who delivers vaginally, in terms of vital signs and fundus and lochia assessments. Additional care includes assessment of oxygen saturation and respiratory status, observation of urine output from the indwelling catheter, pain needs, and respiratory care (turning, coughing, deep breathing). Anesthesia-related care includes level of consciousness (primarily if general anesthesia was used) and return of movement and sensation (primarily if epidural or subarachnoid block was used).

SUMMARY CONCEPTS

Prolapse and compression of the umbilical cord are the primary risks of amniotomy. As the fluid gushes out, the cord can become compressed between the fetal presenting part and the expectant woman's pelvis.

SUMMARY CONCEPTS

Infection is more likely to occur when membranes have been ruptured for a long time (such as 24 hours or longer).

SUMMARY CONCEPTS

Induction of labor may be done if continuing the pregnancy is more hazardous to the maternal and fetal health than the induction. It is not done if a maternal or fetal contraindication to labor and vaginal birth exists.

SUMMARY CONCEPTS

Oxytocin-stimulated uterine contractions may be hypertonic, decreasing placental perfusion.

SUMMARY CONCEPTS

External cephalic version is done to promote vaginal birth by changing the fetal presentation from a breech or transverse lie to a cephalic presentation. Internal version sometimes is used to change presentation of a second twin after the birth of the first twin.

SUMMARY CONCEPTS

Trauma to maternal and fetal tissue is the primary risk associated with use of forceps and vacuum extraction. Possible trauma to the mother includes vaginal wall laceration and hematoma. Trauma to the infant may include ecchymoses, lacerations, abrasions, facial nerve injury, and intracranial hemorrhage.

SUMMARY CONCEPTS

The median episiotomy is less painful but more likely to extend into the rectum than the mediolateral episiotomy.

SUMMARY CONCEPTS

The preferred uterine incision for cesarean birth is the low transverse incision because it is least likely to rupture in a subsequent pregnancy. The skin incision does not always match the uterine incision and is unrelated to the risk of later uterine rupture.

SUMMARY CONCEPTS

Some women have feelings of guilt and inadequacy if they have a cesarean birth or if they choose not to try VBAC when given that choice. Therapeutic communication and sensitive, family-centered care are essential to help them achieve a positive perception of their birth experience.

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