NCM 107: Care of Mother, Child, Adolescent (Well-Client)

DEFINITION OF TERMS 6. Cesarean Delivery

1. Operative Obstetrics - Or birth accomplished through an abdominal
- Uses procedures that assist the mother in labor incision in the uterus
and delivery
- It may be mechanical or chemical procedures to
save life of both the mother or fetus
➔ Mechanical – with the use of stainless
instruments or the vacuum extraction
➔ Chemical Procedures – with the use of
medications
- It also facilitates the process of labor

2. Induction of Labor

- Labor is started artificially

- With this, the doctor will be requiring for
administration of medicines that would help in
choosing the labor of the mother
3. Amniotomy
- Artificial rupturing of membranes during labor if
they do not rupture spontaneously to allow the
fetal head to contact the cervix more directly
- This also increases the speed of labor and
utilizes at least 2 types of instruments:
1. Amniohook – long thin crochet-like
instrument
2. Hemostat
4. Analgesia
- Medications that alleviates the sensation of
pain
- When we say, alleviates the sensation of pain, it
would be a reduction of the pain, yet the pain is
still there
5. Anesthesia
- An absence of sensation or pain sensation by
interrupting the nerve impulse
- In anesthesia, there is a total absence of pain
- In the picture, we have here the abdominal
incision through horizontal incision or your low
segment type of cesarean delivery
7. Normal Delivery
- Is otherwise known as NSVD
- Normal Spontaneous Vaginal Delivery
8. Forceps Delivery
- A method of delivery with the use of obstetrical
forceps
- The obstetrical forceps being utilized in here are
made of stainless steel and they had been
sterilized
9. Vacuum Extraction Delivery
- Uses a vacuum device to assist in extracting a
baby
We must know that both vacuum extraction and forceps
are methods that can be used to assist the birth of the
baby especially the fetal head. The woman as well as
the infant needs special or specific observation after
these procedures to detect head trauma or cervical or
vaginal tearing

MODULE 4F: OPERATIVE OBSTETRICS YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- In the picture, there will be an insertion of those
instruments inside the vagina of the mother to
facilitate the delivery of the head of the baby
- So, it is very much needed that right after the
delivery, one must assess for the head trauma
of the baby and as well as the cervical or vaginal
tearing of the mother
10. Amniotomy
- Increases the efficiency of contraction and
therefore increases the speed of labor
- However, it puts a fetus momentarily at risk for
cord prolapse if a loop of cord escapes into the
vagina with the fluid
- It is also a risk for possible cesarean section
- Amniotomy itself increases the speed of labor
- Now, in amniotomy, the mother who is in labor
still has her membrane intact and so, if there
will be a prolonged intact of the membrane
then there is a possibility that the labor itself is
slower on its base.
- So, with amniotomy, there will be an increase of
labor by rupturing the amniotic membrane and
so there will be an escape of the amniotic fluid.
This puts the fetus momentarily at risk for cord
prolapse especially if the fetal cord is within the
presenting part of the baby.
➔ If there will be a cord prolapse or if the cord
escapes to the vagina, you have to
immediately cover the exposed cord with
sterile saline compress to the presenting
part.
➔ You must not attempt to push back the
exposed cord to the vagina because this
would add additional risk or compression
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Prior to amniotomy or Before:
✓ The mother must assume a dorsal recumbent
position that would mean supine position with
knees flexed
After Amniotomy:
✓ which the mother and the baby must be
assessed.
✓ First you have to time as to when the amniotic
membrane has been ruptured followed by
assessing for the fetal heart rate.
Why is this important?
- Because we have to rule out cord prolapse.
- Now, if there will be a cord prolapse and then
core compression happens, then the supply of
oxygen to the baby will be compromised. Thus,
would put the baby at risk
➔ At the same time also, we have to time as
to when the amniotic membrane has been
ruptured so that we can observe for
possible or potential for infection
- As mentioned earlier amniotomy utilizes both
amniohook and hemostat.
DIFFERENT FACTORS OF WHICH WOMEN
AT RISK FOR OPERATIVE DELIVERY
Maternal Factors
1. Active genital herpes or (perhaps) human
papillomavirus
• If the patient is having herpes or HIV or AIDS
as much as possible it is advisable to undergo
cesarian section because genital herpes is a
communicable disease and could be
transmitted especially genital herpes.
• The baby will be coming out from the vagina
and will be exposed with this infection
2. AIDS or (perhaps) HIV-positive status
3. Cephalopelvic disproportion
• The pelvis itself is not conducive for normal
delivery
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
4. Cervical cerclage
• Cervical cerclage is when there has been a
stitching of the cervix.
• Probably the reason for this treatment that
had happened to the mother was because of
some cervical weakness
5. Disabling conditions, such as severe gestational
hypertension, that would prevent pushing to
accomplish the pelvic division of labor
• You must know that if there is an intensity of
the contraction itself then the vital signs
would go up.
• So, if the mother has a severe gestational
hypertension, this is not advisable
6. Failed induction or failure to progress in labor
7. An obstructive benign or malignant tumor
8. Previous cesarean birth by classic incision
9. Fear of birth or wish to help prevent uterine
prolapse or urinary incontinence in later years
Placental Factors
1. Placenta previa
• It is when there is attaching of the placenta
inside the uterus but is normally positioned
near or lower or over the cervical opening
2. Premature separation of the placenta
3. Umbilical cord prolapse
• This would put the child’s life or the baby’s
life at risk for possible compression of the
cord and lack of oxygen
• In order to save the baby, obstetrical
procedures has to be done
Fetal Factors
1. Compound conditions such as macrosomic fetus
in a breech lie
2. Extreme low birth weight
Fetal Distress
1. A major fetal anomaly, such as hydrocephalus
2. Multigestation or conjoined twins
3. Transverse fetal lie and perhaps breech
presentation
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INDUCTION OF LABOR
- Labor is started artificially whether through
medical or surgical means of stimulating the
uterine contractions prior to onset of
spontaneous labor
- It is initiated before the time when it would
have occurred spontaneous contractions
because the fetus is endanger.
- Usually, if the mother probably has not yet
started labor but when they were assessing for
the fetal heart rate, the fetal heart rate is not
conducive anymore or not normal. So, there is a
fetal distress that is why there would be an
induction of labor.
- However, in Augmentation of Labor, this refers
to assisting labor that has started
spontaneously but is not effective
➔ The labor started itself however possible
there is a prolonged time.
➔ So, the progress that the duration of labor
for the primigravida and also for the
multigravida. Under estimation, if it is way
too more then that would still put the baby
and the mother’s life at risk. That is why
augmentation or a certain assistive like
medications has to be done so that there
will be a faster or you will be able to hasten
the progress of the labor itself
➔ Augmentation of labor is used when labor
contractions becomes weak, irregular or
ineffective
Indications for Induction of Labor
1. Pre-eclampsia
• Onset of high blood pressure and often a
significant amount of protein in the urine
• So, for those pregnant mother whose blood
pressure is way above the normal could be
one of the candidate for the induction of
labor
2. Eclampsia
3. Severe Hypertension
4. Diabetes
• Because there will be a constant
consumption of energy or glucose during the
labor itself
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
5. Rh Sensitization
• It is when there is incompatibility of Rh
between the mother and the baby
6. Prolonged ruptured of the membranes or PROM
• We have to detect this one because if there
will be a prolonged rupture of the
membranes as earlier being stated, this
would put the child’s life at risk
7. Intrauterine Growth Restrictions and Post
Maturity
• We all know the maturity or the AOG of a
fetus or a baby that is without complications
would be approximately between 36 to 40
weeks AOG
• So, with this one, the lung is already
functioning and vital to be outside the world
Contraindications for Induction of Labor
1. Complete Placenta Previa
• When there is an attachment of the placenta
near or over the cervical opening
2. Abruptio Placentae
• This happens when your placenta separates
early from the uterus before childbirth
• In this case, it is very alarming because the
baby is still inside and then your placenta
already detached.
• So, where will the baby get its nutrients and
its oxygen if the placenta will detach from the
uterine wall of the mother?
3. Transverse Fetal Lie
4. Prolapsed Umbilical Cord
5. Prior Classic Uterine Incision that entered the
uterine cavity
• Usually with the previous cesarean section
6. Pelvic structure is abnormal
• Cephalopelvic disproportion
7. Previous Myomectomy
8. Unknown cause of vaginal bleeding
• Why is this important?
➔ Because some factors wherein causes of
the bleeding could either be genetically
or you have your clotting factors that are
deficient enough so if you will do these
things, you will be inducing labor and
then the process would go on and with
the labor and delivery, there will be a
tendency that there will be a possible
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bleeding, hemorrhage would happen and
this could lead a patient into shock
9. Invasive Cervical Cancer
10. Active genital herpes infection
11. Abnormal FHR (fetal heart rate) patterns
Considerations for Induction of Labor
1. Ultrasound
- We have to check the position of the baby,
the placement
2. Pelvimetry
- To rule cephalopelvic disproportion
3. Nonstress Test
- This would be checking the contraction also
both from the mother and the fetal heart
rate of the baby
4. Phosphatidylglycerol
- It is a glycophospholipid that is found in
pulmonary surfactant in the membrane
- This would help us determine if the baby is
mature enough with the lecithin and
sphingomyelin surfactant
- The lungs surfactant are normal level so the
baby is viable
5. Nitrazine Paper or Fern Test
- This would help us check if there is a
premature rupture of membrane wherein
upon testing the vaginal fluid, we detect that
there will be a change of color
- The color will be blue on the nitrazine paper.
This would indicate that the membrane has
ruptured
6. CBC and Urinalysis
- We have to know the baseline data for the
blood level of your client and possible also for
any infections either also in the urine
7. Vaginal Examination
- This would help us more to determine the
effacement and dilation of the cervix
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Risk Factors of Induction of Labor
1. Uterine Rupture
2. Decrease in the fetal blood supply
3. From prior cotyledon filling
- Cotyledon are the ones that are found in your
placenta.
- This is a part of your embryo but are
commonly found in your placenta because
your placenta is the first organ of
development
- So, there would be a possible risk of fetal
blood supply decrease
3. Premature separation of placenta
METHODS OF INDUCTION
1. Oxytocin or Oxytocin Injection
- Oxytocin is a synthetic form of naturally
occurring pituitary hormone that can be used
to initiate labor contractions if a pregnancy is
at term
- Usually, once the mother is already admitted
and the labor has started, you have to assess
the characteristics of the contraction and also
if it is strong or not
➔ Prior to informing the doctor and for the
duration of time before the doctor would
decide and countercheck if there is a
need for an induction of labor
- It is administered intravenously
➔ Usually this is mixed with your
intravenous fluid
- The other name for oxytocin would be Pitocin
or syntocynon or syntocinon
- Solution: mixed in the proportion of 30 iu in
1000 ml of Ringers’ Lactate
➔ Ringers’ solution would be your LR
➔ You will be indicating this one in your IV
tab that there is medication being added
Indications of Oxytocin:
• Inadequate uterine contractions
• Premature rupture of the membranes
• Post term pregnancy
• Pregnancy-induced Hypertension
• Fetal Demise
➔ Fetal demise would be still birth
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➔ If there will be a still birth, then a
tendency that the contraction is not that
strong enough. The mother will be having
a difficulty to push.
➔ Pain is subjective, so if the pain will be on
the abdomen or lower back then that
would help the mother to push more so
that there will be an explosion of fetus
but if there will be a fetal demise then
possible there will be no or less
contraction because there will be no
more pain
➔ That is why we have to induce the labor
Contraindications of Oxytocin:
• CPD, Cord Prolapse, Transverse Lie
• Placenta Previa
• Prior classic uterine incision
• Active genital herpes
• Invasive cancer of the cervix
Criteria to maintain dose:
a. Check the intensity of the contractions
results in intrauterine pressure of 40 to 90
mmHg
b. Duration of contractions: 40-90 seconds
c. Frequency of contractions: 2-3 minute
interval
d. Cervical dilation of 1 cm/hr. in the active
phase
REPORTABLE CONDITIONS:
• Uterine hyperstimulation
• Non reassuring fetal heart rate pattern
➔ There will be a possibility for fetal
distress
• Suspected uterine rupture
• Inadequate uterine response at 20 mU/min
Maternal and Fetal Assessment with Oxytocin
administration:
✓ Assess maternal pulse and blood pressure,
and watch for hypotension
➔ These are vital thing to assess because
this would help us determine also if there
is a possibility that our client is going for
a shock or there is a bleeding inside
✓ Monitor fetal heart rate for signs of fetal
distress
✓ Monitor the frequency, duration and
strength of contraction during the infusion
✓ Monitor the intake and output and watch for
signs of water intoxication
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ Oxytocin would promote fluid retention
to the mother that is why we have to
check the intake and output and signs for
water intoxication of the mother
✓ Check for possible adverse effects like
nausea, vomiting, cardiac arrhythmias,
uterine hypertonicity, tetanic contractions,
uterine rupture and bradycardia
EMERGENCY MEASURES WHEREIN WE HAVE TO
STOP THE OXYTOCIN ADMINISTRATION DIRECTLY:
❖ Discontinue use of oxytocin per hospital
protocol
❖ Turn the mother to her left side
➔ This would promote oxygenation also for
the baby by not compressing the major
blood vessel which is the vena cava
❖ Increase primary IV rate up to 200 ml/hr
unless patient has water intoxication, in
which case, the rate is decreased to one that
keeps the vein open
➔ Usually, the primary IV is your plain NSS
and it should be without incorporation
meaning without medications
incorporated to the IV unless the patient
has water intoxicity
➔ Take note on this one because if there
will be a fluid retention, you can see that
the mother is already having breathing
problem and edema or swelling. So, you
cannot add more water or more fluid into
her body or else she will be drowning (?)
from it
➔ So, the purpose of your primary IV line
for this area is to keep vein open in cases
we need access for emergency
medications. Around 15 gtts/min or 15 to
20 gtts/min, sometimes 10 to 15 as
advised by the physician or by the doctor
❖ Give woman oxygen by face mask at 6 to 10
L/min or per protocol of the hospital or
physician’s order
➔ Some hospitals will allow you to give
oxygen to the patient at 2 L/min
regardless if there is a physician order or
not because sometimes doctors are not
always there by your side. So, they have
this standard protocol that if in cases
there are emergency and your client is
having difficulty in breathing, you can
MODULE 4F: OPERATIVE OBSTETRICS
begin with a low dose of oxygen at 2
liters
➔ By the time on, if there will be an
increase in the rate, then you have to
refer ahead of time to the attending
physician
2. Amniotomy
- Artificial rupturing of membranes
Characteristics of Amniotic Fluid:
• Odorless
• Color: clear/straw
➔ Color straw is much lighter than yellow.
Yellow is darker
➔ The color should be a bit lighter that is
light yellow or straw
• pH: 7-7.5
Advantage of Amniotomy:
 It increases the efficiency of contractions and
therefore increases the speed of labor
Disadvantage of Amniotomy:
 It puts the fetus at risk for cord prolapse
You have to know that there will be an expectation of
putting the mother into cesarean delivery
Nitrazine Test
- Identify rupture of amniotic sac
- Green to blue would mean there is a
presence of amniotic fluid
- Yellow – no presence of amniotic fluid
Klelhauer-Betke (Kleihauer-Betke)or Fetal Cell Blood
Test
- Used to determine if the blood cells are
maternal or fetal
- Maternal: remains colorless when stained
➔ There is no amniotic fluid leakage
- Fetal: turns purple pink in color when stained
Nursing Responsibilities:
✓ Explain the procedure to the client and
family
➔ This will reduce the anxiety of both the
client and the family regardless if they
are medically oriented or not
➔ This would also promote cooperation
both to the client and the family
themselves
✓ Assure the client that the procedure is
painless to her and her baby
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
✓ Assess the fluid color, odor, and consistency
of the amniotic fluid
➔ This is to disregard if there is an infection
➔ So, again it has to be a pH of 7 to 7.5
➔ It has to be odorless and clear or straw
➔ If you find that there is a color change
you need to report that. Like blood and
things like that
✓ Note and document the time of rupture
➔ This is very important because we have
to know if the onset of the labor itself
started and to prevent at the same time
infection and distress to the baby
✓ Note and document the fetal heart rate
before and after the procedure
✓ Assess the client’s temperature every 1 to 2
hours to check for infection
✓ Frequently assess the client’s level of comfort
✓ Maintain adequate intake and output records
✓ Document maternal and fetal assessments in
the medical record
Nipple Stimulation to Induce Labor
- This helps in releasing the hormone oxytocin,
that initiates labor by increasing the intensity
of contraction
- So, this will be done by the mother, or the
health care staff
- Now you have to inform the mother ahead of
time. Some mothers are against or let's just
say would feel awkward if the staff who will
be doing this one will be a male. So, out of
respect it should be a female staff
- Nipple stimulation usually are very
observable during the pushing delivery of the
baby we do this one in the delivery room
because this would help in the contraction
Advantage:
 Shortens Labor
 Avoids the necessity of cesarean section
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NORMAL SPONTANEOUS VAGINAL
DELIVERY
Episiotomy
- Surgical incision of the perineum made to
prevent tearing of the perineum
Uses:
- It uses to facilitate birth in the presence of
maternal and fetal distress
- It creates more room in the presence of
breech presentation or multiple gestation
- It creates room for the use of instruments to
assist birth
Factors that predispose a client to episiotomy:
• Primigravida
➔ First time mother
➔ Usually they are done with episiotomy
because this would prevent laceration
➔ There are four categories of laceration:
a. First degree
b. Second degree
c. Third degree
d. Fourth degree
➔ Primigravida patients or clients usually
there is a technique as to when to push
➔ The mother has to push at the peak of
the contraction and not at the beginning
of the contraction and must know when
to exert more effort and when to stop
• Macrosomic fetus
➔ The big baby
• Occiput posterior position
• Use of forceps or vacuum extractor
• Shoulder dystocia
➔ Shoulder dystocia is wherein the baby
cannot fully be out without some
interventions especially something done
with the shoulder of the baby like a
breakage on the clavicle side just to
facilitate faster delivery of the baby
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Types of Episiotomy: Nursing Responsibilities:
1. Midline Episiotomy During/Immediate:
- Incision is made with blunt-tipped scissors in 1. Monitor the vital signs
the midline of the perineum ➔ Vital signs is very important because if
- This is less painful, it easily heals, decreases there is intense bleeding then we can
blood loss, less postpartum discomfort prevent for possible shock and we can
- If there would be a tendency that it will not intervene with the hemorrhage
properly support that during the birth or 2. Observe aseptic technique
delivery of the head, then there will be a ➔ This is to prevent infection
possibility for a further laceration that would 3. Support perineum properly
go directly to the anus compared to your ➔ Upon delivery of the baby, especially if
mediolateral which is slanting position on the you are the assist nurse, you have to hold
side the perineal area properly and not to let
2. Mediolateral Episiotomy go or else once the baby’s head comes
- Begun in the midline but directed laterally out and out of your anxiety(?), expect
away from the rectum that there will be a laceration on the
- Creates less danger of a rectal mucosal tear perineal area
Episiorrapphy After/Postpartum:
- The surgical repair of injury to the vulva by 1. Do perineal care
suturing ➔ Initially, during your perineal care, it will
- If the mother has had Episiotomy, the be washing it right after episiotomy
surgical repair is known as your episiorrapphy ➔ The area will be washed to check and
internal examination will be done
Episiotomy Degrees ➔ Wash with aseptic solutions
1st Degree Laceration ➔ Instruct the mother in every time after
- The area that is affected would be your urinating or possible for toilet to be very
vaginal mucosa, perineal fascia and perineal careful on the sutures side and wiping
skin from front to down and not the other
nd
2 Degree Laceration way around
- Vaginal mucosa 2. Apply ice pack or cold compress within three
- Perineal body muscle hours
➔ It goes a bit deeper now ➔ This would cause vasoconstriction thus to
- Perineal fascia lessen the bleeding
3rd Degree Laceration 3. Provide hot sitz bath
- Vaginal mucosa, perineal fascia and muscles, ➔ This is to decrease the pain and promotes
rectal wall, anal sphincter healing on the suture side
th
4 Degree Laceration ➔ This would usually happen after 8 to 12
- Vaginal mucosa hours and not prior to that or
- Perineal fascia and muscles immediately
- Rectal wall 4. Render Perilite Exposure after 24 hours
- Anal sphincter ➔ Perilite exposure would be the use of
- This will be stitched with the different light ball and the client will be positioned
sutures that are available and corresponding in a dorsal recumbent and this will be put
sutures between your absorbable and non- in between the legs with an appropriate
absorbable sutures distance and it will be lit for 15 to 30
minutes
➔ This will promote healing and drying of
the surgical site
5. Administer analgesics as ordered

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Possible complications: Cervical Ripening Methods
• Bleeding from undetected low-lying placenta -
Is a change in cervical consistency from firm
• Inadvertent rupture of membranes to soft
• Introduction of infection 1. Chemical Agents
➔ If aseptic technique has not been a. Prostaglandin E1 – ex. Misoprostol (Cytotec)
followed ◼ This would encourage faster delivery of
Nursing Responsibilities: the baby since your cervix is ripe and soft
1. Document the number of dilators and enough. This would facilitate with labor
sponges inserted during the procedure b. Prostaglandin E2 – Dinoprostone (Cervidil
➔ After the delivery of the baby there will insert; prepigil gel)
be cleaning on the inside so the doctor ◼ Used before induction to “ripen” (soften
will be inserting some sponges okay so as and thin) the cervix
a nurse you have to count those 2. Mechanical Methods
whatever that has been put in should be a) Laminaria tents – natural cervical dilators
the number that has been put out made from seaweeds
2. Assess for urinary retention b) Hydroscopic dilators – substances that
➔ You have to see that during either absorb fluid from surrounding tissues and
delivery or incision suturing, the urinary then enlarge
area has not been damaged at the same c) Synthetic dilators containing magnesium
time sulfate (Lamicel) – inserted into the
➔ You can ask the mother if still probably endocervix without rupturing the membranes
there's still a sense of urgency to urinate d) Stripping the membranes – separating the
but you have to double check most of membranes from the lower uterine segment
most mothers at this time most not all ◼ This would promote labor itself
are with urinary catheter
3. Assess for rupture of membranes, uterine
tenderness/pain FORCEPS DELIVERY
4. Assess vaginal bleeding and fetal distress - One of the method for delivering or assisting
the delivery of the head of the baby
- Uses a stainless-steel instrument, similar to
Types of Episiotomy
tongs, with rounded edges that fit around a
Characteristic Midline Mediolateral
Surgical Repair Easy (because More difficult fetus’s head for delivery
the cut is (since it is Purpose:
straight) slanting on the
side) • To prevent pressure from being exerted on the
Faulty Healing Rare (heals fast More Common fetal head
and good) • To avoid subdural hemorrhage in the fetus as
Postoperative Minimal Common the fetal head reaches the perineum
Pain
Anatomical Excellent Occasionally Indications:
Results faulty
1. Mother At Risk:
Blood Loss Less More
Dyspareunia Rare Occasional • Heart disease problems
Extensions Common Uncommon ◼ Because most of this mother cannot bear
enough to push harder
• Acute pulmonary edema
• Intrapartal infection

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
• Maternal exhaustion
• Unable to push with contractions in the pelvic
division of labor such as after regional
anesthesia

2. Fetal Conditions:

• Fetal distress
• Premature separation of the placenta
• Prolapsed of the umbilical cord
• Arrest of rotation
• Abnormal position - In here you can see the station zero should be
in line with your ischial spine
3. Cessation of progress in the 2nd stage of labor
- Forceps delivery should not be on your pelvic
- The labor itself is ineffective that is why we floor so it should not go down to your positive
have to induce by cervical five six seven it should be between your two
and your three
Categories - This can be determined when your physician
1. Outlet Forceps will do the internal exam
Criteria:
• Forceps are applied when the fetal skull has
reached the perineum
• Scalp is visible between the contractions
• Sagittal sutures is not more than 45 degrees
from the midline

2. Low Forceps
Criteria:
• Presenting part of the skull must be at a
station of +2 or below (e.g. +3) but not on the Certain Conditions before forceps delivery:
pelvic floor
• Membranes must have ruptured
• Rotation of the fetal head is less than 45
degrees • CPD is not present
• Cervix must be fully dilated to avert lacerations
and hemorrhage
3. Midforceps • Presenting part must be engaged
Criteria: • Woman’s bladder must be empty
• Fetal head must be engaged (level of ischial
➔ So that this will not be the problem upon
spine, station 0) but the presenting part of
the delivery of the baby and also at the
the skull is above a station of +2 (e.g. +1, 0,
-1, -2) same time this would help hasten the
delivery of the baby itself

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Nursing Responsibilities when it comes to forceps 4. Simpson’s Forceps – used most commonly as
delivery: outlet forceps
5. Tarnier’s – Axis traction forceps
✓ Explain the procedure to the mother, tell her
what to expect Complications of Forceps Delivery:
➔ We don't want the mother to be surprised
• Laceration of the vaginal canal
how come there are some markings on the
fetal head when she will be seeing her • Cerebral trauma of the baby
newborn for the first time that is why we • Increased perinatal morbidity and mortality
have to tell and explain what is the • Low IQ
outcome of this procedure ➔ Because there will be an insertion of this
➔ In Philippine settings, usually the doctor instrument
who explained for this things that to get the ➔ There is a tendency that there will be a
concept from the mother but regardless of compression of the blood supplies on the
that one we have to know “ma'am was the head area
doctor was able to explain to you the
procedure the outcome of this one” and so
on and so forth
✓ Assess and record FHR before and after
application
➔ Again because there will be a possibility
that there it might cause injury to the baby
✓ Assess the mother for vaginal and cervical
laceration
✓ Record the time and amount of first voiding
➔ Especially if there is some trauma that
happens on the vaginal area on the
perineum
✓ Assess the newborn for facial palsy and
subdural hematomas
➔ Since the forceps will be clipped on the
head area
✓ Explain to the parent that a forceps birth may
have a transient erythematous mark on the
newborn’s cheek, face in 1 to 2 days

Different Types of Forceps Delivery:

1. Barton – used to rotate the fetal head to a more

favorable position (ROP to ROA)
2. Kielland’s - With short handles and marked
cephalic curve.
◼ Used to rotate the fetal head to a more
favorable position
3. Piper – Used to deliver the head in a breech
presentation or position

MODULE 4F: OPERATIVE OBSTETRICS YUSON, DREA

VACUUM ASSISTED 1. It causes a marked caput

DELIVERY that may be noticeable as long

as 7 days after birth.

Vacuum Extraction Delivery
- so there is like a cone head
- Birth method involving the
attachment of a vacuum cup to the
that would occur on the top
fetal head, using negative
pressure to assist in the birth of
nose.
the head.

2. Tentorial tears from

Advantages Over Forceps
extreme pressure can occur.
Delivery:
- especially of the pulling

 Little anesthesia is delivery of the baby.

necessary

 Fewer lacerations of the Indications:

 Prolonged labor
birth canal occur
 Mother with cardiopulmonary
disease
 Mother with high BP

- why is it ? because you are

Contraindication:
cupping the head rather than
 Preterm (soft skull)
- because of their soft skull it
in the forceps, there will be
is not allowed.
- we know that there will be a cup
a use of instrument that is
being put on the scalp of the baby
and negative pressure will be
made of stainless steel.
done.
- Preterm babies are not allowed
or contraindicated in your vacuum
extraction delivery.
Major Disadvantages:
 Fetus who have undergone scalp
blood sampling (high risk for
bleeding)

Bandiola, Jovelyn P.
  Vaginal cervical
Nursing Responsibilities:
laceration of your soft
1. Provide emotional support to
both mother and significant
tissue trauma
others.

- prior to your vacuum extraction

it should also have been explained
of the possible outcome or outlook
of the baby with the caput.
- emotional support to the mother
and significant other sometimes
they would ask you questions, will
the baby be okay? Will there be
some mental issues and so on and
so forth.

3. Asses fetal heart rate (FHR)

during the procedure.

4. Position the mother in

lithotomy position to allow for
- there will be some degree of
sufficient traction.

lacerations on the perineum

5. Newborn should be observed for
signs of trauma and infection at
area.
the application site and for
cerebral irritation.

Newborn Complications:
Risk of Vacuum Extraction
1. Cephalhematoma -
Delivery
happening on the inside.
- pressure that is applied to

the fetal head

- there could be some under

maternal complications:

 Perenial
Bandiola, Jovelyn P.
2. Scalp laceration - there may be done either internally

is a shape of the cup of the or externally.

vacuum cup.

External cephalic version

- quite familiar to us here as

for those “manghihilot” or

“mananabang”, especially if

they can sense that the baby

is not in the normal position,

they will try to move it

3. Subdural hematoma - which
externally by massaging on
is also on the inside.
the client’s abdomen.

 Turning of the fetus to a

vertex presentation by

external exertion of

pressure on the fetus

through the maternal

VERSION
abdomen.
- the turning of the fetus
 Turning of the fetus from
officially from one
a breech to a cephalic
presentation to another and
position prior to birth.

Bandiola, Jovelyn P.
 Attempted in a labor and abdomen with the

birth setting after 37 administration of the

weeks of gestation tocolytic agents.

- magnesium sulfate will be

- this is attempted after 37 given IM near your buttocks

weeks of gestation because area.

earlier we all do know that

fetus are considered to be

mature between 36 to 40 weeks.

So with this if there will be

a problem then the fetus is

viable already in the outside

world.

 Tocolytic agent such as

magnesium sulfate is given

to relax the uterus and

Contraindications:
facilitate the maneuver.
 Uterine anomalies

 Previous cesarean birth

- there has to be no
 CPD (cephalopelvic
contractions to be happening
disproportion)
and we can manipulate the
 Placental previa
Bandiola, Jovelyn P.
  Check maternal vital signs
 Multifetal/multiple
 Ultrasound should be recorded
continuously
gestation
 Assess the woman’s level of
comfort
 Oligohydramnios

 Rh incompatibility Internal Version

 The fetus is turned by the
- you are to avoid the
physician who inserts a hand
into the uterus and changes
separation or the mixing of
the presentation to cephalic
or podalic (feet)
the fetal maternal blood .
 May be used in multifetal
pregnancies to deliver the
 Unexplained third
second fetus.
- especially this happens if the
trimester bleeding
baby is not yet fully engaged, so
the baby would still turn.
- there will be some unknown
- upon internal exam, the doctor
will notice that there has been a
bleeding or clotting factors
change on the presentation of the
baby, provided that it is not on
disorder that happens to the
a transverse, then this can be
done.
mother or not yet diagnosed
- maybe used in multifetal
pregnancy to deliver the second
and this would promote
baby.

possible for hemorrhage later

on.

 Ruptured amniotic

membrane

 History of premature labor

Nursing Responsibilities:
Contraindications:
 Continuously monitor FHR
especially bradychardia  Lack of anesthesia

Bandiola, Jovelyn P.
- there has to be an anesthesia
because this is internally done
before the baby is out for
delivery.
 Unskilled health care team
member in internal podalic
version
 Retracted cervix or
contracted thickened uterus.
- the uterus has to be on a relaxed
state and there has to be an
anesthesia in order to perform
internal version.
PAIN
- pain in peripheral terminals is
automatically reduced by the
production of endorphins and
encephalins, naturally occurring
opiates that limit transmission
of pain from the end terminals.
Pain can be reduced further at
these end points by mechanically
irritating nerve fibers through
an action such as rubbing the skin,
which blocks nerve transmission.
A major way to block spinal cord
neurotransmitters (i.e., never
allowing the pain impulse to cross
to a spinal nerves) is by the
administration of pain
medications. In addition, the
brain cortex can be distracted
from sensing impulses as pain by
such techniques as imagery ,
thought stopping, and perhaps
aromatherapy or yoga.
Sensory impulses from the
perineum, which is involved in the
second stage of labor are carried
by the pudendal nerve to join the
spinal column at S2, S3, and S4.
When the perineum is initiating
the pain, anesthetic pain relief
must block these lower receptor
sites. Some interventions
relieve pain for both the first
and second stages of labor whereas
others work for one stage but not
both.
- because we all know nothing is
a subjective.
 So the pain that the mother
feels could be different from
the other. One person might
have a higher threshold of
pain compared to the other.
Intrapartum pain experience
Pain
- any sentation of discomfort
- a subjective symptom
Subtle signs of pain:
- facial tenseness
- flushing or paleness
- rapid breathing, rapid PR
- fisted hands
- muscle tension
- muscle activity like pacing,
turning, twisting
- nonverbal expressions of pain
may include withdrawal,
hostility, fear or depression
- verbal expressions of pain may
include statements of pain,
moaning or groaning
Etiology:
 contracting of the uterus
 stretching of the cervix
during dilation and
effacement
Bandiola, Jovelyn P.
 - DILATION is the opening of equipment, this would lessen the
the cervix, if basement is anxiety and lessen the pain felt
your thinning of the cervix. by the mother.
 Traction on stretching and
displacement of the perineum 2. Provide comfort measures
 Pressure on the presenting - example: backrub (always ask
part of the fetus on tissues permission to the mother)
and surrounding organs such as
urethra, bladder and rectum 3. Encourage comfortable
during descent positioning
 Uterine anoxia due to - position the mother on the left
compressed muscle cells side, you can add additional
during contraction pillows if the mother feels
 Stretching of uterine uncomfortable
ligaments (area of the pelvic
area) 4. Assist with prepared
 Distention of the lower childbirth exercises (e.g.
uterine segment breathing exercise, Lamaze)
 Compression of the nerve distraction by focusing on
ganglia in the cervix and external object, therapeutic
lower uterine segment during touch, muscle therapy, guided
the contraction. imagery, hypnosis
- it has to be done prior to the
active stage of labor as much as
possible.
Intrapartum Pain Management
- you have to orient your patient
Goals: and teach your patient of some of
1. To provide maximal relief of this non-pharmacological pain
pain management so that this would
2. To provide maximal safety for facilitate and help you during the
the mother and the fetus active phase of labor.
3. To facilitate labor and
delivery as a positive family Nonpharmacologic Methods:
experience 1. Support from a doula or couch
Doula
Nonpharmacologic Pain - woman who is experienced in
Management: childbirth and postpartum
1. Reduce anxiety with support.
explanations of the labor - may hold certificates as
process. birth or postpartum doulas.
- if we are able to educate our - increase woman’s self esteem,
patient and explain the speed the labor process, and
procedures that we will be doing improve breastfeeding success
to her even attaching, monitoring as well as decrease rates of

Bandiola, Jovelyn P.
 oxytocinaugmentation, there will be a removal of
epidural anesthesia, cesarean anxiety and fear.
birth, and postpartum - if there is no tension built
complications. up there will be less pain to
the client.
 Support group or individual
who could teach women of the Lamaze Method
possible outcome of the (Psychoprophylactic)
pregnancy or birth or delivery
itself would help the mother. - combine’s relaxation,
concentration, focusing and
2. Hypnosis complex well-paced breathing
- used for relief in both patterns to reduce the
obstetrics and surgical perception of pain through a
patients conditioned response to labor
- reduces or eliminates the contractions.
need for depressant drugs
Bradley Method (Husband - Coached
3. Acupressure Childbirth)
- your pressure points
- husband takes an active role
4. Yoga in assisting the woman to
- teaches relaxation, relax during labor and use
concentration and “complete correct breathing techniques
breathing” ( combination of - focuses on slow breathing
abdominal and chest and deep relaxation for labor
breathing) - focuses on reduced
responsiveness to external
Dick-Read Method stimuli
- emphasized the use of - focuses on the role of the
relaxation and proper male partner as coach
breathing with contractions
as well as family support and Pharmacologic Pain Manageent:
education
- provides information on 1. Narcotic Analgesics
labor and birth as well as
nutrition, hygiene and - given in labor because of
exercise. analgesic effect
- it is the total control of - contraindicated in preterm
your pain wherein if the labor because it is a CNS and
patient is more or less almost respiratory depressant.
the same with doulas, there
will be an explanation on why Examples:
these things happen so that

Bandiola, Jovelyn P.
 Demerol (meperidine
hydrochloride)
- has additional sedative and
antispasmodic actions
- Given IM or IV
- Crosses the placental barrier
thereby causing fetal
depression
- Fetal liver takes 2-3 hours to
activate the drug so must be
given 3 hours away from birth
 Morphine Sulfate
 Nalbuphine (Nubain)
 Fentanyl (Sublimaze)
 Naloxone (Narcan) - narcotic
antagonist should be
available
- it is a must if the client
has a possibility or is given
Demerol, Morphine, Nalbuphine,
Fentanyl and Naloxone on hand
since it is your antagonist
from this narcotics.
- narcotics would cause CNS
and respiratory
depression,not just on the
baby but also the mother.
2. Sedative-Hypnotics and
Ataratics (compliments the
action of narcotics)
 Secobarbital sodium (Seconal)
- to encourage rest
 Promethazine (Phenergan) - to
decrease anxiety
Post-op Pain:
 Narcotic analgesia given with
a PCA pump for the 1st to 48
hours after the surgery
 Oral analgesic like
acetominophen are given
1. PCA - Patient Controlled
Analgesia
- A method of pain control
- Patient administer doses of
IV narcotic analgesic
2. TENS - Transcutaneous Nerve
Stimulation
- Transmission of electrical
impulses/ current across the
skin
- Two electrodes are
positioned on each side of the
abdominal surgical incision
- Effective in controlling
pain
REGIONAL ANESTHESIA
- injection of a local anesthesia
to block specific nerve pathways
interspace.
Spinal Anesthesia
- injection of bupivacaine
(Marcaine) into the subarachnoid
space at the level of 3rd and 4th
lumbar interspace
- block nerves and suspend
sensation and motion to the black
nerves and suspend sensation and
motion to the lower extremities,
perineum and lower abdomen.
Major Complications:
 Hypotension - validation
- turn the woman to her left
side to reduce a vena cava
compression
 Spinal Headache
Bandiola, Jovelyn P.
 - Administer analgesic
- advise to lie flat

 Epidural - introduced in the

epidural space
- blocks the sympathetic nerve
in order to increase
contraction strength and
blood flow to the uterus.
- Side effect: Spinal headache
rarely happens
- otherwise known as PAINLESS
DELIVERY

Advantage:
 Used with heart problem,
pulmonary disease
 Used in diabetic mother
Disadvantage:
 Induced hypotension
Nursing Responsibilities:
 Start IV to hydrate the mother
and for emergency purposes
 Elevate leg
 Administer oxygen
Local Anesthesia
( Pudendal Block/Pudendal Nerve
Block)
 Injection in the right or left
pudendal nerves at the level
of the ischial spine
 Position mother in the dorsal
recumbent position
 Provides relief of perineal
pain
 Check FHR and maternal blood
pressure
 Takes effects and after 2 to
10 mins and lasts for 60 mins
- given if there will be a
Physiography or the repair of the
surgical side of your episiotomy.

General Anesthesia
 Never preferred for
childbirth because of dangers

Bandiola, Jovelyn P.
 of hypoxia, possible
Common indications for
inhalation of vomitus.

cesarean section include:

Examples:
1. Dystocia
 Inhalant (nitroud axide, 2. Placenta previa
Halothanol) and Intravenous 3. Fetal distress
(Penthotal)

Drugs that should be readily Other conditions requiring

available: cesarean may include:

1. Ephedrine - used when blood 1. Multiple births
pressure falls 2. Large tumors of the uterus
2. Atropine Sulfate - to dry and 3. Genital herpes or other
respiratory secretions to prevent infections
aspiration 4. Uncontrolled diabetes or
3. Thiopental Sodium - rapid hypertension
induction of a general anesthetic
in an emergency
Before the procedure:
4. Succinylcholine - to achieve
laryngeal relaxation for
intubation in an emergency 1. IV line
5. Diazepam - to control 2. Catheter
convulsions, a reaction to 3. Regional or general anesthesia
anesthetic
6. Isoproterenol - to reduce
After the procedure:
bronchospasm if aspiration should
occur
1. 3-5 day hospital stay
2. Breastfeed, nap when the baby
sleeps, and get out of bed
CAESARIAN DELIVERY
3. 6-8 weeks for full recovery
A surgical procedure in which the 4. Scar lightens as it heals
newborn is delivered through the
abdomen from the incision made
2 TWO TYPES OF CESAREAN
through the maternal abdomen and
the uterine myometrium
SECTION:
Done to preserve the life of the 1. Scheduled Cesarean Section
mother and her fetus 2. Emergency Cesarean Section

Bandiola, Jovelyn P.
Indications of CS:
Maternal factors
- CPD
- severe hypertension during
pregnancy
- active genital herpes
inspection
- previous cesarean section
Fetal factors
- transverse fetal lie
- breech presentation
- Fetal distress
- Extreme low birth weight
- macrosomia
- multiple gestation
Placental factors
- placenta previa
- abruptio placenta
Classical Incision
- made vertically
Advantages:
- bigger space for the baby
- larger version, less possible
trauma
Can be used in placenta previa
Disadvantages:
- more blood loss
- risk for rupture of the uterus
- higher incidence of infection
Low Segment Incision
- most common type
- a.k.a. Pfannenstiel incision or
bikini incision
Advantages:
- less uterine rupture
- Less blood loss
- easier to suture
- less likely to cause postpartum
or gastrointestinal
complications
Disadvantages:
- visual area is small
- prone to infection (located near
the perineum (located near the
perineum)
- impractical for emergency
cesarean section
MATERNAL RISK FACTORS:
- pulmonary embolism
- wound infection
- hemorrhage
Bandiola, Jovelyn P.
- Injuries to the bladder or bowel wearing of hospital gown, remove
nail polish
Effects of Surgery: - Gastrointestinal tract prep
1. stress response (enema)
 Epinephrine - increase HR, - Baseline intake and output
blood glucose level, determination
bronchial dilation - Hydration (IVF is given)
 Norepinephrine with - Preoperative meds:
circulatory function - IM Cimetadine (tagamet) -
decrease stomach secretions
2. Interference with body - No citrate (Bicarta) -
defenses neutralize stomach secretions
- Prepare the client’s chart and
3. Interference with circulatory surgery checklist
function - Transport mother to operationg
 Extensive blood loss - room for delivery
hypovolemia, lowered BP

4. Interference with body organ In the Operating Room

function
5. Interference with self - image
or self - esteem
Pre-operative interview
- establish operative risk
- person must be in the best
possible physical and
psychological fit before surgery
- skin preparation
- Administration of anesthesia by
anesthesiologists
- Surgical procedure
- Birth of the infant
- Immediate newborn and mother
care
- Woman is transferred to the
recovery room

Nursing Problems:
Preoperative diagnostic
procedures - Fear related to impending
surgery
- Vital signs determination - Pain r/t a surgical incision
- Urinalysis - Deficient fluid volume related
- Blood studies (CBC) to blood loss from surgery
- Serum electrolytes and pH - Powerlessness r/t medical need
- Blood typing and crossmatching for episiotomy or cesarean birth
- Sonogram - Risk for anxiety r/t
- Immediate pre-operative care unanticipated circumstances
measures surrounding birth
- Obtain informed consent - Risk for infection related to
- Overall hygiene-shower, surgical procedure

Bandiola, Jovelyn P.
- Risk for hemorrhage related to
surgical procedure
- Risk for impaired parent-infant
attachment related to unplanned
method of birth
- altered skin integrity r/t
surgical incision
- High risk for altered peripheral
tissue perfusion related to
immobility during and after
surgery

Bandiola, Jovelyn P.