Module 4F – Operative Obstetrics

Definition of Terms

Operative obstetrics

- Special procedures that the physician or nurse may use to assist the mother in labor
and delivery
o Mechanical or chemical procedures to hasten labor to save life of both mother
and fetus
o Facilitate the process of labor
o Provide alternate breathing mechanism

Induction of Labor

- The stimulation of uterine contractions by medical or surgical means to produce delivery

before the onset of spontaneous labor
- NO START OF LABOR

Augmentation of Labor

- Enhances ineffective contractions after labor has began

o Nipple stimulation
o Shortens labor and avoids necessity of cesarean section
- LABOR HAS STARTED

Woman at risk for operative delivery

- 35 years old and above - Received epidural anesthesia 1

- Height is less than 150 cm (4 ft. 11 hours before birth
in.) - Receive oxytocin infusion
- Weight gain is more than 15 kgs - Racial origin
- Smoker o Black – 40% less than
- Gestational age is 41 weeks or white
more o Asian – 63% greater than
white

Labor Induction

- Involves intravenous therapy, bed rest, continuous electronic fetal monitoring,

significant discomfort from stimulating contractions, epidural analgesia/ anesthesia,
prolonged stay on the labor unit
- Indications
o Post-term gestation – beyond term week
o Prolonged premature rupture of membranes – takes around 24 hours for
infection to set in
o Gestational hypertension
o Renal disease
o Chorioamnionitis – infection on amniotic area
o Isoimmunization – incompatibility of blood with child
o Dystocia – difficult labor
o Intrauterine fetal demise
- Contraindications
o Complete placenta previa
 o Abruptio placentae
o Transverse fetal lie
o Prolapsed umbilical cord
o Prior classic uterine incision that entered uterine cavity
o Pelvic structure abnormality
o Previous myomectomy
o Vaginal bleeding with unknown cause
o Invasive cervical cancer
o Active genital herpes infection
o Abnormal FHR patterns
- Considerations

- Use induction of labor cautiously in: Risks to:

o Multiple gestation
o Uterine rupture
o Hydramnios – more
o Decrease in the fetal blood
amniotic fluid
o Grand parity supply from prior cotyledon
filling
o Maternal age older than 35
years o Premature separation of
the placenta
o Presence of previous
uterine scars

Methods

Use of oxytocin

- Synthetic form of a naturally occurring pituitary hormone

- Intravenous oxytocin infusion (pitocin, syntocinon)
- Criteria to maintain dose:
o Intensity of contractions result in intrauterine pressures of 40-90 mmHg
o Duration of contractions is 40-90 seconds
o Frequency of contractions is 2-3 minutes interval
o Cervical dilation of 1 cm/hour in active phase
- Indications
o Inadequate uterine contractions
o Premature rupture of membranes
o Post-term pregnancy
o Pregnancy-induced hypertension
o Fetal demise
- Contraindications
o Cephalopelvic disproportion (CPD), cord prolapse, transverse lie
o Placenta previa
o Prior classis uterine incision
 o Active genital herpes
o Invasive cancer of the cervix
- Reportable conditions
o Uterine hyperstimulation
o Non-reassuring fetal heart rate pattern
o Suspected uterine rupture
o Inadequate uterine response at 20 microunit/minute
- Emergency measures
o Discontinue use per hospital protocol
o Turn woman to her left side
o Increase primary IV rate up to 200 mL/hour, unless patient has water
intoxication, in which case, the rate is decreased to one that keeps the vein
open
o Give woman oxygen by face mask at 6-10 L/ minute

Amniotomy

- Artificial rupturing of the membrane

- Amniotic fluid characteristics:
o Smell – odorless
o Color – clear/straw
o pH – 7-7.5
- Nitrazine test
o Identify rupture of amniotic sac
o Green-blue color – presence of amniotic fluid
o Yellow – absence of amniotic fluid
- Klelhauer-Betke or Fetal Cell Blood Test
o Used to determine whether the blood cells are maternal or fetal
o Maternal – colorless when stained
o Fetal cells – purple/ pink when stained

Vaginal Delivery

Episiotomy

- Surgical cut made at the opening of the vagina during childbirth, to aid a difficult
delivery and prevent rupture of tissues
- Facilitate birth in the presence of maternal and fetal
distress
- Create more room in the presence of a breech
presentation or multiple gestation
- Create more room for the use of an instrument to
assist birth
- Indications
o Primigravida status
o Macrosomic fetus – larger than expected
o Occiput posterior position
o Use of forceps or vacuum extractor
o Shoulder dystocia
- Epissiorhaphy – surgical repair of injury to vulva by suturing
- Types
o Median (midline) – less painful, heals easily, decreased blood loss
o Mediolateral – increased blood loss

Type of Episiotomy
Characteristic Midline Mediolateral
Surgical repair Easy More difficult
Faulty healing Rare More common
Postoperative pain Minimal Common
Anatomical results Excellent Occasionally faulty
Dyspareuina Rare Occasional
Extensions Common Uncommon

Cervical ripening

- During pregnancy, the cervix is closed to keep the fetus inside the uterus
- Once labor begins, the cervix will open, or dilate wide enough to let the fetus come
through
- When the cervix changes from being closed and firm to soft and thin
- Methods
o Chemical agents – prostaglandins
o Mechanical methods – dilators/ sponges
- Possible complications
o Bleeding from undetected low-lying placenta
o Inadvertent rupture of membranes
o Introduction of infection

Forceps Assisted Delivery

- Uses a stainless-steel instrument, like tongs, with rounded edges that fit around a
fetus’s head for delivery
- Purpose
o Prevent pressure from being exerted on the fetal head
o Avoid subdural hemorrhage in the fetus as the fetal head reaches the perineum
- Indications

Mother at risk Fetal conditions

o Heart disease problems o Fetal distress premature

o Acute pulmonary edema separation of the placenta
o Intra-partal infection o Prolapsed umbilical cord
o Maternal exhaustion o Arrest of rotation
o Unable to push with o Abnormal position
contractions in the pelvic
Cessation of progress in the 2nd
division of labor such as
stage of labor
after regional anesthesia

- Conditions before delivery

o Membranes must have ruptured
o No CPD
o Fully dilated cervix to avert lacerations and hemorrhage
o Engaged presenting part
 o Empty bladder
- Types of forceps used
o Barton – rotate fetal head to more favorable
position (ROP to ROA)
o Keilland’s – short handles and cephalic curve,
used to rotate fetal head
o Piper – deliver head in breech presentation
o Simpson’s – outlet forceps
o Tarnier’s – axis traction forceps
- Complications
o Laceration of vaginal canal
o Cerebral trauma of baby
o Increased perinatal morbidity and mortality
o Low IQ

Vacuum Extraction Delivery

- Birth method involving attachment of a vacuum cup to the fetal head, using negative
pressure to assist in the birth of the head
- Advantages
o Little anesthesia
o Fewer lacerations
- Disadvantages
o Marked caput noticeable as long as 7 days after birth – not permanent
o Territorial tears from extreme pressure can occur
- Indications
o Prolonged labor
o Mother with cardiopulmonary disease
o Mother with high BP
- Contraindications
o Preterm (soft skull)
o Fetus who have undergone scalp blood sampling (high risk for bleeding)
- Risks
o Cephalohematoma
o Scalp laceration
o Subdural hematoma
o Mother – perineal, vaginal, cervical lacerations
o Soft tissue hematoma

Cesarean Section

- A surgical procedure in which the newborn is delivered by an incision made through the
maternal abdomen and the uterine myometrium
- Preserve life of mother and fetus
- Types
o Scheduled
o Extended – arise from complications during labor
- Indications

Maternal o Abruptio placenta

o CPD Fetal
o Severe hypertension
o Transverse lie
o Active genital herpes
o Breech presentation
infection
o Previous cesarian section o Fetal distress
o Extreme low birth weight
Placental o Macrosomia
o Multiple gestation
o Placenta previa

- Types of incision

Classical – made vertically Low segment – Pfannenstiel or

Bikini incision
o Bigger space for baby
o Larger vision, less possible o Less uterine rupture
trauma o Less blood loss
o Used in placenta previa o Easier to suture
o Emergency operations o Less likely to cause
o More blood loss postpartum gastrointestinal
o Risk rupture of uterus complications
o Higher incidence of o Visual area is small
infection o Prone to infection – located
near perineum
o Impractical for emergency
cesarean section
- Maternal risks
o Pulmonary embolism
o Wound infection
o Hemorrhage
o Injuries to bladder or bowel
- Effects of surgery
o Stress response
▪ Epinephrine – increase HR, blood glucose level, bronchial dilation
▪ Norepinephrine – peripheral vasoconstriction, increase BP
o Interfere body defenses
o Circulatory function
▪ Extensive blood loss – hypovolemia, lowered BP
o Body organ function
o Self-image or self-esteem
- Nursing care
o Preoperative interview
o Establish operative risk – person must be physically and psychologically well
o Preoperative diagnostic procedures
▪ Vital signs determination
▪ Urinalysis
▪ Blood studies (CBC)
 ▪ Serum electrolyte and pH
▪ Blood typing and crossmatching
▪ Sonogram

In the operation room

o Skin preparation
o Administration of anesthesia by anesthesiologists
o Surgical procedure
o Birth of the infant
o Immediate newborn and mother care
o Woman is transferred to the recovery room
o Drugs that should be available
▪ Ephedrine – used when BP falls
▪ Atropine sulfate – dry oral and respiratory secretions to prevent
aspirations
▪ Thiopental sodium – rapid induction of general anesthetic in an
emergency
▪ Succinylcholine – achieve laryngeal relaxation for intubation in an
emergency
▪ Diazepam – control convulsion, reaction to anesthetic
▪ Isoproterenol – reduce bronchospasm if aspiration occurs

Intrapartum Pain Experience

Pain

- Any sensation of discomfort

- Subjective symptom

Signs of pain

- Facial tenseness, flushing/paleness, rapid breathing/ PR, fisted hands, muscle tension,
muscle activity (pacing, turning, twisting), nonverbal expressions of pain (withdrawal,
hostility, fear, depression), verbal expressions (statements of pain, moaning/ groaning)

Etiology

- Contraction of uterus
- Stretching of cervix during dilation and effacement
- Traction on stretching and displacement of perineum
- Pressure on presenting part and surrounding organs (urethra, bladder, rectum) during
descent
- Uterine anoxia – compressed muscles during contraction
- Stretching of uterine ligaments
- Distention of the lower uterine segment
- Compression of the nerve ganglia in the cervix and lower uterine segment during
contraction

Pain management

- Goal
o Provide maximal relief of pain
o Provide maximal safety for the mother and the fetus
 o Facilitate labor and delivery as a positive family experience
- Nonpharmacological
o Reduce anxiety with explanations of the labor process
o Provide comfort measures
o Encourage comfortable positioning
o Assist with prepared childbirth exercises – breathing exercise, Lamaze
▪ Distraction by focusing on the external object, therapeutic touch,
muscle therapy, guided imagery, hypnosis

Hypnosis Acupressure

o Used for pain relief in both Yoga

obstetric and surgical
o Relaxation, concentration,
patients
and complete breathing –
o Reduce or eliminate the
need for depressant drugs abdominal and chest
breathing
- Pharmacologic

Narcotic analgesics

o Given in labor because of analgesic effect

o Contraindication: preterm labor – CNS and respiratory depressants

Demerol (meperidine HCl) Morphine sulfate

o Additional sedative and o Nalbuphine (nubain)

antispasmodic action
Fentanyl (sublimaze)
o IM/ IV
o Crosses placental barrier – Naloxone (narcan)
fetal depression
o Fetal liver takes 2-3 hours o Narcotic antagonist
to activate drug o Dose = 0.1 mg/kg injected
to umbilical vein

Sedative-hypnotics and Ataratics

o Complement the action of narcotics

o This alone cannot relieve pain, only reduce anxiety

Secobarbital sodium (seconal) – encourage rest

Promethazine (phenergan) – decrease anxiety

Childbirth Preparations

Dick-Read Method

- Provides information on labor and birth as well as nutrition, hygiene, and exercise
- 3 techniques:
o Physical exercise – prepare body for labor
o Conscious relaxation
o Breathing patterns

Lamaze Method (Psychoprophylactic Method)

 - Relaxation, concentration, focusing, and complex, well-paced breathing patterns to
reduce the perception of pain through a condition response to labor contractions

Bradley Method (Husband-coached childbirth)

- Husband takes active role in assisting woman to relax during labor and use correct
breathing techniques
- Focuses on slow breathing and deep relaxation for labor
- Reduced responsiveness to external stimuli
- Role of the male partner as coach

Post-operative Pain

- Narcotic analgesia with a PCA pump for the 1st 24-48 hours after surgery
- Oral analgesics – acetaminophen

Patient controlled analgesia

- Method of pain control

- Administer doses of IV narcotic analgesia

Transcutaneous Nerve Stimulation

- Electric impulses/ current across skin

- Two electrodes are positioned on each side of the abdominal surgical incision
- Effective in controlling pain

Types of Anesthesia

Regional anesthesia

- Injection of local anesthesia to block specific nerve pathways

Spinal anesthesia

o Injection of bupivacaine (marcaine) into the subarachnoid space at the 3 rd level

and 4th lumbar interspace
o Block nerves and suspend sensation and motion to the lower extremities,
perineum, lower abdomen
o Major complications
▪ Hypotension – validation
• Turn the woman too the left side to reduce vena cava
compression
▪ Spinal headache
• Administer analgesic
• Advise to lie flat

Epidural

o Introduce in epidural space

o Block sympathetic nerve in order to increase contraction strength and blood
flow to the uterus
o Side effect: spinal headache rarely happens
o Advantages – used with heart problems, pulmonary disease, diabetic mother
o Disadvantage – induced hypertension
o Nursing responsibilities
 ▪ Start IV to hydrate mother and emergency purposes
▪ Elevate leg
▪ Administer oxygen

Local Anesthesia

- Pudendal Block/ pudendal nerve block

- Injection in the right/left pudendal nerves at the level of the ischial spines
- Position mother in dorsal recumbent
- Provide relief for perineal pain
- Check FHR and maternal BP
- Takes effects and after 2-10 minutes, lasts for 60 mins.

General Anesthesia

- Never preferred for childbirth because of dangers of hypoxia, possible inhalation of

vomitus
- Inhalant (nitrous oxide, halothanol) and IV (penthotal)

Potential Nursing Diagnoses

- Pain related to surgical incision

- High risk for fluid volume deficit related to blood loss during surgery
- Fatigue related to effects of surgery
- Altered skin integrity related to surgical incision
- High risk for altered peripheral tissue perfusion related to immobility during and after
surgery
1. hypotension 4. determine if contraction has effect on
cervix
2. assess contractions
5. common s/s of oxytocin infusion
3. prevent water intoxication – antidiuretic
effect 6. CTG – cardiotocograpy

1. facial palsy – weakness on one side of the face

3. take note of lacerations

4. hasten healing – icepack, hot sitz, perilite exposure