Birth Related Procedures

Professor Burke
Spring 2009

Impact of Procedures
on Childbearing Woman
Disappointment
Guilt
Conflict between expectation and need for
intervention

Contraindications to
Induction

Relative Contraindications

Prelabor Status Evaluation

Version

External Cephalic Version (ECV)

Podalic Version (Internal)

Figure 271 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.

Figure 272 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 babys head
up toward the top of the uterus with one hand, the physician pulls the babys foot down toward the cervix. C, Both feet have been pulled
through the cervix and vagina. D, The physician now grasps the babys trunk and continues to pull downward on the baby to assist the birth.

Figure 272 (continued) 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 babys head up toward the top of the uterus
with one hand, the physician pulls the babys foot down toward the cervix. C, Both feet have been pulled through the cervix and vagina. D, The physician now
grasps the babys trunk and continues to pull downward on the baby to assist the birth.

Nursing Management
Maternal/fetal
assessments
NST
Lab studies
Psychological support

Education
Monitor VS
EFM
Mediation
administration Betamimetics, 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 womans
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

Figure 273 The two most common types of episiotomies are midline and mediolateral. A, Right mediolateral. B, Midline.

Nursing Management

Support
Assist with communication of womans 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

Forceps-Assisted Birth:
Fetal Indications

Premature placental separation

Prolapsed umbilical cord
Nonreassuring fetal status

Figure 275 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. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, 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.

Figure 275 (continued) 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. B, The right blade is inserted along the right side wall of the pelvis over the parietal
bone. C, 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.

Figure 275 (continued) 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. B, The right blade is inserted along the right side wall of the pelvis over the parietal
bone. C, 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.

Types of Forceps

Outlet forceps
Midforceps
Breech forceps

Figure 274 Forceps are composed of a blade, shank, and handle and may have a cephalic and pelvic curve. (Note labels on
Piper and Tucker-McLean forceps.) The blades may be fenestrated (open) or solid. The front and lateral views of these forceps
illustrate differences in blades, open and closed shanks, and cephalic and pelvic curves. Elliot, Simpson, and Tucker-McLean
forceps are used as outlet forceps. Kielland and Barton forceps are used for midforceps rotations. Piper forceps are used to
provide traction and flexion of the aftercoming head (the head comes after the body) of a fetus in breech presentation.

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

Maternal Risks
Lacerations of the birth
canal
Periurethral lacerations
Extension of a median
episiotomy into the anus
More likely to have a thirdor fourth-degree laceration
Postpartum infections

Cervical lacerations
Prolonged hospital stay
Urinary and rectal
incontinence
Anal sphincter injury
Report more perineal pain
and sexual problems in the
postpartum period

Nursing Management

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

Figure 276 Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a
downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the
vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Figure 276 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is
applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge
from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Figure 276 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is
applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge
from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.

Nursing Management

Inform woman about procedure

Pumps the vacuum
Supports the woman
Assesses the mother and neonate for
complications

Neonatal Risks with

Vacuum Extraction

Scalp lacerations and bruising

Shoulder dystocia
Subgaleal hematomas
Cephalhematomas
Intracranial hemorrhages
Subconjunctival hemorrhages

Neonatal Risks with

Vacuum Extraction (continued)

Neonatal jaundice
Fractured clavicle
Erbs palsy
Damage to the sixth and seventh cranial
nerves
Retinal hemorrhage
Fetal death

Indications for
Cesarean Birth

Complete placenta previa

CPD
Placental abruption
Active genital herpes
Umbilical cord prolapse
Failure to progress in labor

Indications for
Cesarean Birth (continued)
Proven nonreassuring fetal
status
Benign and malignant
tumors that obstruct the
birth canal
Breech presentation
Previous cesarean birth
Major congenital anomalies
Cervical cerclage

Severe Rh isoimmunization
Maternal preference for
cesarean birth

Impact on the Family

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
Supporting the couple
Instrument count

Nursing Management
After Cesarean Birth

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

Vaginal Birth After Cesarean

(VBAC): Risks