The Intrapartal Experience

9. Alterations affecting protective function
   1. Induction of labor-deliberate initiation of uterine contractions.
      1. Indications for:
         1. History of rapid or silent labors, precipitate birth.
         2. Woman resides some distance from hospital (controversial).
         3. Coexisting medical disorders:
            1. Uncontrolled diabetes.
            2. Progressive preeclampsia.
            3. Severe renal disease.
            4. Cardiac disease.
         4. PROM-spontaneous rupture of membranes before onset of labor and less than 37 weeks from last menstrual period.
            Hazards:
            1. Maternal-intrauterine    infection(chorioamnionitis, endometritis).
            2. Fetal-sepsis; prolapsed cord.
         5. Rh or ABO incompatibility, fetal hemolytic disease.
         6. Congenital anomaly (anencephaly).
         7. Postterm pregnancy with nonreactive nonstress test (NST), or oligohydramnios.
         8. Intrauterine fetal demise.
      2. Criteria for induction:
         1. Absence of CPD, malpresentation, or malposition.
         2. Engaged vertex of single gestation.
         3. Nearing, or at term.
         4. Fetal lung maturity.
            1. Survival rate-better at 32 weeks or more.
            2. Lecithin/sphingomyelin ratio greater than 2:1.
            3. Diabetic mother-PG is present in amniotic fluid.
         5. “Ripe” cervix-softening, partially effaced, or ready for effacement/dilation (if not already present). Note: Intravaginal or paracervical application of prostaglandin gel, or misoprostol may be used to prepare cervix for labor.
      3. Methods:
         1. Amniotomy-artificial rupture of membranes with fetal head engaged and dilation of cervix.
         2. Intravenous oxytocin infusion.
      4. Potential complications:
         1. Amniotomy-irrevocably committed to birth. Hazards:
            1. Prolapsed cord.
            2. Infection.
         2. IV oxytocin infusion:
            1. Overstimulation of uterus.
            2. Decreased placental perfusion/fetal distress (neonatal jaundice).
            3. Precipitate labor and birth.
            4. Cervical/perineal lacerations.
            5. Uterine rupture.
            6. Postpartum hemorrhage.
            7. Water intoxication-if large doses given in D/W over prolonged period (antidiuretic effect increases water reabsorption).
            8. Hypertensive crisis.
      BEFORE INDUCTION
      5. Assessment-before induction:
         1. Estimate of gestation (EDB, fundal height, cervical status).
         2. Bishop score: evaluation of cervical inducibility
         3. General health status:
            1. Weight, vital signs, FH R, edema.
            2. Status of membranes.
            3. Vaginal bleeding.
            4. Coexisting disorders.
         4. History of previous labors, if any.
         5. Emotional status.
         6. Knowledge/understanding of anticipated procedures:
            1. Amniotomy (artificial rupture of membranes).
            2. IV oxytocin infusion.
            3. Fetal monitoring
         7. Preparation for childbirth (Lamaze, etc.); coping strategies. Identify support person.
      6. Analysis/nursing diagnosis:
         1. Knowledge deficit related to process of induction.
         2. Anxiety/fear related to need for induction of labor.
         3. Ineffective individual coping related to psychological stress.
         4. Pain related to uterine contractions.
      7. Nursing care plan/implementation:
         1. Goal: health teaching.
            1. Explain rationale for procedures:
               1. Amniotomy.
                  1. Induces labor.
                  2. Relieves uterine overdistention.
                  3. Increases efficiency of contractions, shortening labor.
               2. Oxytocin infusion.
                  1. Induces labor.
                  2. Stimulates uterine contractions.
               3. Internal fetal monitor.
                  1. Provides continuous assessment of uterine response to oxytocin stimulation.
                  2. Provides continuous assessment of fetal response to physiological stress of labor.
            2. Describe procedure-to reduce anxiety and increase cooperation.
            3. Explain advantages/disadvantages- to ensure “informed consent.”
         2. Goal: emotional support-encourage verbalization of concerns, reassure, as possible.
      8. Evaluation/outcome criterion: woman verbalizes understanding of process, rationale, procedures, and alternatives.
      DURING INDUCTION AND LABOR
      9. Assessment-during induction and labor:
         1. Amniotomy-same as for spontaneous rupture of membranes:
            1. Observe fluid-note color, amount.
            2. Monitor FHR; assess for fetal distress.
            3. Observe for signs of prolapsed cord.
            4. Assess fetal activity.
               1. Excessive activity may indicate distress.
               2. Absence of activity may indicate distress or demise.
         2. IV oxytocin infusion:
            1. Continually assess response to oxytocin stimulation/flow rate; always given by controlled infusion.
               1. Uterine contractions.
               2. Maternal vital signs, FHR.
            2. Identify signs of:
               1. Deviation from normal patterns:
                  1. Lack of response to increasing flow rate.
                  2. Uterine hyperirritability (contractions-less than 2 minutes apart).
                  3. Lack of adequate uterine relaxation between contractions.
               2. Side effects of oxytocin: diminished output-potential water intoxication.
               3. Hazards to mother or fetus:
                  1. Sustained (over 90 seconds) or tetanic (strong, spasmlike) contractions-potential abruptio placentae, uterine rupture, fetal hypoxia/ anoxia/death.
                  2. Fetal arrhythmias, decelerations.
                  3. Maternal hypertension- potential for hypertensive crisis, cerebral hemorrhage.
      10. Nursing care plan/implementation:
          1. Same as for other women in labor.
          2. If indications of deviations from normal patterns:
             1. Change maternal position.
             2. Stop oxytocin infusion, maintain IV with Ringer’s lactate, etc.
             3. Begin oxygen per mask; up to 8-10 L/min.
             4. Notify physician promptly.
             5. Check maternal blood pressure and pulse rate.
          3. Anticipatory guidance: may have strong contractions soon after induction starts.
      11. Evaluation/outcome criteria:
          1. Demonstrates response to oxytocin stimulation.
             1. Establishes desired contraction pattern, not hyperstimulated.
             2. Progresses through labor-within normal limits:
                1. Normotensive.
                2. Voids in adequate amounts.
                3. No evidence of deviation from normal contraction patterns.
          2. No evidence of fetal distress.
          3. Experiences normal vaginal birth of viable infant.
   2. Operative obstetrics-procedures used to prevent trauma/reduce hazard to mother or infant during the birth process.
      1. Episiotomy-incision of perineum to facilitate infant’s birth.
         1. Rationale:
            1. Surgical incision reduces possibility of laceration.
            2. Protects infant’s head from pressure exerted by resistant perineum.
            3. Shortens second stage of labor.
         2. Types:
            1. Midline-chance of extension into anal sphincter greater than with mediolateral.
            2. Mediolateral-healing is more painful than midline.
         3. Assessment:
            1. REED A:
               1. Redness
               2. Edema
               3. Ecchymosis
               4. Discharge
               5. Approximation (suture line intact, separated)
            2. Healing.
            3. Bruised; hematoma.
            4. Tenderness; pain. Note: Evaluate complaints of pain carefully. If intense, and unrelieved by usual measures, report promptly. May indicate vulvar, paravaginal, or ischiorectal abscess or hematoma.
         4. Analysis/nursing diagnosis:
            1. Pain related to labor process.
            2. Impaired skin integrity related to surgical incision.
            3. Fluid volume deficit related to hematoma.
            4. Sexual dysfunction related to discomfort.
         5. Nursing care plan/implementation:
            1. Goal: prevent/reduce edema, promote comfort and healing.
               1. Place covered ice pack during immediate postpartum
               2. Administer analgesics, topical sprays, ointments, witch hazel pads, hydrocortisone.
               3. Encourage use of sitz bath or rubber ring.
               4. Encourage Kegel exercises.
               5. Do health teaching:
                  1. Instruct in tightening gluteal muscles before sitting.
                  2. Instruct to avoid sitting on one hip.
            2. Goal: minimize potential for infection.
               1. Teach/provide perineal care during fourth stage of labor.
               2. Health teaching: instruct in selfperineal care after voiding, defecation, and with each pad change.
         6. Evaluation/outcome criteria:
            1. Woman’s incision heals by primary intention.
            2. Woman demonstrates appropriate self-perineal care.
            3. Woman evidences no signs of hematoma, infection, or separation of suture line.
            4. Woman experiences minimal discomfort.
      2. Forceps-assisted birth-use of instruments to assist birth of infant.
         1. Indications:
            1. Fetal distress.
            2. Maternal need:
               1. Exhaustion.
               2. Coexisting disease, such as cardiac disorder.
               3. Poor progress in second stage.
               4. Persistent fetal OT or OP position.
         2. Criteria for forceps application:
            1. Engaged fetal head.
            2. Ruptured membranes.
            3. Full dilatation.
            4. Absence of CPD.
            5. Some anesthesia has been given; usually, episiotomy has been performed.
            6. Empty bladder.
         3. Types:
            1. Low-outlet forceps.
            2. Mid-applied after head is engaged (rarely used).
            3. Pipers-applied to after-coming head in selected breech births.
         4. Potential complications:
            1. Maternal:
               1. Lacerations of birth canal, rectum, bladder.
               2. Uterine rupture/hemorrhage.
            2. Neonatal:
               1. Cephalhematoma.
               2. Skull fracture.
               3. Intracranial hemorrhage, brain damage.
               4. Facial paralysis.
               5. Direct tissue trauma (abrasions, ecchymosis).
               6. Umbilical cord compression.
         5. Assessment:
            1. FHR immediately before-and after-forceps application (forceps blade may compress umbilical cord).
            2. Observe mother/newborn for injury or signs of complications.
         6. Analysis/nursing diagnosis:
            1. Self-esteem disturbance related to inability to give birth without surgical assistance.
            2. Anxiety/fear related to infant’s appearance (forceps marks) or awareness of potential complications.
         7. Nursing care plan/implementation:
            1. Goal: minimize feelings of failure due to inability to give birth “naturally.”
               1. Explain, discuss reasons/indications for forceps-assisted birth.
               2. Emphasize no maternal control over circumstances.
            2. Goal: reduce parental anxiety, maternal guilt over infant bruising/forceps marks. Explain condition is temporary and has no lasting effects on child’s appearance.
         8. Evaluation/outcome criteria:
            1. Woman verbalizes understanding of reasons for forceps-assisted birth.
            2. Woman evidences no interruption in bonding with infant.
            3. Woman experiences uncomplicated recovery.
      3. Vacuum extraction (soft plastic cup with vacuum from a suction pump). Used to assist in rotation or delivery of the fetal head.
         1. Risks may include caput succedaneum and cephelhematoma.
         2. Causes neonatal jaundice, IVH-death.
      4. Cesarean birth-incision through abdominal wall and uterus to give birth.
         1. Indications for elective cesarean birth:
            1. Known CPD.
            2. Previous uterine surgery (myomectomy), repeated cesarean births (depends on type of incision done).
            3. Active maternal genital herpes II infection; human papilloma virus (HPV).
            4. Breech presentation. (Note: To reduce infant morbidity/mortality, elective cesarean birth is common method of choice.)
            5. Neoplasms of cervix, uterus, or birth canal.
            6. Maternal diabetes with placental aging; fetal macrosomia (CPD); >425 g.
         2. Criteria for elective cesarean birth: L/S ratio greater than 2:1 -indicates presence of pulmonary surfactant; less risk of respiratory distress syndrome.
         3. Indications for emergency cesarean birth:
            1. Fetal:
               1. Fetal distress: prolapsed cord, repetitive late deceleration, prolonged bradycardia.
               2. Fetal jeopardy: Rh or ABO incompatibility.
               3. Fetal malposition/malpresentation.
            2. Maternal:
               1. Uterine dysfunction; rupture.
               2. Placental disorders:
                  1. Placenta previa.
                  2. Abruptio placentae, with Couvelaire uterus.
               3. Severe maternal PIH/eclampsia.
               4. Fetopelvic disproportion.
               5. Sudden maternal death.
               6. Carcinoma.
               7. Failed induction.
         4. Types:
            1. Low segment-method of choice:
               1. Transverse incision through abdominal wall and lower uterine segment.
               2. Transverse incision through abdominal wall, with vertical incision of lower uterine segment.
               3. Advantages-fewer   complications:
                  1. Less blood loss.
                  2. More comfortable convalescence.
                  3. Less adhesion formation.
                  4. Lower risk of uterine rupture in subsequent pregnancy/labor and birth.
                  5. Cosmetically more acceptable.
            2. Classic-vertical incision through abdominal wall and uterus. Necessary for anterior placenta previa and transverse lie, <28 weeks prematurity.
            3. Porro’s-hysterotomy followed by hysterectomy. Necessary in presence of:
               1. Hemorrhage from uterine atony.
               2. Placenta accreta/percreta.
               3. Large uterine myomas.
               4. Ruptured uterus.
               5. Cancer of uterus or ovary.
         5. Assessment:
            1. Maternal physical status.
               1. Vital signs.
               2. Labor status, if any.
               3. Contractions (if any).
               4. Membranes (intact; ruptured).
               5. Bleeding.
            2. Fetal status.
               1. FHR pattern.
               2. Color and amount of amniotic fluid.
               3. Biophysical profile (BPP)
            3. Maternal emotional status.
            4. Understanding of procedure, indications for, implications.
            5. Other-as for any abdominal surgery.
         6. Analysis/nursing diagnosis:
            1. Self-esteem disturbance related to perceived failure to give birth vaginally.
            2. Anxiety/fear related to impending surgery and/or reasons for cesarean birth.
            3. Ineffective individual coping related to anxiety and fear for self, infant.
            4. Fluid volume deficit related to abdominal surgery or reason for cesarean birth.
            5. Pain related to abdominal surgery.
            6. Constipation related to decreased bowel activity.
            7. Altered urinary elimination related to fluid volume deficit.
         7. Nursing care plan/implementation:
            1. Preoperative:
               1. Goal: safeguard fetal status.
                  1. Monitor fetal heart rate continually.
                  2. Notify neonatology and neonatal intensive care unit (NICU) of scheduled surgical birth.
               2. Goal: health teaching.
                  1. Describe, discuss anticipated anesthesia.
                  2. Explain rationale for preoperative antacids to minimize effects of aspiration: cimetidine, Bicitra, histamine blocker to decrease production of gastric acid. Reglan (metoclopramide), to hasten gastric emptying.
                  3. Describe, explain anticipated procedures - abdominal shave, indwelling catheter, intravenous fluids - to woman and support person.
               3. Other - as for any abdominal surgery.
               4. Prepare for cesarean birth.
            2. Postoperative:
               1. Same as for other abdominal surgical patients.
               2. Same as for other postpartum women.
         8. Evaluation/outcome criteria:
            1. Verbalizes understanding of reasons for cesarean birth.
            2. Successful birth of viable infant.
            3. Evidences no surgical/birth complications.
            4. Evidences no interference with bonding.
            5. Expresses satisfaction with procedure and result.
      5. Trial of labor after cesarean (TOLAC)
         1. Candidates for TOLAC.
            1. Previous low transverse cesarean birth.
            2. Head well-engaged in pelvis (vertex presentation).
            3. Soft anterior cervix.
            4. Preexisting reason for repeated cesarean birth not apparent.
         2. Assessment:
            1. Monitor FHR carefully during trial of labor.
            2. Monitor contractions carefully for adequate progress of labor.
            3. Observe mother for signs of complications/uterine rupture.
         3. Analysis/nursing diagnosis:
            1. Knowledge deficit related to trial of labor.
            2. Fear related to outcome for fetus.
            3. Ineffective individual coping related to labor progress and outcome.