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.