06.05 Obstetrical Procedures

Overview

  1. Various procedures are utilized to facilitate and assist the safe delivery of the fetus and prevent injury to the mother

Nursing Points

General

  1. Procedures can include the use of medications or tools to facilitate and assist in delivery
    1. Induction of Labor
    2. Amniotomy
    3. Episiotomy
    4. Forceps-Assisted Delivery
    5. Vacuum-Assisted Delivery
    6. External version
    7. Caesarean Section

Assessment

  1. Fetal heart rate
    1. Is the fetus safe in its environment
  2. Does delivery need to happen now?
    1. Induction
    2. C-section
  3. Is there enough room for the baby to fit?
    1. Episiotomy

Therapeutic Management

  1. Induction
    1. Artificial initiation of labor by stimulating contractions
      1. Oxytocin (Pitocin) typically used
      2. D/C Pit if contractions are less than 2 min apart, longer than 1.5 minutes, or if fetal distress is apparent
  2. Amniotomy
    1. When amniotic sac is intentionally ruptured to stimulate labor
      1. Baby must be at 0+ station
      2. Watch for meconium stained amniotic fluid, which is associated with fetal distress
      3. Note if amniotic fluid is malodorous, which can indicate infection
  3. External version
    1. Moves baby from an abnormal position to a normal position, much more favorable for a successful vaginal delivery
    2. Monitor appropriately
    3. Tocolytics given
  4. Episiotomy
    1. An incision made in the vagina to make the outlet larger for delivery
      1. Nurses are responsible for assessment and care
      2. Ice for first 24 hr, sitz bath after
      3. Prevent infection, educate on s/s infection to watch for
  5. Forceps
    1. Use of forceps to help deliver the baby’s head
    2. Check for injury, assist with repair of any lacerations on mom/baby
    3. Risk for Postpartum Hemorrhage
  6. Vacuum
    1. Suction device applied to baby’s head to aid in delivery of head
    2. Should not have more than 3 “pop offs”
    3. Assess newborn’s scalp immediately after birth and routinely after for signs of trauma/hematoma and report as needed
    4. Watch for caput succedaneum (edema of scalp from prolonged pressure from cervix, vacuum)
      1. Typically resolves in 24 hours
  7. Caesarean Section
    1. Insert foley
    2. Typically spinal block used unless emergent/no time, then they’ll use general anesthesia
    3. Monitor, administer meds as appropriate
      1. Antibiotic prior to c-section-prophylactic
    4. Post op, watch for:
      1. Tender uterus, malodorous lochia (endometritis)
      2. Painful urination (bladder or urinary tract infection)
      3. Pain, edema, redness of an extremity (thrombophlebitis)
      4. Surgical site – REEDA

Nursing Concepts

  1. Safety
  2. Reproduction

Patient Education

  1. Risks of forceps, vacuum
  2. Sitz baths
  3. S/S of infection
  4. Hand hygiene

Reference Links

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Video Transcript

In this lesson I will explain the various obstetrical procedures and your role in this care.

Procedures are done to ensure a healthy, safe delivery of the baby. We need to ensure mom is kept safe too. These procedures can include the medications or tools to facilitate and assist in delivery. These procedures include Induction of Labor, amniotomy, episiotomy, forcep-assisted delivery, vacuum-Assisted delivery, and a caesarean section.

Let’s talk about our assessment and management. So several different things. How is the fetal heart rate? Is the fetus stressed or in a safe in its environment. So if the fetus was stressed we would see signs based on the fetal heart rate. The heart rate could be low or high. Does delivery need to happen now? If the baby needs to be delivered we can induce labor either with medications or foley bulb, which is a balloon placed in the cervix to get it to start to dilate. It could also mean a c-section for delivery. Is there enough room for the baby to fit? An episiotomy can be done to make more room at delivery.

Let’s look at these procedures in more detail. Induction is done by stimulating contractions and getting the body to go into labor. This can be done with Oxytocin or Pitocin. Induction can also be done with cytotec or foley bulb. Both of these go into the cervix to help cause dilation to occur. An amniotomy is done to intentionally rupture the sac to stimulate labor. This will cause the head to drop lower into pelvis on the cervix to cause contractions and dilation. When the water is broken we need to watch for meconium stained amniotic fluid, which is associated with fetal distress, it should be clear and no odor. An external version is done to move the baby from an abnormal position to a normal position, much more favorable for a successful vaginal delivery. This is a painful procedure because it is manually turning a large fetus and pushing and turning on the large uterine muscle. The fetus needs to be monitored appropriately. Tocolytics will be given to relax the uterus and prevent contractions. An episiotomy is an incision made in the vagina to make the space larger for delivery. You can see in this image where the cut is made. It will allow room but also cause swelling. These patients will need ice to their perineum for the first 24 hr. Sitz baths can also be given.

Forceps are a tool to help deliver the baby’s head. In this image you can see they look like salad tongs. They go on either side of the head and the physician pulls as mom pushes. The fetus will need to be checked for injury from this to the face. Sometimes have some brachial plexus also. The mother will be at risk for postpartum hemorrhage so this needs to be monitored. A vacuum is an instrument applied to the fetal head. It is a way for the physician to steer the infant as the mom pushes. You can see in this image the vacuum is applied to guide the head out. Sometimes suction is lust and the vacuum pops off. There should not be more than 3 pop offs of the vacuum. So each pop off should be documented and you need to mention to the doctor “that is the third pop off”. So this is where it can get a little intense. We need have a plan.You have to advocate for that patient and ensure the physician doesn’t try again. If they choose to then this must be well documented that you told the doctor or doctor aware and that the vacuum was reapplied. Usually now the OR has been opened, which means everything is set and ready. If 3 pop offs occur the physician will either have a come to Jesus moment with the patient she has to push hard and deliver this baby or we have to go to the OR. This is never good because the fetus is so low that a nurse is going to have to push the fetus back up as the physician pulls up through a cesarean opening. I’ve been in a few of these deliveries and it is hard not to feel panicked! Everyone sort of holds their breath but it is a lot of stressed on the fetal head to be manipulated with a vacuum and then being pushed up when it’s head is so well applied! The baby should be assessed on the scalp immediately after birth and routinely after for signs of any trauma. Caput succedaneum needs to be watched for. This is edema of scalp from prolonged pressure from the vacuum. A caesarean section might be necessary for a breach delivery or if the fetus is not handling labor or labor isn’t progressing.This patients are more at risk for blood clots because they aren’t moving as much and their incision also needs to be watched.

The nursing concepts for this patient will be safety and reproduction. We need to ensure the safety of the mother and the fetus.
Now we can review the main points. Obstetrical procedures are interventions to facilitate a safe delivery for mom and baby. There are several but the main ones are episiotomy, which is a cut at the perineum that will make more room for the baby to deliver. This patient will need ice for 24 hours to her perineum. A vacuum-assisted delivery is a suction placed on the fetal head and the physician will guide the baby out as the mom pushes. No more than 3 pop offs for this. A forcep-assisted delivery look like salad tongs that go on the sides of the head and the baby is pulled down and out. This is a risk for facial injury. And an, external version which is done to turn the baby to vertex position. The mother is given tocolytics to stop contractions and relax the uterus during the procedure. The mom and fetus will be monitored.

Make sure you check out the resources attached to this lesson and review the different procedures and signs and symptoms to watch for after they are done. Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 10

A postpartum client is recovering from a cesarean section in which she had an epidural placed for pain control. Following removal of the epidural, the client develops a severe headache when she sits up in bed. The provider has instructed the client that she will need a blood patch. Which best describes this procedure?

  • Question 2 of 10

A nurse is caring for a client who had an episiotomy during her vaginal delivery. Which intervention would be most appropriate when caring for a client with this condition?

  • Question 3 of 10

A pregnant client is preparing to have a cesarean section to deliver her baby. The provider ordered for placement of an epidural for the procedure. What information should the nurse include about this type of anesthesia when teaching this client? Select all that apply.

  • Question 4 of 10

A nurse is performing a newborn assessment on a baby born by a vacuum assisted vaginal delivery. Which of the following findings would be the most concerning?

  • Question 5 of 10

A nurse is assessing the results of a non-stress test on a pregnant client. During the test, the infant had a baseline heart rate of 120, which rose to 125 for 15 seconds on the 3 movements that the fetus had. How should the result be documented?

  • Question 6 of 10

A nurse is caring for a client who underwent an episiotomy during a vaginal delivery. What is the most important nursing intervention?

  • Question 7 of 10

A nurse who works on the postpartum unit is caring for a client who delivered a baby by cesarean section three hours ago. The mother has an epidural in place and is unable to get out of bed. Which information must be reinforced to this parent that would protect the safety of both the mother and the baby in this situation?

  • Question 8 of 10

A pregnant patient who is in labor has an epidural placed because she will be undergoing a cesarean section. The epidural remains in place for the next 24 hours after delivery. Which of the listed side effects is most commonly associated with an epidural following cesarean section?

  • Question 9 of 10

A nurse is performing a postpartum assessment on a client who underwent a forcep delivery. Which of the following findings is the most concerning?

  • Question 10 of 10

A nurse is caring for a mother and baby delivered today at 39 weeks gestation in a forcep-assisted delivery. What possible complications should the nurse be looking out for?

Module 0 – OB Course Introduction

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