Induction of Labor
Prostaglandin suppository:
Use before oxytocin drip.
Ripen the cervix à soften up and start dilating.
Vaginal exam done to make sure effacement and dilation is occurring before giving pitocin.
Inductionà not having contractions and given pitocin to start.
Augmentationà having contractions and given pitocin to help the progress.
Dystocia:
Difficult labor.
Labor that progresses at a slower than normal rate.
Labor prolonged, >24 hours.
Any of 3 p’s result of
- passenger à size of baby
- passage à CPD
- powers à failure to progress
- Passage à absolute CPD: baby can’t be delivered, must have C-section.
- Position à in posterior, don’t get flexion to come out, malpresentations- breech.
- Failure to progress à general term used to describe the lack of cervical changes and fetal descent during active phase.
- Uterine dysfunction à contractions at slower rate than expected, 0 dilation.
- Premature Rupture of Membranes (PROM):
- Membranes rupture after 37 weeks.
- PPROM before 37 weeks.
- After 37 weeks, baby’s lungs good and mom may go into spontaneous contractions.
- Biggest problem is risk for infection if not gone into labor.
- The chorion and amnion will get infected.
- S&S: increased temp, uterus tender to touch.
- TX: prophylactic antibiotic.
- Fetus is also at risk for infection.
- PPROM - may give saline.
- Hydramnios à
- ROM greater chance of prolapse cord.
- AKA: polyhydramnios - more than 2000ml amniotic fluid.
- Prolapse Cord
:
- The cord preceeds the presenting part of the baby.
- Do not ambulate if ROM or prolapse cord or baby not engaged.
- Prolapse cord à get pressure off by putting in Trendelenburg or knee chest position. May also put 3 pillows under hips.
-
- Uterine Rupture
:
- Medical emergency.
- Causes:
- dehiscence of uterus à common cause
- oxytocin induction
- prolonged labor
S&S: sever sudden intense abdominal pain.
No contraction and no FHR.
Must be taken to surgery immediately for C-section. Mom may die due to hemorrhage shock. Fetus may die due to hypoxia.
Most of the time a hysterectomy is performed.
Also caused uterine inversion à uterus turns inside out.
In postpartum, if uterus is not firm apply firm pressure to express the clots = uterine inversion.
Operative Procedures:
Forceps and vacuum extraction help deliver vaginally.
Forceps:
Metal blades that come apart.
Used to help remove baby from vaginal canal.
Levels:
- Low forceps delivery à see baby’s head and blades placed on each side. When mom pushes the MD pulls, helps guide and control head.
- Mid-forceps delivery à head is engorged but higher than 2+ station.
- High forceps delivery à baby not engaged.
When baby is born, may have sign of forceps on head and the head is elongated.
Vacuum Extraction:
Suction applied to head and put traction on when mom pushes.
Conehead appearance.
Caput (swelling) or cephalohematoma (bleeding in skull between periosteum, does not cross suture line).
Surgical Procedure: C- section.
Lot more today due to modern technology and detects problems with baby sooner and legal problems.
Deal with labor patient and post op patient.
Elective C-section à already scheduled and needs pre-op teaching.
Emergency C-section à no time to do pre-op teaching.
Prior to surgery, they will have a foley catheter put in to drain the bladder so it is no accidentally knicked.
Incisions:
- vertical à up and down
- low transverse horizontal à at mom’s pubis
- A person who has had a horizontal incision can have a vaginal birth the next time. There is not a lot of uterine activity with a horizontal incision.
- A vertical incision C-section puts a woman more at risk for having uterine rupture the next time if they try to deliver vaginally.
-
- Post-op Care
: (same as any post-op with addition of post partum)
- NPO until they have BS.
- Will abulate the next day.
- Will have a foley inserted for 24h. After d/c, we need to check 3 voidings because 250-300 is the amount they need to void if they do not in 6-8 hours, the we get concerned.
- For vertical incision à check on each side of the incision for the fundus.
- For horizontal cut à check the fundus the regular way.
- It will be painful, but the fundus still must be cheked.
- Also asess lochial flow.
- Lung sounds, should TCDB, and use IS.
- Splint incision when cough and deep breathe.
- Take out staples every other one.
- After mom is awake the baby is brought to her. If breast feeding, mom should lie on her side with baby on the bed. Tension and pain affects production of milk.
- They should never ambulate the first time without somebody with them.
- Heparin:
- anticoagulant
- ordered in units
- prevents formation of clots
- should be on a pump
- narrow therapeutic range
- too much will cause a potential for bleeding
- LPN’s cannot mix Heparin in the IV bags but can monitor
- dosage is always double checked with another nurse
When MD orders heparin, it is in U/hr or cc/hr. If in cc/hr then he will tell you how to mix it.
Must determine if order is a safe dose: 20,000-40,000U/24hr.
Monitor lab values of PTT for anyone on heparin. PTT will be done until it is where they want it.
PTTà partial thromboplastin time. How long it takes blood to clot.
Control may be 12-24 seconds. MD may want it to be 2x the control which would be 24-48. MD may order 1 ½ -3 times whatever the control is.
When lower, Heparin is increased, when higher Heparin is decreased.
After IV therapy, may be on heparin subq or coumadin. Lovenox is administered in the love handles. Heparine injections cause PTT to be more irradic whereas Lovenox keeps it more accurate.
When you have an injury, the first thing that happens is the thromboplastin is released by the vessel (which is the beginning of the clotting processes). Heparin and Lovenox stops this process.
Some meds are titrated, which means they are started with the lowest dose possible and dose will be regulated to obtain a measurable response. Used for powerful drugs and ordered per minute. Examples are Mag Sulfate and Pitocin.
