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Lecture 14

Nursing Care of a Family Experiencing a Complication of Labor or Birth-2

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Complication of Labor and Birth (2)

Cesarean Section & Dystocia

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Objectives

Discuss how to detect deviations from normal and assess the woman experiencing a complication during labor.

Establish nursing care plan related to potential complications in labor or birth.

List five indications for cesarean birth: scheduled and emergency of caesarian birth.

Describe the preoperative and postoperative nursing care for a woman who is going to have a cesarean birth.

Plan appropriate nursing care for a woman anticipating a cesarean birth.

Identify shoulder dystocia and its management.

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Cesarean birth

Cesarean birth, or birth accomplished through an abdominal incision into the uterus, is one of the oldest types of surgical procedures known.

It is a procedure always slightly more hazardous than vaginal birth.

However, when compared with other surgical procedures, it is one of the safest types of surgeries and one with few complications.

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Cesarean Birth

The word “cesarean” is derived from the Latin caedore, which means “to cut.”

At one time, there was a popular belief that Julius Caesar was born by a cesarean birth and the procedure was named for him.

However, because Caesar was born before antibiotics and sterile surgical technique, it seems unlikely that his mother (who is known to have been alive in his adult years) would have survived such a procedure.

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Successful Caesarean section performed by indigenous healers in Kahura, Uganda. As observed by R. W. Felkin in 1879.

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Cesarean Birth

Currently, cesarean birth is used most often as a prophylactic measure, to alleviate problems of birth for conditions such as those listed:

Selected Indications for Cesarean Birth

Maternal Factors

Placenta Factors

Fetal Factors

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Cesarean Birth/ Maternal Factors

1. Active genital herpes or papilloma

2. AIDS or HIV-positive status

3. Cephalopelvic disproportion

4. Cervical cerclage (cervical stitch)

5. Disabling conditions, such as severe hypertension of pregnancy, that prevent pushing to accomplish the pelvic division of labor

6. Failed induction or failure to progress in labor

7. Obstructive benign or malignant tumor

8. Previous cesarean birth by classic incision

9. Elective—no indicated risks

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Cesarean Birth/ Placenta Factors

1. Placenta previa.

2. Premature separation of the placenta.

3. Umbilical cord prolapse.

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Cesarean Birth/ Fetal Factors

Compound conditions such as

macrosomic fetus in a breech lie

2. Extreme low birth weight

3. Fetal distress

4. Major fetal anomalies, such as hydrocephalus

5. Multigestation or conjoined twins

6. Transverse fetal lie

conjoined twins

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Cesarean Birth

There are two types of cesarean birth:

scheduled 2. emergency.

1. scheduled, there is time for thorough preparation for the experience throughout the antepartal period. Some women even take a childbirth preparation class specifically for cesarean birth.

2. emergency cesarean birth-, preparation must be done much more rapidly but with the same concern for fully informing a woman and her support person about what circumstances created the need for a cesarean birth and how the birth will proceed.

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Scheduled Cesarean Birth

Cesarean birth became a status symbol when Hollywood stars asked to have cesarean births. Today, a physical indication for a cesarean birth, such as:

transverse presentation,

genital herpes,

cephalopelvic disproportion,

or avoidance of postprocedure stress incontinence, must be documented before a cesarean procedure can be performed.

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Emergency Cesarean Birth

Emergency cesarean births are done for reasons such “as

1. placenta previa,

2. abruptio placentae,

3. fetal distress,

4. or failure to progress in labor.

An emergency cesarean birth carries with it the risk of any emergency surgery: the woman may not be a prime candidate for anesthesia and is psychologically unprepared for the experience.

In addition, the woman may have a fluid and electrolyte imbalance and be both physically and emotionally exhausted from a long labor.

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Effects of Surgery on a Woman

1. Stress Response:

Whenever the body is subjected to stress, and norepinephrine will be released from the adrenal medulla.

Epinephrine causes an:

1. increased heart rate,

2. bronchial dilatation,

3. and elevation of the blood glucose level.

4. It also leads to peripheral vasoconstriction, which forces blood to the central circulation and increases blood pressure.

In the pregnant woman, such responses may minimize blood supply to the lower extremities. The woman is already prone to thrombophlebitis from stasis of blood flow, and these responses compound or greatly increase the risk of thrombophlebitis

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Effects of Surgery on a Woman

2. Interference with Body Defenses:

The skin serves as the primary line of defense against bacterial invasion.

When skin is incised for a surgical procedure, this important line of defense is lost.

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Incision

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Effects of Surgery on a Woman

Strict adherence to aseptic technique during surgery and in the days following the procedure are necessary to compensate for this impaired defense.

If cesarean birth is performed hours after the membranes ruptured, a woman's risk for infection will be higher than if the membranes were intact.

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Effects of Surgery on a Woman

3. Interference with Circulatory Function:

Although vessels that must be cut for surgery are immediately clamped and ligated, some blood loss always occurs with surgery.

Extensive blood loss can lead to hypovolemia and lowered blood pressure.

This could lead to ineffective perfusion of all body tissues if the problem is not quickly recognized and corrected.

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Effects of Surgery on a Woman

The amount of blood lost in cesarean birth is comparatively high, because pelvic vessels are congested with blood waiting to supply the placenta.

During a vaginal birth, a woman loses 300 to 500 mL of blood. This loss increases to 500 to 1,000 mL with a cesarean birth.

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Effects of Surgery on a Woman

4. Interference with Body Organ Function:

When any body organ is handled, cut, or repaired in surgery, it may respond with a temporary disruption in function. Pressure from edema or inflammation as fluid moves into the injured area further impairs function of the primary organ involved, as well as that of surrounding organs.

If blood vessels become compressed as a result of edema, distant organs may be deprived of blood flow, leading to reduced function in those organs.

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Effects of Surgery on a Woman

Because the uterus is handled during cesarean birth, it may not contract well afterward, which can lead to postpartum hemorrhage.

Lower-extremity circulation may be compromised due to edema.

Surgery also puts pressure on the intestine, so a paralytic ileus or halting of intestinal function is yet another possibility.

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Effects of Surgery on a Woman

5. Interference with Self-Image or Self-Esteem:

Surgery always leaves an incisional scar that will be noticeable to some extent afterward.

Fortunately, the scar resulting from cesarean birth (a horizontal one across the lower abdomen) is not overly noticeable, but its appearance may cause a woman to feel self-conscious later.

Although most women accept cesarean birth well, a woman may feel a loss of self-esteem if she believes it marks her as a woman less than others because she was unable to give vaginal birth.

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Operative Risk for a Woman

1. Nutritional Status:

A woman who is obese is at risk because obesity interferes with wound healing.

A prolonged healing period increases the risk for infection and rupture of the incision (dehiscence).

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Operative Risk for a Woman

The person's heart may also have an increased workload.

An obese person often has more difficulty turning and ambulating postoperatively than does a person of normal weight and therefore has an increased risk for development of respiratory or circulatory complications such as pneumonia or thrombophlebitis.

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Operative Risk for a Woman

2. Age Variations:

Age affects surgical risk because it can cause decreased circulatory and renal function.

Fortunately, most pregnant women fall within the young adult age group, so they are excellent candidates for surgery.

A woman older than 40 years of age falls into a category of slightly higher risk.

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Operative Risk for a Woman

3. Altered General Health:

A woman who has a secondary illness (e.g., cardiac disease, diabetes mellitus, anemia, kidney or liver disease) is at greater than usual surgical risk, depending on the extent of disease.

woman with a secondary illness may also have an accompanying nutritional or electrolyte imbalance related to her primary illness.

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Operative Risk for a Woman

4. Fluid and Electrolyte Imbalance:

A woman who enters surgery with a lower than normal blood volume will feel the effect of surgical blood loss more than a woman who has a normal blood volume.
Recent vomiting, diarrhea, or a chronic poor fluid intake can compound her risk.

5. Fear: Women who are extremely worried need a very detailed explanation of the procedure before they can enter surgery without intense fear.

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Operative Risk to the Newborn

Cesarean birth places a newborn at a greater risk than does a vaginal birth.
When a fetus is pushed through the birth canal, pressure on the chest helps to rid the lungs of lung fluid.
Therefore, respirations are more likely to be adequate at birth than if the fetus had not been subjected to this pressure.
For this reason, more infants born by cesarean birth develop some degree of respiratory difficulty for a day or two after birth than those born vaginally, which is often referred to as transient tachypnea of the newborn.

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Preoperative Diagnostic Procedures

Vital sign determination
Urinalysis
Complete blood count
Coagulation profile (prothrombin time [PT], partial thromboplastin time [PTT])
Serum electrolytes and pH
Blood typing and cross-matching
Sonogram to determine fetal presentation and maturity

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Preoperative Teaching

Explain the preoperative measures that will be necessary, such as
surgical skin preparation,
eating nothing before the time of surgery,
premedication (if this will be used),
and method of transport to surgery.
Review the necessity for
an indwelling catheter,
intravenous fluid administration,
placement of an epidural catheter (if used for postprocedural pain relief),
and the advantage of early ambulation afterward.

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early ambulation

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Preoperative Teaching

Teaching to Prevent Complications.
Deep Breathing.
Incentive Spirometry.
Turning.
Ambulation

Incentive Spirometry

Deep Breathing

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Immediate Preoperative Care Measures

- Informed Consent

- Overall Hygiene

- Gastrointestinal Tract Preparation

- Baseline Intake and Output Determinations

Hydration

- Preoperative Medication

- Patient Chart and Presurgery Checklist

- Transport to Surgery

- Role of the Support Person

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Intraoperative Care Measures

Administration of Anesthesia.

Skin Preparation.

Surgical Incision.

Types of Cesarean Incision: The type chosen depends on the presentation of the fetus and the speed with which the procedure will be performed.

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Intraoperative Care Measures

A classic cesarean incision, the incision is made vertically through both the abdominal skin and the uterus. It is made high on the uterus so that it can be used with a placenta previa, to avoid cutting the placenta. A disadvantage of this type of incision is that it leaves a wide skin scar and runs through the active contractile portion of the uterus.

Because this type of scar could rupture during labor, it is likely, if this type of incision is used, that the woman will not be able to have a subsequent vaginal birth.

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Cesarean section. (A), Classic; (B), low vertical; (C), transverse incisions.�

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Intraoperative Care Measures

A low segment incision is made horizontally across the abdomen just over the symphysis pubis and also horizontally across the uterus just over the cervix.

This is the most common type of cesarean incision currently used. It is also referred to as a Pfannenstiel incision or a “bikini” incision, because even a low-cut bathing suit would cover it.

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Intraoperative Care Measures

The major disadvantage of this incision is that it takes longer to perform, possibly making it impractical for an emergency cesarean birth.

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Intraoperative Care Measures

Because this type of incision is through the nonactive portion of the uterus (the part that contracts minimally with labor), it is less likely to rupture in subsequent labors, making it possible for the woman to have a VBAC with a future pregnancy.

It also results in (advantage)

1. less blood loss,

2. is easier to suture,

3. decreases postpartal uterine infections,

and is less likely to cause postpartum gastrointestinal complications.

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Intraoperative Care Measures

Birth of the Infant

Introduction of the Newborn

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Postpartal Care Measures

As with all postpartal women, the postpartal phase for a woman who has her child by cesarean birth can be divided into an:

1. immediate recovery period (the so-called fourth stage of labor) and

2. an extended postpartal period.

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Discharge Planning

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Dystocia

Difficult, dysfunctional or abnormal labor

Results from problems in

- Power: ineffective uterine contractions

- Passage way: abnormal pelvic size or shape

- Passenger: abnormal fetal size or presenting part

- Psyche: past experiences, culture, preparation and support system

- Professional: experience of health care provider

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Assessment for complications

Uterine monitoring: is the major assessment tool for the woman during labor.

Learn to reassure the woman and her partner when complications develop.

cooperation of the woman is essential to provide high quality of professional nursing care

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Therapeutic management

Induction: mean that labor is artificially started.

augmentation of labor: means assessing labor that has spontaneously started to be more effective

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Reasons for induction

1. When the fetus is full term and labor does not occur spontaneously, or

2. if the fetus is in danger

The primary reasons are PET, eclampsia, hypertension, diabetes, Rh sensitization, prolonged rupture of membrane, postmaturaity>42 weeks

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precautions

Should be used cautiously with:

-multiple gestation,

-hydramnios,

-grand parity,

-maternal age> 40 years, and

-the presence of previous uterine tears.

The following conditions should be present before induction:

Fetus is in longitudinal lie

Cervix is ripe

Presenting part is engaged

No cephalopelvic disproportion

Mature fetus

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Induction of labor

Cervical ripening: softness of the cervix is necessary for dilatation of the cervix and coordination of the uterine contractions.

To ripen the cervix there are several methods

Prostaglandin suppositories (2-3 doses/6 hours)

Observe FHR,

vomiting,

diarrhea, and

hypertension

Used with caution in women with asthma, renal or cardiovascular disease.

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Induction of labor

Induction using oxytocin: administered intravenously so it can be discontinued rapidly

Half life is 3 minutes

Drug is usually mixed with 1000ml ringer+10IU (10,000mu)oxytocin (pitocin; syntocinon)

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Infusion usually starts at a rate of 0.5-1 mu/min.

If there is no response the infusion is gradually increased in amount every 15-60 min by small increments of 1-2mU until contractions begin

Many women respond at 4mU/min; most women respond at 16mU/min

Aggressive induction ( an increment of 6mU/min instead of 1-2mU) have been recommended to shorten labor and is used in research facilities

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When cervical dilatation reaches 4 cm, artificial rupture of membrane might be done and IV infusion should be stopped. For some women the infusion will be continued till full dilatation

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Nursing care

-Watch V/S every 30 minutes, if hypertension occurs discontinue.

- Monitor FHR and watch for signs of fetal distress

- Contractions should occur NO more than every 2 min, should be stronger than 50mmhg, and should last NO longer than 70sec. The resting pressure should not exceed 15 mmhg

Watch for signs of water intoxication:

Headache ,vomiting) if happened limit iv fluids to 150ml/hour

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Forceps birth

Are rarely used because they may lead to increased urinary stress incontinence in women

Membrane must be ruptured,

woman’s bladder must be empty

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Vacuum extraction

Established if the fetal head is far enough down in the birth canal and at the perineum.

Contraindicated if fetal blood sampling was established, or in preterm infants

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Anomalies of placenta

Normal placenta weighs 500gm(1/6 of the fetus), and is 15-20cm in diameter and 1.5-3 cm thick.

Might weigh half as much as the fetus in cases such as syphilis, erythroblastosis.

If the uterus has a septum or scars the placenta might be wide, because it was forced to spread out.

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Problems with the power

-Inertia: or dysfunctional labor

- Primary: occur at the onset of labor

- Secondary: occur later in labor

It is vital to prevent dysfunctional labor because it is a major cause of increasing percentages of maternal and fetal mortality and morbidity

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Ineffective uterine force

Contractions can be measured using either:

- electronic uterine monitoring measuring intensity, duration and interval

- Montevideo units (MVU); Units are calculated by internally (not externally) measuring uterine pressure above baseline tone and multiplying by the number of contractions in a 10 minute period. Uterine pressure is generally measured through an intrauterine pressure catheter.

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Causes

- Inappropriate use of analgesia

- Pelvic bone contraction that has narrowed pelvic diameter

- Poor fetal position: Extension rather than flexion of fetal head

- Over distension of the uterus( hydramnios, oversized baby)

- cervical rigidity

- Presence of full rectum or full bladder impedes fetal descent

- Exhausted mother

- primgravida

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Types of ineffective uterine contractions

Hypotonic contractions

Hypertonic contractions

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Hypotonic contractions

Number of contractions is low or ineffective; less than 2 in 10 minutes duration

The resting tone of the uterus remains less than 10mmhg; and the strength of the contraction does not rise above 25mmhg during the active phase of labor

Not painful because they are of mild intensity but remember that pain is SUBJECTIVE experience

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Hypotonic contractions

Prolong the labor and might make the uterus during the posrpartum period unable to contract which in turn cause postpartal hemorrhage

If cephalopelvic disproportion is ruled out, oxytocin infusion can be administered.

In the first postpartum hour make sure to assess the uterus and lochia every 15 minutes

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Hypertonic contraction

Increase resting tone of the uterus to more than 15mmhg; however the intensity may be no stronger than hypotonic contractions

Most commonly seen in latent phase of labor

Occur because muscle layer of the uterus does not polarize after a contraction

Painful, Explain WHY?

Fetal anoxia: explain why?

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Nursing care

Any woman complain from severe pain her contractions should be assessed for at least 15 continuous minutes, WHY?

To ensure the resting phase of the contraction is adequate and the fetal pattern is not showing late deccelaration

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Nursing care

Administer pain relief medications

Give emotional support, change linens, gown, darken room lights, and decrease noise and stimulation are also helpful.

If late decelerations, or long first stage, lack of progress with pushing happen then cesarean birth is recommended

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Precipitate labor

Occur when uterine contractions are so strong and woman gives birth with only few contractions.

Can be predicted if the rate of dilatation is greater than 5cm.h and 10cm/h in multiparas

A tocolytic might be administered to decrease rate and strength of the contraction

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Problems with the passenger

Prolapsed cord: a loop of the UC slips in front of the presenting part of the fetus

Might occur at any stage of labor if the presenting part is not fitted firmly into the cervix

Tend to occur with premature rupture of the membrane, placenta previa, fetal presentation other than cephalic, small fetus, cephalopelvic disproportion

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Problems with the passage

Inlet contraction: narrowing of the anterio-posterior diameter to less than 11cm, or a maximum transverse diameter of 12 cm or less.

In primgravidas if the fetus engages in weeks 36-38 of pregnancy; this indicates that the inlet is of adequate size.

Outlet contraction: narrowing of the transverse diameter of the outlet of less than 11 cm.

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Psyche

Continuous monitoring of laboring woman and emotional support are important during all stages of labor, because complications can arise at any stage of labor

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Shoulder Dystocia

Shoulder dystocia is a birth problem that is increasing in incidence along with the increasing average weight of newborns.

The problem occurs at the second stage of labor, when the fetal head is born but the shoulders are too broad to enter and be born through the pelvic outlet.

This is hazardous to the mother because it can result in vaginal or cervical tears.

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Shoulder Dystocia

It is hazardous to the fetus if the cord is compressed between the fetal body and the bony pelvis. The force of birth can result in a fractured clavicle or a brachial plexus injury for the fetus.
Shoulder dystocia is most apt to occur in women with:

1.diabetes,

2.in multiparas,

3. and in post-date pregnancies.

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Shoulder Dystocia

Although there is no evidence-based data, asking a woman to flex her thighs sharply on her abdomen (McRobert's maneuver) may widen the pelvic outlet and let the anterior shoulder be delivered.

Applying suprapubic pressure may help the shoulder escape from beneath the symphysis pubis and be delivered.

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Cesarean Section Surgery Begins�

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Multiple Layers of Incisions for a Cesarean Section�

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The Uterine Incision

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Suctioning Amniotic Fluids�

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Disengaging Baby from the Pelvis

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Baby's Head is Born

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Suctioning the Baby�

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Baby's Shoulders Born

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Baby's Body Born�

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Uterine Repair

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Nursing Process: A Woman Who Develops A Complication

Assessment
Nursing diagnosis
Outcome identification, planning
Implementation
Outcome evaluation

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Question

A woman who had preterm labor successfully halted reaches her 36th week of pregnancy and is doing well on home care. Which of the following nursing diagnoses would be most pertinent for her?
Risk for fetal infection related to early rupture of membranes
Hopelessness related to potential loss of pregnancy
Anticipatory grieving related to high probability for fetal death from placental dysfunction
Powerlessness related to inability to sustain pregnancy

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Answer

A. Risk for fetal infection related to early rupture of membranes
Rationale: Once membranes have ruptured, the seal to the fetus is broken and microorganisms may infect the uterus or fetus.

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Question

After reporting to the unit, you are assigned the patients listed below. Which of the patients should be evaluated first?
A 7-week-pregnant woman who had a cervical cerclage performed 4 hours ago
A patient diagnosed with pregnancy-induced hypertension experiencing urine output of 75 cc per hour, blood pressure of 135/90, and slight proteinuria
A woman at 5 weeks gestation with suspected ectopic pregnancy complaining of shoulder and abdominal pain
A patient in her 20th week of pregnancy suspected of having a trophoblastic pregnancy

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Answer

C. A woman at 5 weeks gestation with suspected ectopic pregnancy complaining of shoulder and abdominal pain
Rationale: The patient having a suspected ectopic pregnancy is at the highest risk to develop complications suddenly .

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Question

A woman with premature rupture of the membranes tells you she is worried that her birth will be extremely painful because it is “dry.” Which of the following would be your best response?
“This is true, but you can receive pain medication to help relieve this.”
“No birth is ever really dry, because amniotic fluid continues to be manufactured.”
“Don’t think so far ahead; concentrate on the problem at hand.”
“Although the birth will be dry, it won’t be painful.”

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Answer

B. “No birth is ever really dry, because amniotic fluid continues to be manufactured.”
Rationale: Because amniotic fluid is continually formed, no birth is ever dry.

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Question

A woman whose membranes have prematurely ruptured is discharged to home care. Which of the following therapies would you anticipate including in her teaching plan?
Monitoring temperature twice a day
Induction of labor by oxytocin
Bed rest in a semi-Fowler’s position
Hourly assessment of Homan’s sign

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Answer

A. Monitoring temperature twice a day
Rationale: Rupture of the membranes without the onset of labor places the woman at risk for infection.