Forceps Birth

Forceps birth is an assisted birth, sometimes called an instrumental or operative vaginal birth, uses instruments that are attached to baby’s head so that baby can be pulled out. Forceps are described as stainless steel that come in two intersecting parts and have curved end to cradle baby’s head. It can be used as low or outlet forceps or for mid-forceps procedures.
This procedure is done to provide traction or to assist in rotation of the fetus.

Advantages:

• Provide assistance when laboring women is exhausted
• May decrease need for cesarean birth

Disadvantages:

• Maternal complication such as vaginal and perineal lacerations and postpartal hemorrhage
• Neonatal complication such as facial bruising, edema and cerebral trauma.

Nursing care:

• Explain the procedure to woman
• Encourage her to relax perineum and breathe during forceps application
• Advice physician when contraction is present
• Assess newborn for facial bruising or edema.

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Induction

Induction labor is a procedure to stimulate uterine contraction during pregnancy before labor begins spontaneously. It is done for various reason, especially for mother and baby health reason. Elective induction may be accomplished by oxytocin infusion.

Advantages:

• IV oxytocin induction is usually successful when labor readiness has been established, fetal maturity is established and Bishop score is 9 or more.
• Maternal and fetal status can be monitored closely.

Disadvantages:
Induction is an invasive procedure.
Hypertonic labor, fetal distress, alterations in blood pressure, ruptured uterus.

Indications:

• Postmaturity
• Premature rupture of membranes
• PIH
• Presence of maternal disease such as diabetes mellitus
• Fetal demise.

Contraindications:

• Grand multiparity
• Placental abdominalities
• Previous uterine surgery
• Fetal distress
• Preterm fetus
• Positive CST
• Abnormal fetal presentation
• Presenting part above inlet
• Cephalopelvic disproportion (CPD).

Nursing Intervention:

• Obtain baseline tracing of uterine contractions
• Follow established protocols
• Increase IV dosage only after assessing contractions, FHR, and maternal blood pressure and pulse.
• Do not increase rate once desired contraction pattern is obtained.
• Discontinue oxytocin if contraction frequency is less than 2 minutes of duration is more than 90 seconds, or if fetal distress is noted.

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Amniotomy

Amniotomy is the artificial rupture of membranes, sometimes called as AROM. It is done to stimulate labor.

Advantages:

• Amniotomy can stimulate contractions
• Amniotomy can evaluate the amniotic fluid

Disadvantages:

• Birth must occur within 24 hour when amniotomy is done, and may be need cesarean birth.
• Increased risk of prolapsed cord
• Risk of Infection

Nursing Care:

• Auscultate Fetal Heart Rate before and after amniotomy
• Record the time of Amniotomy, Fetal Heart Rate, and characteristics of fluid (amount, color and odor).
• Instruct woman to remain in bed unless fetal presentation part is well engaged. It is done to prevent prolapsed of umbilical cord.

Risks for Mother:

• Increases the risk of infection.
• Labor may become more aggressive
• The mother increases her chances of having uneven dilation.

Risk for Baby:

• Increase of umbilical cord compression
• The pressure on the baby’s head causes swelling in some part.

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Diabetes in Pregnancy

Client with diabetes and their infants are at risk for complication during pregnancy. Infants of diabetic mother tent to be large for gestational age. It is caused by glucose that crosses the placenta, whereas insulin does not, these infants tend to gain weight. The problem is that high glucose environment impedes lung development and although the infants are large for gestational age, they are often premature.

Complication of infants from maternal diabetes:

• Patent ductus arteriosus (PDA)
• Polyhydramnions
• Premature delivery
• Respiratory distress syndrome

Complications of mother with diabetes pregnancy:

• Hypertension
• Renal disease
• Ketoacidosis
• Vascular compromise
• Seizure activity related to hypoglycemia

Another problem in diabetes pregnancies is that the fluctuations in maternal blood sugar can result in fetal brain damage or sudden fetal death due to ketosis. That's why the client should be taught to check their blood glucose levels frequently during the day. Level over 120 mg/dL should be reported to the doctor for treatment.

Infants born to diabetic mothers might be delivered by cesarean section because of their large sizes and they should be assessed immediately after delivery for hypoglycemia by performing a dextrostix. The glucose level of 40 mg/dL or lower indicates hypoglycemia in the infant.

The blood is usually drawn from a heel stick and should be stuck on the lateral aspect of the heel. Blood test should be performed to detect hypocalcemia, hypokalemia and acidosis status.

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Ectopic Pregnancy

Ectopic pregnancy is the condition in which the ovum implants in area other than the endometrial lining of the uterus. This pregnancy is not commonly successful since the areas outside of the uterus cannot sustain for a full-term pregnancy. It’s studied that it usually happens when there is a tubal blockage that prevents the fertilized ovum from passing through the fallopian tubes.

Ectopic pregnancy can be happened at abdominal, tubal, myometrial or cervical.

Ectopic pregnancy at abdomen:
The abdomen is usually unable to sustain for embryo growth

Ectopic pregnancy at tubal:
This is the most common site of ectopic pregnancy. It can causes mother at risk for tubal rupture that can be a life threatening condition.

Ectopic pregnancy at myometrial:
We cannot recognize it until delivery that usually requires a hysterectomy to stop bleeding. Sometime it is called as placenta accrete.

Ectopic pregnancy at cervical:
It has relation with placenta previa

Precipitating Factors:

1. Pelvic Inflammatory Disease
2. Previous tubal surgery or tubal pregnancy
3. Endometriosis, and
4. Congenital anomalies of the fallopian tubes

Sign and Symptoms:

1. Sharp one-sided pain
2. Tenderness of adnexal, area over ovary and tube
3. Vaginal bleeding (may or may not seen)
4. Hard and rigid abdomen and signs of circulatory collapse when tubal is ruptured.

How to care patient with ectopic pregnancy:

• Provide emotional support for whom undergoing surgical or medical treatment
• Provide emergency resuscitation and emergency surgery
• Teach mother about pre and post operative self care
• Consider to refer mother to a Fetal Demise Support Group

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Anesthesia in Labor and Delivery

There are five types of anesthesia used in labor and delivery: local anesthesia, pudendal block, lumbar epidural block, subarachnoid (spinal) block, and general anesthesia.

Local Anesthesia:

• It is used for blocking pain during episiotomy
• It is administered just before the birth of the baby
• The anesthetic has no effect on fetus

Pudendal Block:

• It is administered just before the birth of the baby
• The anesthetic is injected into the pudental nerve through a transvaginal route
• It has effect last about 30 minutes
• It blocks the perineal area for episiotomy
• There is no effect on contraction or the fetus

Lumbar Epidural Block:

• The anesthetic relieves pain from contractions and numbs the vagina and perineum
• The anesthetic is injected in epidural space at L3 to L4 and may cause hypotension, so assess the maternal blood pressure
• The anesthetic is administered after labor is established or just before a scheduled casarean birth
• Keep mother in side-lying position or place a rolled blanket beneath the right hip to displace the uterus from the vena cava
• Administer IV fluids if prescribed
• Increase fluids if hypotension occurs

Subarachnoid (spinal) Block:

• The anesthetic is injected into the spinal subarachnoid space at L3 to L5 and administered just before the birth
• It relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities
• The anesthetic can cause maternal hypotension and postpartum headache
• Keep mother lie flat for 8 to 12 hours following spinal injection
• Administer IV fluids as prescribed

General Anesthesia:

• General anesthesia may be used for some surgical interventions
• It might cause a danger of respiratory depression and vomiting
• The mother is not awake

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STAGES OF LABOR – Stage IV

LAST STAGE

• Last stage of labor begins with delivery of placenta and ends with postpartum stabilization
• Duration: usually 1-2 hours after delivery (primipara or multipara)
• Blood pressure returns to the pre-labor level
• Pulse is slightly lower than during labor
• Fundus remains contracted, in the midline, 1-2 fingerbeadths below the umbilicus

Nursing Interventions:

• Maternal assessment every 15 minutes for 1 hours, every 30 minutes for 1 hours, and hourly for 2 hours
• Administer oxytocin product if ordered
• Assess fundus every 15 minutes, if soft, massage with side of hand
• Assess lochia, checking peripad and under lower back
• Assess bladder for distention because full bladder will prevent contractions and increase bleeding
• Assess episiotomy for intactness and possible bleeding

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