Download Operative Obstetrics

Operative Obstetrics
Operative obstetrics refer to a number of procedures (episiotomy, forceps
delivery, cesarean delivery) that may be used to assist the mother in labor
and delivery.
Episiotomy
Is an incision made in the perineum to enlarge the vaginal outlet during
the second stage of labor. It serves the following purposes:
 Prevent tearing of the perineum. It substitutes a straight surgical
incision for the laceration that may otherwise occur.
 Facilitate repair of laceration and to promote healing.
 Minimize prolonged and severe stretching of the muscles supporting
the bladder or rectum which may later lead to stress incontinence or
vaginal prolapse.
 Shorten the second stage, which may be important for maternal
reasons, as PIH or fetal reasons as persistent bradycardia.
 Enlarges the vagina in case manipulation is needed to deliver an infant
for example in a breech presentation or for application of forceps.
Types of Episiotomies:
The type of Episiotomy is designated by site and direction of the incision.
1. Median:
- Is the one most commonly employed.
- It is effective, easily repaired and generally the least painful.
- Incision is made in the middle of the perineum and directed
toward the rectum.
- Is believed to heal with few complications, more comfortable
for the woman.
- If a long and large incision is needed during delivery, it may
necessitate incision into anal sphincter.
2. Mediolateral:
- Incision is made laterally in the perineum to the 5 o’clock or 7
o’clock position.
- This method avoids the anal sphincter if enlargement is needed.
- Women find it very uncomfortable during healing.
- The blood loss is grater, the repair is more difficult.
Note:
Because sutures used to repair episiotomy are of absorbable material they
don't need to be removed and no dressing is applied.
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Assessment:
- The Episiotomy site is inspected every 15 minutes during the first
hour after delivery, then on a daily basis.
- The site is assessed for redness, edema, ecchymosis, discharge, and
approximation (REEDA) and
- then document all fi ndings
Management and nursing interventions:
 Patient teaching:
- Explain reasons for episiotomy.
- Discuss methods to reduce discomfort and promote healing.
- Explain that with good hygienic measures, healing should be
completely reached in several weeks.
- Inspect area daily for signs of infection.
 Reduction of pain and discomfort:
- Apply ice packs after procedure to reduce edema and promote comfort
during the first 24 hours.
o The ice bag should be wrapped in a towel or disposable paper
cover to prevent a thermal injury. Application of cold provides
local anesthesia and promotes vasoconstriction while reducing
edema and the incidence of peripheral bleeding.
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o Thereafter, warm sitz baths (3-4 times a day) and dry heat help
increase circulation to the area and promote healing.
- Use local analgesic sprays or oral analgesic to promote comfort.
Forceps Delivery
Obstetric forceps are made from two double-curved, spoon-like
articulated blades. Forceps are designed for rotating or extracting the fetal
head.
Conditions Requiring Forceps Delivery:
1. Fetal conditions:
- Fetal distress. - Cord prolapsed.
- Abruption placenta.
- Excess pressure on the fetal head from arrested descent.
2. Maternal conditions:
- Eclampsia.
- Heart disease.
- Maternal hemorrhage.
- Maternal exhaustion.
- Failure of progress in the second stage because of poor uterine
contractions (dystocia).
Prerequisites for application of Forceps:
 Cervix must be completely dilated.
 Fetal head must be engaged, preferably deeply engaged.
 Vertex or face presentation. (Accurate diagnosis of position station).
 Pelvis should be adequate with no disproportion.
 Membranes should be ruptured.
 Some form of anesthesia should be used.
 Rectum and bladder should be empty to avoid laceration and fistula
formation.
 Forceps are never applied to an unengaged presenting part.
Types of Forceps delivery:
1. Outlet forceps are used when the fetal scalp is visible on the maternal
perineum without manual separation of the labia.
2. Low Forceps: forceps are applied after the head has reached the
perineal floor (at a +2 station or more). This will be an easy forceps
delivery.
3. Mid Forceps: are used when the fetal head is engaged but at less than
a +2 station.
 Because birth trauma has been associated with the use of
midforceps, this procedure has been largely replaced by
cesarean birth, which poses less risk to the fetus.
Management and Nursing Intervention:
 Reducing any anxiety:
- Explain needs for forceps delivery.
- Keep the woman informed of procedures progress.
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Focus on positive outcome of the birth.
Reducing potential for trauma and subsequent complications:
Assist the woman to relax between contractions.
Have the woman empty her bladder.
Monitor the woman for signs of complications following forceps
delivery.
a) Laceration of vagina and cervix (bleeding, tachycardia,
hypotension).
b) Rupture uterus (massive bleeding, shock).
c) Injury to bladder to rectum.
Check and record FHR before forceps are applied.
Examine the infant for complications following forceps delivery:
Facial paralysis.
Injury to eyes and skull.
Abrasions of the face.
Vacuum Extraction (Vacuum Assisted-birth)
A vacuum extractor applies suction to the fetal head creating an artificial
caput within the suction cup, thus allowing adequate traction for delivery
of the infant's head.
Uses:
- Dysfunctional labor.
- Fetal distress.
- PIH.
- Abruptio placenta.
- When forceps are to be avoided.
- Maternal cardiopulmonary disease.
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Nursing Intervention:
1. Explain procedure to the woman and why it is needed.
- Help the woman relax during application of suction to fetal scalp.
- Coach the woman to push with contractions when needed.
2. Following delivery:
- Examine the infant's scalp for lacerations, cephalohematoma or
intracranial hemorrhage.
- Examine the woman for vaginal or cervical lacerations.
- Explain to the woman that fetal caput will regress in a few days.
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Cesarean Delivery
Is removal of the infant from the uterus through an incision made in the
abdominal wall and in the uterus.
Indications:
1. Cephalopelvic disproportion (CPD).
2. Uterine dysfunction, inertia, inability of the cervix to dilate.
3. Neoplasm obstruction birth canal or pelvis.
4. Malposition and malpresentation.
5. Previous uterine surgery (cesarean delivery, hysterotomy …).
6. Complete or partial placenta previa.
7. Abruption placenta.
8. Fetal distress.
9. Prolapsed umbilical cord.
The basic purpose of cesarean delivery is to preserve the life or health of
the mother and her fetus.
Types of Cesarean Delivery:
1. Low Segment (Operation of choice):
 Incision is made transversely in lower uterine segment, in the
thinnest portion so that blood loss is minimal and uterus is easier to
open. Lower uterine segment is also area of least uterine activity.
 Postoperative convalescence is more comfortable.
 Possibility of later rupture is lessened.
 Peritoneal flap is brought over uterine incision, preventing lochia
from entering peritoneal cavity.
 Incidence of postoperative adhesions and danger of intestinal
obstruction are reduced.
2. Classic:
 Vertical incision is made directly into the wall of the body of
uterus.
 Useful when bladder and lower uterine segment are involved in
extensive adhesions.
 Useful when fetus is in transverse lie.
 Selected when anterior placenta previa exist.
 Rarely used today, the classic cesarean incision is reserved for
some cases of shoulder presentation, placenta previa, and when
birth must take place immediately. Since this type of uterine
incision is associated with complications including considerable
blood loss, infection, and uterine rupture with subsequent
pregnancies, women who undergo classic cesarean births may not
attempt future vaginal births.
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3. Extra Peritoneal:
 The tissue around bladder is dissected, providing access to lower
uterine segment without entering into peritoneal cavity.
 Devised to prevent peritonitis.
 Availability of blood and antibiotics has reduced use of this
method.
4. Cesarean delivery and hysterectomy ( Porro’s operation).
Cesarean delivery followed by the removal of the uterus.
Indications for Porro’s operation:
 Hemorrhage due to uterine atony after conservative therapy fails.
 Uncontrollable hemorrhage from placenta previa or abruption
placenta.
 Placenta accreta (abnormal attachment of placenta to uterine
endometrium).
 Not repairable rupture of the uterus.
 Cross multiple fibromyomas.
Nursing Intervention:
 Preparations for Emergency cesarean birth:
Standard preoperative measures include:
- Nothing by mouth (NPO).
- Abdominal and perineal shaved from nipple line to pubis.
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Indwelling catheter to dependent drainage.
Signed operative permit.
Two units of whole blood ready for administration.
I.V. line in place.
Preoperative medications (atropine), narcotics are avoided.
Infant preparations: warmer, resuscitation and suction equipment, and
notification of the pediatrician.
 Promoting Coping Abilities:
- Have the woman discuss her perception of why the cesarean delivery
is needed, correct misinformation and provide further knowledge.
- Have the woman / couple listens to fetal heart sounds to reassure them
of the well being of the fetus.
- Explain postoperative care and procedures:
 Provide Postoperative Care similar to that following abdominal
surgery:
- Observe for hemorrhage, inspect perineal pads and abdominal
dressing, and assess vital signs frequently.
- Administer oxytocics as prescribed.
- Check fundus for firmness.
- Continue IV fluid as prescribed.
- Check urinary output from indwelling catheter for amount and
evidence of bleeding.
- Provide medications to relief pain as prescribed.
- Encourage woman to turn frequently from side to side, to breathe
deeply and to cough.
- Assist woman out of bed on first postoperative day.
- As soon as possible, have the woman hold and care for infant to
reassure her of infant's well being.
- Maintain cleanliness and prevent infection.
Note:
When a mother who has had cesarean birth wants to deliver vaginally, a
trial labor may be undertaken.
 She must be in a good health, her medical history should be available,
and the fetus should be in vertex position with no CPD or other
complications.
 The birthing center must be able to provide fetal and maternal
monitoring, blood transfusions, anesthetic services and physician
availability.
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Induction of Labor
Is the deliberate initiation of uterine contractions before their
spontaneous onset.
Is the use of physical or chemical stimulants to initiate or intensify
uterine contractions.
The need for initiating labor may arise from maternal or fetal sources.
E.g. PIH , postterm pregnancy , D.M, PROM, I.U.F.D….
Elective induction may be indicated for the woman who has a history
of precipitate labor to avoid unexpected out of hospital birth.
There are a number of medically approved methods to induce labor;
they include chemical induction with prostaglandins, oxytocin and
mechanical as rupture of membranes.
Prostaglandins
A prostaglandin gel for local application to the cervix has been
formulated to soften the cervix and induce labor.
For those women whose cervix is unfavorable, induction using PGE is
more effective than using oxytocin.
On admission, routine assessments are completed, dilation of cervix
and effacement are determined.
A 30 minutes electronic monitoring of FHR and uterine contractions is
done to establish base line data.
The physician instills 0.5 mg of PGE intracervically using a plastic
catheter. The catheter is then removed.
The woman remains in bed for 30 minutes, then may ambulate.
FHR, BP and pulse are monitored at least every 30 minutes.
Contractions usually begins 1/2 hour after administration of gel, the
time of contraction is recorded.
An amniotomy is performed at 4 cm of cervical dilation and internal
fetal monitoring is applied.
Progress of labor is recorded.
Any hypertonic contractions of the uterus are reported immediately.
If the woman doesn`t deliver within 24 hours, the cervix is reassessed
and an induction using oxytocin is done if indicated.
Because prostaglandin administration is effective, free of side effects
and non invasive, some authorities believe it will replace amniotomy
and oxytocin as the method of choice for induction of labor.
The woman is kept informed of the progress of labor.
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Oxytocin
May be used either to induce the labor process or to augment a labor that
is progressing slowly because of inadequate uterine contraction, or to
assess fetal response to the stress of contractions (OCT).
Indications:
- Prolonged pregnancy.
- Preterm delivery in diabetic mother.
- Severe Preeclampsia, Abruptio placenta or I.U.F.D.
- Multigravida with a history of precipitate labor.
- Prolonged rupture of membrane.
- Management of abortions.
Contraindications:
- Fetopelvic disproportion .
- Fetal distress.
- Previous uterine surgery.
- Over distended uterus e.g. multiple pregnancy.
Hazards:
 Maternal: titanic contractions, Abruptio placenta, Postpartum
hemorrhage, infection, DIC, Amniotic fluid embolism, anxiety and
fear.
 Fetal: Asphyxia, Hypoxia, physical injury and Prematurity.
 10 IU of oxytocin is added to 1L of 5% dextrose or saline solution.
 Initial dose 2 milliunits/minute via constant infusion pump.
 Dose is increased every 15-20 minutes until dose is 20 milliunits per
minute.
 Monitor the woman's BP, P, respiratory rate, contractions and FHR
every 15 minutes.
 If FHR indicate distress or if contractions last 70 seconds or more,
reduce or discontinue administration immediately.
 Increase IV solution without oxytocin, give O2, turn on her left side
and call the physician.
 Satisfactory labor has usually been initiated when the woman has 3
contractions in 10 minutes.
 Reduce anxiety.
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Amniotomy
Transcervical amniotomy or artificial rupture of membranes can be
used to stimulate labor.
The cervix should be soft, partially effected and slightly dilated with
presenting part engaged.
Vulva is cleansed.
Simple rupture of the membranes using sharp instrument passes over a
finger into the cervix will allow the discharge of amniotic fluid.
Procedure is explained to the woman, FHR recorded.
Note and record amount and quality of fluid (clear, color, bloody,
meconium…).
Artificial rupture of the membranes is often done to augment labor
already in progress, since the membranes serve as a barrier against
infection.
Delivery is usually accomplished soon after the membranes have been
ruptured artificially.
Some obstetricians prefer to first stimulate the uterus with IV oxytocin
and as soon as good contractions are evident, rupture the membranes.
Others prefer merely to rupture the membranes.
Reduce anxiety.
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