١ University of Mosul / College of Nursing Maternity & Neonatal nursing

Part V: Midterm Examination

Part VI: Obstetrical operation

Outlines

Nursing care during obstetrical operation (Episiotomy, forceps, C/S & induction of labor). Learning objectives

At the end of this chapter, the student should be able to:

1. Identify possible medical – surgical interventions for labor: cesarean birth,

induction and augmentation of labor, amniotomy , episiotomy . Forceps &

vacuum extractor.

2. Provide care for a client during labor and delivery.

Nursing care during obstetrical operation

Nursing care during obstetrical operation includes:

1. Lacerations of the birth canal.

2. Episiotomy & repair.

3. Forceps delivery.

4. Caesarian section.

5. Induction of labor &augmentation of labor.

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Lacerations of the birth canal:

1. laceration of cervix

A minor laceration occurs frequently but not causes symptoms.

Extensive laceration occurs in forceps delivery with incomplete cervical

dilatation, or in rapid delivery of head in breech presentation.

Scar of cervix from previous injury may tear.

Management

1. Anesthetize the patient.

2. Insert wide speculum.

3. Hold the anterior & posterior lips by sponge forceps.

4. Suture the tear by catgut.

5. Antibiotic is given to prevent infection.

2. Laceration of perineum & vagina

Laceration of 3 stages:

a. First degree: tear involve the anterior part of perineum & related

posterior wall of vagina.

b. Second degree: tear involve perineum up to external anal sphincter ,

with corresponding tear in vagina.

c. Third degree: tear involve anal sphincter & extend about 2 cm up the

anal canal If this tear not repaired, it will end with incontinence

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,therefore careful examination of vagina & perineum after delivery is

necessary.

Management:

For 1st& 2nd degree :

1. Repair of the tear urgently should be done.

2. Prevent any infection by complete repair under aseptic condition with

giving antibiotics.

3. Repair is done under pudendal block or G.A or local anesthesia by 1%

lignocaine

For 3rd degree:

1. Repair should be done immediately after delivery.

2. If repair not done, rectal incontinence will be the complication.

3. Wash the perineum with soap & water & then dried.

4. Patient may have urine retention therefore catheterization is needed.

5. If the bowel not acted by 4thday,glycerin suppository may be used .

6. If wound infected , remove perineal stitches to permit drainage & giving

antibiotics

Episiotomy

It is an incision in the perineum to enlarge the introitus.

Indications of episiotomy

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1. When perineum threaten to tear: indicated in primigravida .

2. When there is delay in delivery.

3. Forceps delivery.

4. Breechdelivery: to reduce risk of intracranial hemorrhage.

5. Fetaldistress: when fetal distress at 2ndstage of delivery.

6. Prolapsedcord.

7. Prematurelabor: episiotomy routinely done to prevent intracranial injury.

Procedure

Do episiotomy under pudenda block or G.A or local anesthesia by

infiltration with 10 ml of lignocaine 1%.

Incision done when head distending the perineum .

Avoid cutting anal sphincter

Management

1. suture episiotomy in layers

2. don't leave any space between layers to prevent hematoma

3. remove stitches after 5 days

4. daily bathing is advised

5. keep the wound dry

6. antibiotic is given when there is a risk of infection

7. analgesia is given when there is discomfort

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Forceps delivery

It is used to apply traction to the head of fetus in a pelvis of adequate size.

not to attempt forceps delivery when there is disproportion

Indications

1. Delay in 2nd stage of labor.

2. Impending maternal distress.

3. Impending fetal distress.

Delay in 2nd stage of labor: occur in

1. inadequate uterine contraction

2. rigid pelvic floor or perineum

3. large fetus

4. persistent occipitoposterior or deep transverse arrest of the head

5. other malpresentation ( face, brow )

6. contraction of pelvic outlet

Maternal distress: caused by:

1. Heart disease.

2. Severe pulmonary disease.

3. Severe PET or eclampsia.

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Fetal distress: caused by:

1. prolapsed cord

2. placental insufficiency ( e.g. in PET, HT, APH, Post maturity )

3. prolonged or difficult labor

4. uterine infection

Conditions to be fulfilled before applying forceps:

1. The presentation must be suitable.

2. The head must be engaged.

3. Adequate pelvic outlet.

4. Full dilatation of cervix.

5. Rupture fore water bag. (If it is not ruptured).

6. The bladder should be empty.

7. The uterus should be contracting to help pushing the fetus.

Complications of forceps delivery

Maternal Complications Fetal Complications

1. Danger of G.A.

2. Laceration of cervix, vagina or

perineum.

3. Postpartum hemorrhage from

uterine atony or lacerations.

4. Puerperal genital infection.

1.Intracranial hemorrhage.

2. Facial palsy.

3. Cephalhematoma.

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Vacuum extraction

Vacuum extractor consists of metal suction cup attached by a chain which

runs through a rubber tube, to metal handle.

Suction cup of 3 sizes 40, 50, 60 mm in diameter

Negative pressure starts by 0.1 kg/cm'' & increased at 2 minutes interval until

0.8 kg/cm''.

Traction is done intermittently with uterine contraction.

After delivery, the vacuum reduced slowly to prevent damage to scalp.

Indications of Vacuum extraction

1. Same as for forceps.

2. Vacuum used to accelerate cervical dilatation when the 1st stage is prolonged.

3. If there is weak uterine contraction, oxytocin is given.

4. If there is disproportion, C/S is indicated.

External version: it is a process of changing the fetal position to a cephalic

one through abdominal wall manipulation

Internal version: it is done when the cervix is fully dilated, by passing the

hand through the cervix to the uterus to turn the fetus. It is called

podalicversion, used in delivery of 2nd baby of twin if it lies transversely.

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Caesarian Section

Is defined as operation by which the fetus is delivered through an incision in

the uterus after 28th week of pregnancy.

If the same operation done before this 28thweek, it is called hysterotomy.

Indications of Caesarian section

1. Faults in birth canal e.g.

a. Cephalopelvic disproportion.

b. Pelvic tumor. e.g. ovarian cyst or fibromyoma.

c. Cervical or vaginal stenosis.

d. Double uterus.

2. Fetal malpresentation : ( brow, locked twin ).

3. Abnormal uterine action: if 1st stage > 12 hrs.

4. APH: in placenta previa except 1st degree.

In accidental hemorrhage (rarely do C/S because baby is dead)

5. Other maternal indications: in cardiac or respiratory diseases, fulminating

PET.

6. fetal indications : as in diabetes mellitus due to premature delivery of the baby

in placental insufficiency as in PET

Types of Caesarian section

1. Upper uterine segment operation: rarely done (due to risk of rupture scar ).

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2. Trans peritoneal lower uterine segment operation: commonly done both types

could be elective or emergency.

Pre-operative nursing care

1. Checking maternal vital signs.

2. Checking fetal heart.

3. Shaving abdomen with taking a bath the day before operation.

4. Emptying urinary bladder by catheter.

5. I.V glucose –saline drip is inserted.

6. Prepare cross matched liter of blood.

During operation

1. Re-rusticator equipped theater,heat,suction, oxygen, open mask.

2. Checking maternal vital signs regularly.

3. giving oxytocin if uterus is not contracted

Postoperative

1. Giving I.V fluid for 1st 24 hrs is given.

2. Giving analgesic drug to let the mother comfortable & in rest.

3. Daily breast care is carried out & breast feeding is encouraged earlier.

4. Checking urine output.

5. Check for any PPH.

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6. Check for bowel motion early movement of patient will decrease the risk of

DVT.

7. Prophylactic antibiotic is given pre &post-operative.

8. Remove stitches at day 5-7 after operation.

9. Checking for any wound infection.

Caesarian hysterectomy

Removal of uterus at the time of C/S. it is rarely indicated

Indications

1. Rupture uterus with severe vascular damage or uterine infection.

2. Fibromyoma.

3. Cancer of cervix.

4. Concealed accidental APH: when persistent bleeding occurs& risk of

hypofibrinogenaemia is present.

Destructive operation

It is done to reduce the size of baby .it is rarely done e.g. craniotomy ,

cleidotomy ( cut clavicles to facilitate shoulder delivery in anencephaly baby

).

Induction of labor

It means artificial initiation of labor.

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Indications

1. PET & essential hypertension.

2. Post maturity.

3. APH.

4. Hydramnios.

5. Unstable lie.

6. Diabetes mellitus.

7. Hemolytic disease.

8. Fetalabnormality.

9. Fetaldeath.

Methods

1. Administration of oxytocin or prostaglandin.

2. Artificial rupture of membranes ( amniotomy ).

3. A combined method is often used.

Syntocinon in drip can be used .( 2 units/ 500 c.c glucose water ) .

prostaglandins : E2 & F2α may be given I.V infusion , it has nausea &

vomiting as side effect , & not super than syntocinon .( PGE2 , 3mg )

pessaries inserted in vagina , if cervix is ripe .this has no side effects .

Risks of induction labor

1. Combinedamniotomy with oxytocin drip may fail, but rarely occur.

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2. Risk of infection if there is delay of labor after induction, therefore

antibiotic is given.

3. Iflabor fails to occur, C/S is indicated.

Nursing care for patient with induction of labor

1. observe & check the rate of flow of infusion

2. observe the duration of uterine contraction

3. observe fetal heart rate

4. if there is any abnormality of uterine contraction stop the infusion

Augmentation of labor is the stimulation of uterine contraction after

spontaneously beginning but the progress of labor is unsatisfactory

intravenous oxytocin is used in the same manner as for induction of labor .