NCLEX-RN: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Obstetric Medications

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Induction of Labor

Focus topic: Maternal–Newborn Nursing

Definition: To bring about labor through the use of stimulants, such as Pitocin (oxytocin).

Pitocin Infusion
A. Indications for use.

  • Postterm gestation (2 weeks or more); placental functions reduced.
  • Severe preeclampsia.
  • Diabetes.
  • Premature rupture of membranes (should deliver within 24 hours).
  • Uncontrolled bleeding.
  • Rh sensitization: rising titer.
  • Intrauterine growth retardation (IUGR).

B. Prerequisites for successful induction.

  • Fetal maturity.
  • Cervix amenable for induction (may utilize Prostin [prostaglandin E2 gel] or Cytotec [misoprostol] to assist in ripening cervix); client may be induced for several days with rest at night to ripen cervix, if it is desirable to deliver fetus due to complications.
  • Normal cephalopelvic proportions.
  • Fetal head engaged.

Assessment
A. Observe continuous monitoring of contractions and fetal heart rate—danger of ruptured uterus.
B. Evaluate prolonged uterine contractions: over 90 seconds with less than 30-second rest period between. (Safety intervention is to turn off Pitocin.)
C. Assess for uterine relaxation between contractions.
D. Assess for change in fetal heart rate pattern indicating fetal distress.
E. Assess for hemorrhage or shock, which may indicate uterine rupture.

F. Check for rigid abdomen, which may indicate abruptio placenta.
G. Assess vital signs: blood pressure for elevations.
H. Evaluate progress of labor.

Implementation
A. Maintain client on bed rest and explain procedure.
B. Provide supportive care to client in labor.
C. Obtain baseline fetal heart rate and blood pressure; note presence or absence of any contractions.
D. Start IV fluids: usually 500 mL of D5W or lactated Ringer’s (LR) solution.
E. Piggyback oxytocin solution into main line: usually 10 units of Pitocin in 1000 mL normal saline (NS) or LR solution. Controller or Harvard infusion pump may be used to more accurately control drip rate. (Harvard pump may infuse 2.5 units in 50 mL IV fluid.)
F. Begin infusion slowly to test uterine sensitivity to drug: usually begin at rate of 1 to 2 mU/min with dose increased by 1 mU increments every 15 to 30 minutes until regular contraction pattern is established.
G. Monitor labor with external monitor.
H. Discontinue oxytocin solution immediately if hypertonic contractions or signs of fetal distress occur and administer LR solution. Report to physician.

Maternal–Newborn Nursing

Maternal–Newborn Nursing: Analgesia During Labor

Focus topic: Maternal–Newborn Nursing

Assessment
A. Assess client pain status—individual thresholds vary.
B. Check vital signs and fetal heart rate before and after administration.
C. Evaluate allergies to medication.
D. Check time last pain medication was given, if any.
E. Assess progress of labor before and after.

Implementation
A. Narcotics are not given until labor is well established in order to avoid retarding progress of labor.

  • Drugs are usually administered between 4 and 6 cm dilatation.
  • Narcotics given to the mother in labor cross placental barrier and affect infant.

B. Do not administer narcotics within 2 hours of delivery because the infant may be born depressed; drugs are at maximum effect 2 hours after ingestion.

  • In the uterus, gas exchange takes place through the placenta; therefore, analgesia given in labor does not pose a threat to infant.
  • After birth, the infants breathe on their own. Analgesics depress the CNS and affect the respiratory and other centers.
  • Some infants do not become fully alert for 2 to 3 days after delivery.

C. Continually observe client and keep side rails up.
D. Be familiar with normal dosages and the physiologic effect of preparations used.
E. Record time, type, dosage, route, and client’s response.
F. Use precautions for sedatives that are given early in labor to reduce anxiety.
G. For specific drugs, see Appendix 12-1.

Maternal–Newborn Nursing: Anesthesia During Labor

Focus topic: Maternal–Newborn Nursing

Characteristics
A. No optimum anesthesia exists.
B. One of the major causes of maternal death; other three causes are hemorrhage, infection, and eclampsia.
C. History and physical should be obtained before administering anesthesia.
D. Client should be NPO before use.
E. Anesthesia should be administered by skilled personnel.
F. Choice of anesthesia in obstetrics is determined by the specific client situation and condition.

General Inhalation Anesthetics
A. Advantages.

  • May anesthetize client rapidly.
  • Primary use is for rapid induction for emergency cesarean section.
  • These anesthetics cause uterine relaxation may be used for manipulation.
  • Inhalation anesthetics may be preferred in hypovolemic client or if the client’s condition prohibits the use of regional anesthetics.

B. Disadvantages.

  • Client is not awake for delivery.
  • Brings about respiratory depression of the infant.
  • May cause emesis and aspiration in the client.
  • May be flammable.

C. Common types.

  • Nitrous oxide: danger of aspiration and respiratory depression.
  • Fluothane (halothane): potent, used in selected cases only.
  • Pentothal (sodium thiopental): IV anesthesia used as an adjunct; most frequently used for induction; may depress neonate.
  • Trilene (trichloroethylene): often used in self-administration by mask during labor and delivery. Never leave client alone when she is using self-administered anesthesia

Regional Analgesia and Anesthesia
A. Regional analgesia and anesthesia refer to the drugs given to block the nerves carrying sensation from the uterus to the pelvic region.

  • Some common agents used are: Novocain (procaine), Xylocaine (lidocaine), Pontocaine (tetracaine), and Carbocaine (mepivacaine).
  • Vasoconstrictor agents such as Adrenalin (epinephrine) are only used in conjunction with regional anesthetics to:
    a. Slow absorption and prolong the effect of the anesthetic.
    b. Prevent secondary hypotension.
  • Opioids often used with anesthetic agent to produce analgesia (e.g., Avinza [morphine], Actiq [fentanyl]).

B. Nerve root block is a principal type of regional anesthesia.

  • General considerations.
    a. Usually relieves pain completely, if administered properly.
    b. Vasodilation below the anesthetic level: may be responsible for a decrease in blood pressure; blood pools in legs.
    c. Does not depress the respiratory center and, therefore, does not harm the client unless hypotension in the client is severe enough to interfere with uterine flow.
    d. May cause postspinal headache.
    e. Contraindicated in a hypovolemic client or in the case of central nervous system disease.
    f. Drug may impede labor if given too early (before 5–6 cm dilatation).
    g. Special skill of anesthesiologist required to administer drug.
    h. Infant may need forceps delivery because the client usually cannot push effectively due to anesthesia.
  • Types.
    a. Epidural–spinal combined.
    b. Lumbar epidural (may be single dose or continuous).
    c. Spinal block.

C. Peripheral nerve block is a second principal type of regional anesthesia.

  • General considerations.
    a. May be done by attending physician does not require an anesthesiologist.
    b. Local injection of anesthetic to block peripheral nerve endings.
    c. Less effective in relieving pain than nerve root block.
    d. May cause transient bradycardia in fetus, possibly due to rapid absorption of the drug into fetal circulation.
    e. Usually there are no maternal side effects.
    f. Needle guide such as Iowa trumpet usually used.
  • Types.
    a. Local infiltration anesthesia.
    b. Pudendal block.

Assessment
A. Observe progress of labor.
B. Check vital signs and fetal heart rate before and after administration of drug (may cause transient fetal bradycardia).
C. Check drug allergies or hypersensitivity.
D. Observe for signs of dizziness, nausea, faintness, and palpitations.
E. Assess level of anesthesia: relief of pain sensation.
F. Observe for signs of systemic toxic reactions: muscle twitching, convulsions, loss of consciousness, respiratory depression, cardiac arrest.
G. After delivery, check client for return of sensation to lower body.

Implementation
A. Have client void.
B. Bolus IV fluids (500–1000 mL) to help prevent hypotension.
C. Assist client to a knee–chest, side-lying, or sitting position over a bolster or onto left side with head flexed and knees drawn up.
D. Monitor blood pressure every 3–5 minutes until stabilized; then every 30 minutes or prn.
E. Monitor fetal heart rate.
F. If hypotension occurs:

  • Turn client to left side.
  • Administer oxygen by mask.
  • Increase IV fluids.
  • Notify physician.

Maternal–Newborn Nursing: Operative Obstetrics

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Obstetrical Procedures

Focus topic: Maternal–Newborn Nursing

Episiotomy

Definition: An incision made into the perineum during delivery to facilitate the birth process.
A. Types of episiotomy.

  • Midline: incision from the posterior margin of the vaginal opening directly backward to the anal sphincter.
    a. Healing is less painful.
    b. Incision is easy to repair.
    c. May extend to rectal sphincter.
  • Mediolateral: incision made at 45-degree angle to either side of the vaginal opening.
    a. Healing process is quite painful.
    b. Incision is harder to repair.
    c. Blood loss greater.

B. Purposes.

  • Spare the muscles of perineal floor from undue stretching and tearing (lacerations).
  • Prevent the prolonged pressure of the baby’s head on perineum.
  • Reduce duration of second stage of labor.
  • Enlarge vagina for manipulation.

C. Method.

  • Generally done during contraction, as the baby’s head pushes against perineum and stretches it.
  • Blunt scissors are used.
  • Client is usually given an anesthetic: regional, local, or inhalation.

Lacerations

Definition: Perineal or vaginal lacerations are classified as first-, second-, third-, or fourth-degree tears.
A. Lacerations may involve the perineum, folds of the vagina, urethra tissues, cervical tears, or uterine tears.

  • May occur with or without an episiotomy.
  • Repaired with sutures that dissolve.

B. Prevention of lacerations.

  • Maintain mother in positions with relaxed perineum.
  • Slow, controlled exit of fetus will promote an intact perineum.

Assisted Delivery: Forceps or Vacuum

Definition: The extraction of a baby from the birth canal by a physician with the use of a specially designed instrument.
A. Types.

  • Low forceps: presenting part at or below pelvic floor.
  • Midforceps: presenting part below or at the level of the ischial spine.
  • Vacuum extraction: soft silicone cup applied to fetal head; used during prolonged second stage; preferred if borderline CPD.

B. Indications.

  • Fetal distress.
  • Poor progress of fetus through the birth canal.
  • Failure of the head to rotate.
  • Maternal disease (heart disease, acute pulmonary edema, infection) or exhaustion.
  • Client unable to push (as with regional anesthesia).

C. Prerequisite conditions for application of forceps or vacuum cup.

  • Fully dilated cervix.
  • Fetal head engaged in maternal pelvis.
  • Membranes ruptured.
  • Absence of cephalopelvic disproportion.
  • Empty bladder.
  • Fetal heart tones present before and after forceps or vacuum application.
  • Adequate anesthesia must be given for type of forceps or vacuum applied.
  • Vacuum: fetus weight < 2500 g, > 35 week, occiput presentation, no previous fetal scalp blood sampling.

D. Complications.

  • Lacerations of the vagina or the cervix; there may be oozing or hemorrhage.
  • Rupture of the uterus.
  • Intracranial hemorrhage and brain damage to the fetus.
  • Facial paralysis of the fetus.

Cesarean Delivery

Definition: A surgical delivery of an infant through an incision cut into the abdominal wall and the uterus.
A. Types.

  • Classical: vertical incision through the abdominal wall and into the anterior wall of the uterus.
  • Low segment transverse: transverse incision made into lower uterine segment after abdomen has been opened.
    a. Incision made into the part of the uterus where there is less uterine activity and blood loss is minimal.
    b. Less incidence of adhesions and intestinal obstruction.
  • Cesarean hysterectomy: abdomen and uterus are opened, baby and placenta are removed, and then the hysterectomy is performed. The hysterectomy is performed if:
    a. Diseased tissue or fibroids are present.
    b. There is an abnormal Pap smear.
    c. The uterus ruptures.
    d. There is uncontrolled hemorrhage or placenta abruptio or uterine atony, etc.

B. Indications.

  • Fetal distress unrelieved by other measures.
  • Uterine dysfunction.
  • Certain cases of placental previa and premature separation of placenta.
  • Prolapsed cord.
  • Diabetes or certain cases of preeclampsia.
  • Cephalopelvic disproportion.
  • Malpresentations such as transverse lie.

Assessment
A. Check vital signs every 5 minutes until stable, then every 15 minutes: blood pressure, temperature, pulse, respirations.
B. Observe site of incision for bleeding.
C. Assess I&O (note appearance as well as amount of urine).
D. Assess level of consciousness or return of sensation with regional anesthesia.
E. Check fundus for tone and location.
F. Evaluate lochia for amount and color every 15 minutes for 2–3 hours.

Implementation

Preoperative Care
A. Discuss and reassure to decrease anxiety.
B. Preoperative teaching if possible.
C. Preop preparation: IV, insert Foley, abdominal prep, operative permit signed, administer sodium citrate/citric acid antacid (Bicitra).
D. Inform and involve significant other and family as much as possible.

Postoperative Care
A. Institute same care as for the postsurgical client.
B. Institute same care as for the postpartum client.
C. Reinforce abdominal dressing as necessary.
D. Assist client to deep-breathe, cough, and turn.
E. Change perineal pads as needed.
F. Reassure client that the delivery is over and give information regarding the baby. (If something is wrong with the baby, the physician usually discusses this first with the parents.)
G. If mother is able and desires, show her and let her hold the baby. (Client may be too tired or uncomfortable at this time to do so. Be sensitive to her needs.)

Later Care
A. Help ambulate client (usually the first postpartum day).
B. Give stool softener as ordered and needed.
C. Encourage client to talk about delivery and baby; incorporate and accept experience.
D. Reinforce physician’s teaching about care at home.

  • Planned rest periods.
  • No heavy lifting for 4 to 6 weeks.
  • Signs of infection.
  • Care of the breast.
  • Avoidance of constipation.
  • Nutritious diet.

E. Provide regular postpartum care.

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