Amniotomy and Amnioinfusion

Amniotomy

• Involves artificial rupture of amniotic membranes (AROM) to induce or accelerate labor
• Can stimulate or strengthen contractions
• Labor typically begins within 24 hours
• Fetal heart rate (FHR) should be assessed immediately before and after
• Monitor FHR patterns for distress signs like prolonged decelerations or bradycardia, indicating potential umbilical cord compression
• Document color, odor, and amount of amniotic fluid (COA)
• Normal amniotic fluid is clear, possibly with vernix flecks
• Greenish-brown fluid may indicate meconium staining, linked to fetal distress
• Foul odor suggests infection

Amnioinfusion

• Infusion of warmed sterile normal saline or Lactated Ringer's solution into the uterus via an intrauterine pressure catheter (IUPC)
• Relieves recurrent variable decelerations caused by umbilical cord compression
• Can dilute meconium-stained amniotic fluid, reducing risk of meconium aspiration syndrome (MAS)
• Monitor maternal vital signs and uterine activity to prevent overdistension
• Continuously assess FHR patterns for improvement or distress signs
• A urinary catheter may be needed if the woman cannot void

Vacuum Extraction

• Soft plastic cup applied to fetal head with suction to assist delivery
• Used when the mother is exhausted or there are fetal distress signs during the second stage of labor
• The woman must have a fully dilated cervix and engaged fetal head
• Document the number of pulls, maximum pressure, and any cup pop-offs
• Assess the neonate for trauma signs like cephalohematoma, scalp lacerations, or subgaleal hematoma
• The mother should be assessed for perineal or vaginal lacerations

Forceps Delivery

• Metal instruments with curved blades assist in delivering the fetal head
• The woman must have a fully dilated cervix and engaged fetal head
• Considered in cases of fetal distress or maternal exhaustion
• Document the type of forceps used, application process, and any difficulties
• Observe the neonate for trauma signs like facial bruising, nerve injury, or skull fracture
• Assess the mother for vaginal or cervical lacerations and postpartum hemorrhage

Episiotomy

• Incision in the perineum to enlarge the vaginal opening and facilitate delivery
• Performed in fetal distress, shoulder dystocia, or need to expedite delivery
• Midline episiotomy: vertical incision from the posterior vaginal opening toward the rectum
• Mediolateral episiotomy: incision at a 45-degree angle from the posterior vaginal opening
• Assess the site for redness, edema, ecchymosis, drainage, and approximation (REEDA)
• Apply ice packs to the perineum for the first 24 hours to reduce swelling and pain
• Encourage sitz baths after the first 24 hours to promote healing and comfort

Cesarean Birth

• Surgical delivery involving an incision in the abdomen and uterus
• Performed when vaginal delivery is contraindicated (fetal distress, malpresentation, placental abnormalities, or maternal conditions)
• Low transverse incision is most common, allowing possible vaginal birth after cesarean (VBAC) in subsequent pregnancies
• Classical incision (vertical in upper uterus) is for emergencies or when a low transverse incision is not feasible
• Monitor maternal vital signs, bleeding, and pain levels postoperatively
• Encourage coughing and deep breathing to prevent respiratory complications
• Assess the abdominal incision for infection signs
• Provide pain management and emotional support

External Cephalic Version (ECV)

• Manually turning a fetus from breech or transverse to cephalic (head-down) presentation before labor
• Typically performed after 36 weeks of gestation
• Tocolytic medications (e.g., terbutaline) may be used to relax the uterus and improve ECV success
• Monitor maternal vital signs and FHR during and after the procedure
• Assess for placental abruption or uterine rupture signs
• Rho(D) immune globulin should be administered to Rh-negative women

Labor Induction and Augmentation

• Labor induction: stimulating uterine contractions before spontaneous onset
• Labor augmentation: enhancing ineffective uterine contractions
• Indications include post-term pregnancy, preeclampsia, fetal growth restriction, and maternal medical conditions
• Cervical ripening: softening and thinning the cervix
• Mechanical methods: Foley catheter or laminaria
• Pharmacological methods: prostaglandins like misoprostol or dinoprostone
• Oxytocin: synthetic hormone to stimulate uterine contractions
• Administer via infusion pump, starting with a low dose and gradually increasing to achieve adequate contractions
• Continuously monitor maternal vital signs, uterine contractions, and FHR
• Assess for uterine tachysystole (more than five contractions in 10 minutes), which can lead to fetal distress
• Monitor intake and output to prevent water intoxication
• Provide comfort measures, such as position changes, massage, and analgesia, to manage pain
• Nursing responsibilities include preparing the patient, monitoring maternal and fetal status, documenting interventions, and providing emotional support

Complications of Birth-Related Procedures

• Include fetal distress, umbilical cord prolapse, uterine rupture, postpartum hemorrhage, and infection
• Prompt recognition and management are essential for maternal and fetal well-being

Newborn Resuscitation

• Interventions at birth to support breathing and circulation in newborns not breathing or with a heart rate under 100 bpm
• Initial steps: warmth, clearing the airway, drying, and stimulating breathing
• If no response, initiate positive-pressure ventilation (PPV) using a bag-mask device
• Chest compressions if heart rate remains below 60 bpm despite adequate ventilation
• Medications like epinephrine may be administered if the heart rate remains low or absent
• Continuously monitor the newborn's heart rate, respiratory effort, and oxygen saturation
• Post-resuscitation care includes monitoring vital signs, providing respiratory support, and assessing for complications

Neonatal Pain Assessment and Management

• Standardized pain scales are used (e.g., Neonatal Infant Pain Scale (NIPS) or Premature Infant Pain Profile (PIPP))
• Non-pharmacological techniques: swaddling, non-nutritive sucking (pacifier), skin-to-skin contact, and breastfeeding
• Pharmacological options: acetaminophen, ibuprofen, and opioids
• Local or regional anesthesia techniques: EMLA cream or nerve blocks for painful procedures
• Document pain assessments and interventions

Ballard Score

• Tool to assess gestational age based on physical and neuromuscular maturity
• Physical maturity characteristics: skin texture, lanugo, plantar creases, breast tissue, eye and ear development, and genitalia
• Neuromuscular maturity characteristics: posture, square window sign, arm recoil, popliteal angle, scarf sign, and heel-to-ear maneuver
• The total score correlates with gestational age in weeks

Newborn Screening

• Testing infants for genetic, metabolic, and hormonal disorders
• Early detection and treatment can prevent serious health problems and developmental delays
• Common tests: phenylketonuria (PKU), congenital hypothyroidism, cystic fibrosis, and sickle cell disease
• Parents should be informed about the purpose of newborn screening and the implications of abnormal results

Circumcision

• Surgical removal of the foreskin
• Elective, performed for cultural, religious, or social reasons
• Pain management techniques: dorsal penile nerve block or topical anesthesia
• Monitor for bleeding, infection, and urinary retention
• Provide parents with instructions on how to care for the circumcision site