VBAC/TOLAC: Nursing Considerations

• Vaginal Birth After Cesarean (VBAC) and Trial of Labor After Cesarean (TOLAC) are important considerations in obstetric care.

Definitions

• VBAC refers to a vaginal birth in a woman who has had a prior cesarean delivery.
• TOLAC is the attempt to have a vaginal birth after cesarean delivery.

Contraindications for TOLAC/VBAC

• Prior classical or T-incision uterine incision.
• Previous uterine rupture.
• Certain medical conditions.
• Placenta previa.
• Lack of availability of resources for emergency cesarean delivery.

Benefits of VBAC

• Avoidance of major abdominal surgery.
• Reduced risk of hemorrhage, infection, and thromboembolism.
• Shorter recovery period.

Risks of TOLAC/VBAC

• Uterine rupture.
• Fetal morbidity or mortality.
• Need for emergency cesarean delivery.

Nursing Role in TOLAC/VBAC

• Provide education, assess maternal and fetal well-being.
• Continuous fetal monitoring.
• Readiness for emergency interventions.

Cervical Ripening and Induction of Labor

• Cervical ripening is the process of softening and thinning the cervix to prepare it for labor and delivery.
• Labor induction is the stimulation of uterine contractions to initiate labor.

Indications for Cervical Ripening and/or Labor Induction

• Post-term pregnancy.
• Maternal medical conditions such as gestational hypertension or diabetes.
• Premature rupture of membranes.
• Chorioamnionitis.
• Fetal demise.

Methods of Cervical Ripening

• Mechanical methods: include the use of balloon catheters.
• Pharmacological methods: involve the use of prostaglandins such as misoprostol or dinoprostone.

Methods of Labor Induction

• Amniotomy (artificial rupture of membranes).
• Oxytocin administration.

Nursing Role in Cervical Ripening and Labor Induction

• Monitor maternal vital signs, fetal heart rate, and uterine contractions.
• Assess for adverse effects of medications.
• Provide comfort measures and emotional support.

Forceps and Vacuum-Assisted Delivery

• Forceps and vacuum-assisted delivery are operative vaginal delivery methods used to facilitate childbirth in certain situations.

Indications for Forceps or Vacuum-Assisted Delivery

• Prolonged second stage of labor.
• Maternal exhaustion.
• Fetal distress.

Risks of Forceps or Vacuum-Assisted Delivery

• Maternal: perineal trauma, vaginal lacerations, postpartum hemorrhage.
• Neonatal: scalp lacerations, cephalohematoma, subgaleal hematoma, shoulder dystocia.

Nursing Role in Forceps or Vacuum-Assisted Delivery

• Assist the healthcare provider during the procedure.
• Monitor maternal and fetal status.
• Provide support and education to the patient and family.

Cesarean Birth

• Cesarean birth is the surgical delivery of a baby through incisions in the abdomen and uterus.

Indications for Cesarean Birth

• Cephalopelvic disproportion.
• Fetal malpresentation.
• Placental abnormalities.
• Previous cesarean delivery.
• Fetal distress.

Types of Cesarean Incisions

• Low transverse incision: made horizontally across the lower uterine segment.
• Classical incision: vertical incision made in the upper uterine segment.

Nursing Role in Cesarean Birth

• Preoperative care: includes patient education, assessment, and preparation for surgery.
• Intraoperative care: involves assisting the surgical team.
• Postoperative care: includes monitoring vital signs, pain management, and assessment for complications.

Postpartum Care After Cesarean Birth

• Monitor for signs of infection, hemorrhage, and thromboembolism.
• Provide pain relief.
• Encourage early ambulation.
• Promote bonding between mother and baby.

Postpartum Hemorrhage (PPH)

• Postpartum hemorrhage is defined as excessive bleeding after childbirth.

Causes of PPH

• Uterine atony (failure of the uterus to contract adequately after delivery).
• Lacerations of the genital tract.
• Retained placental fragments.
• Coagulation disorders.

Signs and Symptoms of PPH

• Excessive vaginal bleeding.
• Uterine atony.
• Tachycardia, hypotension.
• Pallor, dizziness.

Nursing Interventions for PPH

• Fundal massage.
• Administration of uterotonic medications such as oxytocin, misoprostol, methylergonovine, or carboprost.
• Assessment of vital signs.
• Monitoring of blood loss.
• Fluid resuscitation.
• Blood transfusion if necessary.

Uterine Atony

• Uterine atony is a major cause of postpartum hemorrhage.

Risk Factors for Uterine Atony

• Multiple gestation.
• Polyhydramnios.
• Prolonged labor.
• Grand multiparity.
• Use of certain medications.

Treatment of Uterine Atony

• Fundal massage.
• Uterotonic medications.
• Bimanual compression.
• Uterine tamponade.
• Surgical interventions.

Retained Placental Fragments

• Retained placental fragments can lead to postpartum haemorrhage.

Risk Factors for Retained Placental Fragments

• Succenturiate lobe.
• Placenta accreta, increta, or percreta.
• Manual removal of the placenta.
• Preterm delivery.

Treatment of Retained Placental Fragments

• Manual exploration of the uterus.
• Dilation and curettage (D&C).
• Uterotonic medications.

Obstetric Lacerations

• Obstetric lacerations are tears that occur during childbirth.

Types of Obstetric Lacerations

• First-degree: involves the perineal skin and vaginal mucosa.
• Second-degree: extends into the perineal muscles.
• Third-degree: extends through the anal sphincter muscle.
• Fourth-degree: extends through the anal sphincter muscle and rectal mucosa.

Risk Factors for Obstetric Lacerations

• Nulliparity.
• Macrosomia.
• Forceps or vacuum-assisted delivery.
• Episiotomy.

Nursing Care for Obstetric Lacerations

• Pain management.
• Perineal care.
• Assessment for signs of infection.
• Stool softeners.

Uterine Rupture

• Uterine rupture is a rare but life-threatening complication of childbirth.

Risk Factors for Uterine Rupture

• Prior uterine surgery, especially classical cesarean incision.
• VBAC.
• Uterine overdistension.
• Trauma.

Signs and Symptoms of Uterine Rupture

• Sudden abdominal pain.
• Vaginal bleeding.
• Fetal distress.
• Loss of fetal station.
• Maternal tachycardia, hypotension.

Nursing Management of Uterine Rupture

• Immediate surgical intervention (laparotomy and repair or hysterectomy).
• Resuscitation of the mother.
• Delivery of the fetus.
• Monitoring of vital signs and blood loss.

Amniotic Fluid Embolism (AFE)

• Amniotic fluid embolism is a rare but catastrophic complication of childbirth.

Pathophysiology of AFE

• Amniotic fluid containing fetal cells, lanugo, and vernix enters the maternal circulation, triggering an anaphylactoid reaction.

Signs and Symptoms of AFE

• Sudden respiratory distress.
• Cyanosis.
• Hypotension.
• Coagulation failure.
• Seizures.
• Cardiac arrest.

Nursing Management of AFE

• Cardiopulmonary resuscitation.
• Oxygenation and ventilation.
• Management of hypotension and coagulopathy.
• Transfer to intensive care unit.

Shoulder Dystocia

• Shoulder dystocia occurs when the fetal shoulders become impacted during delivery.

Risk Factors for Shoulder Dystocia

• Macrosomia.
• Gestational diabetes.
• Post-term pregnancy.
• Prior history of shoulder dystocia.

McRobert's Maneuver

• McRobert's maneuver involves hyperflexing the mother's legs tightly to her abdomen to rotate the pelvis and facilitate shoulder delivery.

Suprapubic Pressure

• Application of suprapubic pressure involves applying pressure to the lower abdomen just above the pubic bone to dislodge the impacted shoulder.

Nursing Role in Shoulder Dystocia

• Recognize the situation.
• Assist with maneuvers to facilitate delivery.
• Provide support to the patient and family.
• Document the event.
• Assess the newborn for injuries such as brachial plexus injury or clavicle fracture.

Deep Vein Thrombosis (DVT)

• Deep vein thrombosis is the formation of a blood clot in a deep vein.

Risk Factors for DVT in Pregnancy

• Hypercoagulability of pregnancy.
• Venous stasis.
• Endothelial damage.
• Cesarean birth.
• Obesity.
• Immobility.

Signs and Symptoms of DVT

• Calf pain or tenderness.
• Swelling of the affected extremity.
• Warmth and redness.

Prevention of DVT

• Early ambulation.
• Graduated compression stockings.
• Prophylactic anticoagulation in high-risk patients.

Treatment of DVT

• Anticoagulation therapy.
• Monitoring for complications such as pulmonary embolism.

Pulmonary Embolism (PE)

• Pulmonary embolism is the blockage of a pulmonary artery by a blood clot.

Signs and Symptoms of PE

• Sudden onset of dyspnea.
• Chest pain.
• Tachycardia.
• Hemoptysis.
• Hypotension.

Nursing Management of PE

• Oxygen administration.
• Anticoagulation therapy.
• Hemodynamic monitoring.
• Support for the patient and family.