Medical Interventions

Although labor and delivery are essentially normal processes, sometimes complications arise. At times, the physician needs to intervene to protect the mother or fetus.

Box 26-7 Nurse’s Role in Relaxation and Breathing Techniques

First Stage

Goal: Promote Relaxation of Abdominal Muscles

• • Provide support during contractions: coach breathing, give back rubs, provide cool cloths.
• • Provide distracting activities: guided imagery, focal point, effleurage (rhythmic stroking of abdomen by woman), progressive muscle relaxation, breathing techniques, music.
• • Provide support and reminders for previously learned breathing techniques. If no specific method has been learned, encourage the following pattern:
  • • Early, or latent, phase: slow, deep chest or abdominal breathing, six to nine breaths/min; inhalations through nose and out through pursed lips.
  • • Middle, or active, phase: Slow acceleration, then deceleration of breaths through contraction; breaths shallow; approximately 16 to 20 breaths/min.
  • • Transitional phase: four to six pants followed by a blow for duration of contraction.
• • Remind patient to use breathing techniques only during contractions and normal breathing patterns between contractions.
• • Remind patient to take deep, cleansing breath before and after contraction to increase oxygen intake.
• • Remind patient to avoid rapid breathing, which leads to hyperventilation, because this can result in decreased oxygenation to fetus and symptoms for the mother.

Second Stage

Goal: Increase Abdominal Pressure and Assist in Expelling Fetus

• • Assist patient with natural bearing-down effort (BDE) or urge to push.
• • Help patient into a position that facilitates BDE during contractions: upright (squatting on bed), semirecumbent with shoulders curved and knees bent, or lateral (raise and support upper leg during BDE).
• • Assist patient with breathing during BDE:
  • • Two deep, cleansing breaths at contraction onset; patient takes a breath, holds a few seconds, then pushes while exhaling in short (7-second) periods.
  • • Two deep, cleansing breaths at contraction end.
• • Help patient into a position of comfort between contractions.
• • Provide encouragement for effort and encourage relaxation techniques between contractions.
• • Remind patient to pant during contraction if BDE is to be avoided.

Induction

Induction is an attempt to start labor at a chosen time, rather than waiting for it to begin spontaneously. It may be indicated for either maternal or fetal factors. Maternal factors include rupture of membranes greater than 24 hours, hypertensive disorders, diabetes mellitus, and history of stillbirth or fetal demise (death). Fetal indications may be intrauterine growth restriction (IUGR), nonreassuring fetal status, and oligo­hydramnios. Occasionally an elective induction is scheduled when the woman has a history of precipitous labor (lasting less than 3 hours). This is done to prevent an emergency out-of-hospital delivery. Contraindications for induction of labor include active herpes simplex infection, placenta previa (placenta covers the cervical os), and cord prolapse.

The health care provider assesses the woman to determine that she and the fetus are good candidates for the induction. Bishop scoring is a tool used to evaluate the readiness of the expectant mother for induction of labor. Factors that are evaluated with this tool include cervical dilation, effacement, cervical position, station, and cervical consistency. The medically approved methods of inducing labor include amni­otomy, prostaglandin gel application, and oxytocin administration.

Amniotomy

If the amniotic membranes have not ruptured, the primary care practitioner may use a sterile hook-shaped instrument to open the sac and allow the fluid to drain; this procedure is called an amniotomy (or artificial rupture of the fetal membrane) (Figures 26-26 and 26-27). An amniotomy has the advantage of facilitating contractions much like those in natural labor. In addition, once the membranes are ruptured, internal monitoring can be implemented. Minimal cervical dilation (–2 cm) must be present for rupture of the membranes. Assess FHR for a full minute immediately before and after this procedure. Assess the amount and color of amniotic fluid. Once an amniotomy has been performed, the woman is traditionally allowed 24 hours to deliver. Prolonged rupture of membranes carries the risk of infection.

Prostaglandin Gel Application

Successful induction of labor requires cervical dilation. The cervix begins to soften in the last weeks of pregnancy. In the event the consistency of the cervix is not favorable, prostaglandins may be used to ripen the cervix. Before administration of the prostaglandin, the patient must be assessed. Fetal heart tones are recorded to establish a baseline. The mother is placed on continuous monitoring. After assessment of the mother and fetus, the primary care practitioner applies prostaglandin E (PGE) gel intracervically with a plastic catheter (see Table 26-3). Contractions normally begin within an hour of instillation of the gel. Assessment during the ripening procedure includes close moni­toring of vital signs, FHR, and contractions. Uterine hyperstimulation is a possible side effect of prostaglandin administration. An amniotomy is performed in conjunction with the gel application. An internal fetal monitor is also routinely applied when PGE gel is used. In most facilities, the LPN/LVN does not apply this gel but does monitor vital signs, FHR, and labor progress.