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Indications
- postterm pregnancy (greater than 42 weeks [ati]) must be at least 39 weeks.
-Dystocia (prolonged and difficult labor) due to inadequate uterine contractions
-Prolonged rupture of membranes
-Intrauterine growth restriction
-Maternal health complications (Rh isoimmunization, DM, Pulmonary disease, Gestational hypertension)
-Fetal demise
-Chorioamnionitis

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Elective inductions carry an increase risk of infection, premature delivery, longer labor and the need for a c-section
Failed induction- an induction that does not produce results in 24 hours and may need a c-section
Low FHR- oxytocin and prostaglandins may cause excessive uterine contractions that can cause early FHR deceleration
Increased risk for bleeding- induction increases the risk of uterine atony which decreases the amount that the uterus will contract to stop the possibility of hemorrhage

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Emergent or planned
Risk to mom/baby if vaginal
--Size of mom :: size of baby
--Multiples
--Vaginal labor not progressing
--Baby decel, "nonreassuring fetal status"
--Placenta previa/abruption
--Death of mom, baby still viable
--Fetal demise
--Herpes simplex or active infection
--Prior C-Section and/or perineal trauma or surgery
--Cardiac, pulmonary, serious vascular disease
--Cerclage (cervix sutured)
--Malpresentation (breach, footling, etc)
--Cord prolapse
--Sometimes Pt preference

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Death  2.2 per 100,000 c-sections in US
Bleeding, scarring, infection, etc. (typical surgical risks)
CNS depression of baby d/t anesthesia
May be affect mom's perception of birth experience/bonding
May negatively affect baby's microbiome/gut health
Maternal hypotension -IV access and fluid bolus

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General anesthesia or regional block
-spinal block may contain opioids and mixes of drug classes
---local anesthetic - bupivicaine
--- analgesia - morphine or fentanyl
-Recent resurgence of nitrous oxide
Prophylactic antibiotics
--cephazolin 1-2g or other depending on allergies and history of resistant strains
--Azithromycin if rupture of membranes/infection risk warrants

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IV access needed for fluids/emergency med admin
IV may be used in general anesthesia
Intrathecal catheter for spinal med admin
--uses special tubing, no preservatives, avoid alcohol scrubs

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Vitals
--add O2 if ↓SPO2
--fluid bolus if ↓BP
Degree of analgesia/anesthesia
--trend to use lowest effective dose may leave some without adequate relief unless they have an advocate; can greatly affect bonding & maternal experience
Fetal heart rate

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Treat pain as ordered
Monitor vitals for signs of complications (bleeding)
Contact provider if patient fills up a peripad in 15 minutes or less
Administer fluids as ordered
Assess incision
Employ thrombus prevention (Ted's, scds, medication)
Help mom with proper technique for feeding baby/bonding
Make sure patient has a support system to help post C-section
Monitor for urine output
Empty catheter if patient is still under spinal analgesia

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Oxytocin
Prostaglandins- to induce a spontaneous abortion or cause cervical ripening

Mechanical induction
Amniotomy- small hook to pop the membrane
Balloon dilator- a catheter tune with a balloon to stretch the cervix and cause rupture of the membranes
-Osmotic dilators- spongy material that is placed in the cervix until the cervix is full, causing the cervix to stretch and open. Can be in place for up to 12 hours
-Sweeping of the membranes- a provider will sweep the cervix in a circular motion to release the membrane

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Oxytocin- IV or IM
-baby must be engaged in the birth canal at station 0
-no sooner than 4 hours after the administration of misoprostol for cervical ripening
-given through the infusion port closest to the client
-administered as itermittent IV or IV bolus
-measurement of the maternal BP, P and respirations every 30 -60 minutes and with every dose change

Prostaglandins- PO or vaginally
Misoprostol or Dinoprostone is given for cervical ripening

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Monitor FHR and uterine activity
If cervical ripening was used, baseline data on fetal wellbeing and mother wellbeing
Fetal descent and station
Frequency, duration, and intensity of contractions
An intrauterine pressure catheter may be used to monitor contractions
A bishop score rating- a rating on how close to birth the mother is based on dilation and position of baby's head
Monitor for uterine tachysystole- discontinue oxytocin
-contraction frequency more than every 2 minutes
-Contraction duration longer than 90 seconds
-Contraction intensity greater than 90 mmHg
-Uterine resting tone greater than 20 mmHg
-No uterine relaxation between contractions

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Educate mother on only lifting about 10lbs until doctor says she can lift more
Educate patient on signs and symptoms of infection and hemorrhage
Educate patient not to engage in sexual activity until released by doctor
Help educate mom on importance of skin to skin contact and bonding
Educate patient on feeding and taking care of patient
Educate patient to Contact doctor if filling up a peripad in less than 15 minutes
Educate partner that mom will need extra help for awhile
Teach splinting with pillow when coughing or getting up (ab use)
Teach mom football hold if breastfeeding to keep baby off incision/reduce pain

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Prepare client for cervical ripening
-informed consent
-baseline data on fetal and mother wellbeing
-Monitor FHR and uterine activity
-Monitor for uterine tachysystole and fetal distress-notify provider
Prepare client for administration of prostaglandins
-inserted vaginally
-encourage to void before
Taper dose of oxytocin
-until contractions are 2-3 minutes apart
-Until contractions are lasting 80-90 seconds
-Until contraction intensity is 40-80 mmHg
-until resting tone is 10-15 mmHg
-Cervical dilation is 1cm/hr
-Reassuring FHR of 110-160 bmp
-Discontinue if findings of uterine tachysystole
Monitor FHR and contraction pattern every 15 minutes in the first stage of labor and every 5 minutes in the second stage and with every change of dose of oxytocin
Non-reassuring FHR
-Abnormal baseline FHR
-Loss of variability
-Late or prolonged decelerations
-Notify provider
-Position in side lying position
-Increase rate of IV fluids to 200 mL per hour
-Administer O2 at 8-10 L facemask
-Administer tocolytic terbutaline 0.25 mg to stop uterine activity
- Monitor FHR patterns and uterine activity
-Document responses
-If unable to stabilize FHR, prepare for emergency c-section

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Educate on the process of induction
Risks VS benefits
Pharmacologic methods or mechanical methods
Alternatives to induction
Must be at least 39 weeks gestation
Support the choice of the mother

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·         Indications

o   No uterine scarring or complications after the previous c-section

o   Clients who have an adequate pelvis

o   One or two previous low transverse c-sections

o   Clients who had a c-section due to complications which are considered non-recurrent issues

o   Providers immediately available throughout active labor capable of monitoring labor and preforming an emergency c-section if necessary

o   No current contraindications

§  Large for gestational age newborn

§  Malpresentation

§  Cephalopelvic disproportion

§  Previous classical vertical uterine incision

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·         Indications

o   Prolonged second stage of labor

o   Maternal Exhaustion

o   Fetal distress

o   Abnormal presentation or breach poison

o   Arrest of rotation

o   Advised not to push due to underlying health condition

§  High blood pressure

o   Premature delivery

§  Forceps may protect the fetus’s head from the perineum

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The risk for uterine and scar rupture, but these are very very rare.
o   Need for emergency C-section

§  Blood clots

§  Hysterectomy

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o   Lacerations of the cervix, vagina, or perinium

o   Injury to the bladder

o   Facial nerve palsy of the neonate

o   Facial bruising on the neonate

o   Subdural hematoma in the neonate

o   Higher risk of blood clots or DVT

o   Urinary and fecal incontinence
Hematoma on head if vacuum

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IV Fluids
Analgesics
Pain control (anesthesia, NO opioids past first stage of labor)
Oxytocin

Possibly an anticoagulant after birth- depends on how much the patient is ambulating, if they're wearing SCDs or tedhose, and how much blood loss there is.

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Regional anesthesia (epidural or spinal block)
Prophylactic antibiotics (debated)
Local anesthetic (for episiotomy)

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IV fluids are administered through an IV catheter
Oxytocin-
Has to be carefully monitored as it increases the risk for uterine rupture and scar disseration
FHR is continually monitored in response to oxytocin
Only given when labor has not started on its own or is not progressing on it's own and has to be carefully monitored
Anesthesia is given by anesthesiologists and monitored by the nurse
Ensure the epidural or any other anesthesia is continually flowing and ensure they will have enough by the time it is time to push

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Epidural anesthesia is performed by introducing a needle between the lumbar, thoracic, or cervical vertebrae and injecting anesthetic medication into the epidural space, via the epidural needle and/or a catheter inserted through the needle into the epidural space. Lidocaine is used as a local anesthetic prior to administration

Prophylactic antibiotics are infused through an IV line

Local lidocaine will be injected into the perineum during an episiotomy if an epidural is not in place

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Continuous FHR monitoring
Vital signs monitoring
Monitoring for signs of uterine rupture-

Sudden worsening of uterine pain

Uterine contractions that don't cease.

Regression of your baby in the womb, including a decreased heart rate.

Fetal distress‌

Severe vaginal bleeding or hemorrhaging.

Monitoring for signs of blood clots

Difficulty breathing and shortness of breath

Tachycardia

Chest pain or discomfort, which usually worsens with a deep breath or coughing.

Coughing up blood.

Hypotension, lightheadedness, or syncope.

throbbing or cramping pain in 1 leg, usually in the calf or thigh.

swelling in 1 leg

warm skin around the painful area.

red or darkened skin around the painful area.

swollen veins that are hard or sore when you touch them.

Monitoring for signs of scar rupture- prolonged  postmenstrual spotting, dysmenorrhea and abdominal pain, secondary sterility and at worst peripartum uterine rupture.

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FHR is recorded before, during, and after procedure
-If a decel occurs, forceps will be removed and reapplied
Bleeding from lacerations
I&Os
Urinary retention
Facial nerve palsy of the neonate
Possibility for blood clots

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o   Preprocedure

§  Review medical records for evidence of a previous low-segment transverse cesarean incision

§  Explain procedure and explain risks

o   Intraprocedure

§  Assess and record FHR during labor

§  Assess and record frequency of contractions

·         Evaluate strength, duration and frequency

§  Assess for evidence of a uterine rupture

§  Promote relaxation and breathing techniques during labor

o   Postprocedure

§  Nursing interventions are the same as a vaginal delivery

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o   Assist with procedure as necessary

o   Record fetal heart rate before, during, and after

§  Compression of the cord between the fetal head and forceps will cause a decrease in FHR, forceps are removed then reapplied

o   Observe neonate for bruising and abrasions at the site of forceps application after birth

o   Check the client for possible injuries after birth

§  Vaginal or cervical lacerations-indicated by bleeding in spite of contracted uterus

§  Urine retention resulting from bladder or urethral injuries

§  Hematoma formation in the pelvic soft tissues resulting from blood vessel damage

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This process is the same as a vaginal delivery
Discuss concerns with provider and be realistic about medical history and past history of c-section
It is necessary for continuous FHR
Be prepared for the possibility of an emergency c-section and make sure you're giving birth at a facility that is prepared to do so

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Education on procedure
Risks vs benefits
Complications
-lacerations are normal
-bruising on the neonate is normal
-subdural hematoma on the neonate is normal
-an episiotomy may be required to prevent tearing
Regional anesthesia is recommended
Provide support and calming techniques