Episiotomy, Cesarean Birth, and Vaginal Birth after Cesarean (Nursing)

by Jacquelyn McMillian-Bohler

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    00:01 The next procedure is called an episiotomy.

    00:04 So this procedure can be done in conjunction with forceps or vacuum to help open up the space of the vagina.

    00:12 So it's actually an incision that can be made straight down, which is called a midline episiotomy, or to the side, which is called a medial lateral episiotomy.

    00:21 And this actually opens up the space to help the baby come out.

    00:25 So let's think about the indication.

    00:27 I already mentioned that we can use an episiotomy to help prepare the space for a forcep or a vacuum extraction.

    00:35 So that might be an indication.

    00:37 It may also be done in the case when the provider feels that the vagina may be overly traumatized by the delivery of the baby.

    00:44 So thinking about the fact that the labia have to stretch and sometimes lacerations are normal.

    00:50 But sometimes the lacerations instead of being in the perineum, will actually be upwards, and maybe move into the clitoris, or to the urethral meatus, and that may be less desirable.

    01:00 So some providers may decide to cut an episiotomy, so they can control the tearing.

    01:06 Let's talk about the risks of an episiotomy.

    01:09 So, I'm going to paint a picture for you.

    01:11 Have you ever cut a piece of fabric or wrapping paper and you start cutting, and then maybe about halfway through, you just take your scissors and you just keep pushing rather than continuing to cut? That's an extension.

    01:23 And the same thing can happen in the perineum when we cut an episiotomy, especially a midline.

    01:28 So if we cut a midline episiotomy, and then the head comes out over it, it can actually extend that laceration all the way into the rectum.

    01:36 Now, it's one of the reasons why providers prefer to cut a medial lateral episiotomy because they don't extend as much.

    01:42 The problem with that is that when you cut in a medial lateral episiotomy, that it extends into the muscle.

    01:48 Whereas, the perineum is just skin.

    01:50 So it's a balance, okay? We can also have bleeding.

    01:54 The act of cutting can open up vessels that leads to more bleeding than just the normal lochia.

    02:00 And also, because we're breaking down the skin, we're opening it up to potential for infection is there.

    02:05 So that will be something that needs to be monitored, especially when there's an extension to a fourth degree.

    02:12 So what does the nurse do? They're going to monitor for the bleeding, and the possibility of hematoma formation related to that process.

    02:19 Also thinking about signs of infection.

    02:22 So pain, the patient might complain about that.

    02:25 Or you might be able to see drainage that indicates that there's infection.

    02:29 And monitor for the fact that the wound should stay approximated, so the edges should be together.

    02:35 If the edges begin to open, that's called dehiscence.

    02:38 And that would not be desirable.

    02:41 Now, let's talk about cesarean birth.

    02:43 Notice I use the word birth.

    02:45 Let's try to think about ways that we can create a beautiful experience around cesarean, just as we do around a vaginal delivery or a vaginal birth.

    02:53 Some clients may feel like they failed if they're unable to achieve a vaginal delivery.

    02:58 So we want to be sensitive to that, and try to use words that are uplifting and empowering.

    03:03 So during this procedure, the fetus is actually delivered through an abdominal incision, rather than through the vagina.

    03:10 There are several different types of incisions that can be used.

    03:13 The first one is a classical cut, and this would be made straight up and down.

    03:17 This is the way we originally did cesarean in birth, because it's easier, and it's faster.

    03:23 So we don't have to be quite as careful.

    03:25 So in an emergency, or in a situation where we have multifetal gestation, so maybe triplets, or quads, or something like that, you still may see the classical cesarean done.

    03:37 We also, more often now, see the glow transverse, so the bikini incision.

    03:42 And the reason why we like that one is because -- but really, there are two reasons: One, aesthetically, you can hide it underneath a bikini, which is why it's called a bikini cut.

    03:51 But the other one is, is that if we have a low transverse incision, it's less likely to open up.

    03:57 So it opens up the options for later deliveries.

    04:01 So what might be the indications for a cesarean birth? First of all, infection.

    04:05 So the chorioamnionitis, we talked about before, the baby has to come out.

    04:10 Often we don't have a way to cure that infection.

    04:12 So we may need to do a cesarean birth to get the baby here, now.

    04:17 There are a range of complications that may necessitate getting the baby here because they're safer externally than they are in utero.

    04:25 Fetal distress.

    04:26 So let's imagine a client is in labor, and we start to see those lates and variable decelerations continuously despite our best efforts to change that.

    04:35 Then the baby's going to be safer outside, so a cesarean birth might be indicated.

    04:39 If there's cervical disease.

    04:41 So if the cervix doesn't dilate, because of something else that's happened before, then a cesarean birth will be needed.

    04:49 A breakdown of maternal fetal tolerance.

    04:51 So again, this is a blanket term to cover anything where the mother is not doing well, or the baby's not doing well for any reason.

    04:59 And then finally, a cesarean birth might be performed for any unknown reason, including maternal preference.

    05:06 So maybe the patient has decided that a cesarean birth is what they would like to do.

    05:10 And that is just as good a reason as any of the rest.

    05:15 So what are the actions for preparing a client for a cesarean birth? First, making sure they have all the information that they need as much as possible.

    05:23 Sometimes during an emergency, going through all of those details is going to be really hard, which is why, we often consent clients versus cesarean birth, even when they come in for a vaginal delivery.

    05:34 We need an indwelling catheter because we're going to do abdominal surgery.

    05:38 IV access is going to be important.

    05:40 Both for the administration of just regular fluids, but also for pain medication, anesthesia, and that sort of thing.

    05:47 An antiacid will be given to neutralize stomach acids in case of aspiration.

    05:52 Antibiotics will be given to prevent endometrisis.

    05:56 So you can imagine if we're going to cut open the uterus, the potential for infection is going to be there.

    06:02 We also need to remove any jewelry, or dentures, or nail polish.

    06:06 And nail polish is going to be important because we're going to have an oxygen saturation machine on and it works better if there's no nail polish.

    06:13 So sometimes, if the patient has on nail polish, maybe they don't have polish on their toes, and we'll put it there.

    06:19 The nurse needs to make sure that the consent form has been signed.

    06:23 Sometimes this gets missed, especially in an emergency.

    06:26 We need a baseline nonstress test and continuous fetal monitoring as long as possible during the procedure to make sure that the baby's doing okay.

    06:34 We need to make sure that all the members of the healthcare team are aware of the impending delivery.

    06:39 So that includes anesthesia, the NICU, maybe the pediatrician, obviously, the obstetrician and the second assist.

    06:49 We need to monitor for excessive bleeding at the incision site.

    06:51 So this is going to happen after the patient has delivered by a cesarean.

    06:55 So when we're in the parture, so we're in the area where we watch over the patients after surgery, we want to make sure that the bleeding is okay.

    07:04 We're going to monitor for signs of infection, and this is going to take place over a few days.

    07:09 And then of course, we need to monitor for pain control.

    07:12 They may have pain that's related to the incision, but they also can have pain just related to uterine contractions, because well they just delivered a baby.

    07:21 Throughout the procedure and postpartum, we want to make sure we're monitoring vital signs.

    07:25 This will clue us in to not only signs of infection, but any hypotension or increased bleeding, or any of those other things.

    07:32 We want to monitor intake and output, including blood loss, this is going to be very important.

    07:39 Remember that the client who is pregnant is also in a hypercoagulable state.

    07:44 So they're in the bed for the surgery, and they may have limited mobility afterwards.

    07:48 So the use of sequential compression device or SCDs is going to be very important.

    07:54 Once they're post-op, having the client walk around and move around, sometimes they may not feel like they want to do that but that's going to be really important to keep the blood flowing and hopefully diminished the chances of having any sort of thrombus development.

    08:08 We also want to encourage coughing and deep breathing just like we would do with any other post-op client.

    08:14 So our very last procedure that we're going to talk about today is a vaginal birth after cesarean.

    08:20 The old rules back in the day used to be once a C-section, always a C-section.

    08:26 And then we figured out maybe not always a C-section.

    08:30 So we now have what's called a VBAC.

    08:32 And so a VBAC is a successful vaginal delivery for a client who was previously delivered by a cesarean.

    08:38 We also have something called TOLAC, which is a trial of labor after cesarean.

    08:43 So if they are trying to labor and they haven't quite delivered they're a TOLAC.

    08:48 But once they've delivered vaginally, then they're a VBAC.

    08:51 TOLAC, VBAC.

    08:54 So the indication is going to be for a client who has previously had a low transverse uterine incision.

    09:01 So you want to double check those surgical records and make sure that the uterine incision is also low transverse because sometimes they may have a classical external incision, but the internal incision on the uterus is low transverse.

    09:14 And if that's the way it is, then they're a candidate for a vaginal birth.

    About the Lecture

    The lecture Episiotomy, Cesarean Birth, and Vaginal Birth after Cesarean (Nursing) by Jacquelyn McMillian-Bohler is from the course Procedures During Labor and Delivery (Nursing).

    Included Quiz Questions

    1. Incision of the vagina to facilitate delivery
    2. Puncture of the amniotic sac with a hook
    3. Abdominal incision to facilitate delivery
    4. Fluid infusion into the amniotic sac
    1. Maternal preference
    2. Eclampsia and maternal seizures
    3. Fetal variable decelerations
    4. Fetal heart rate of 175 bpm
    5. Painful uterine contractions
    1. Baseline non-stress
    2. Removal of jewelry, dentures, and nail polish
    3. Antacid and antibiotic administration
    4. Frequent toileting to empty the bladder
    5. Ensure verbal consent was given
    1. Monitor for bleeding at the incision site
    2. Frequent pain assessments
    3. Encourage coughing and deep breathing
    4. Encourage bed rest
    5. Apply TED hose stockings
    1. Previously low transverse uterine incision
    2. Previously classical uterine incision
    3. Negative history of pregnancy complications
    4. Fetus in the cephalic presentation

    Author of lecture Episiotomy, Cesarean Birth, and Vaginal Birth after Cesarean (Nursing)

     Jacquelyn McMillian-Bohler

    Jacquelyn McMillian-Bohler

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