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.