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External Cephalic Version and Cervical Ripening (Nursing)

by Jacquelyn McMillian-Bohler

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    00:01 Today we're going to talk about 11 procedures.

    00:05 So these are going to be things that are done by the provider to assist when there are complications in labor.

    00:11 We're going to talk about 11 complications.

    00:14 They are: external version, cervical ripening, induction of labor, augmentation of labor, amniotomy, amnioinfusion, vacuum-assisted birth, forceps-assisted birth, episiotomy, cesarean birth, and finally, vaginal birth after cesarean.

    00:37 That's a lot, but I know we can do it.

    00:39 Here we go.

    00:41 The first procedure is called an external version.

    00:44 Sometimes it's also called an external cephalic version.

    00:49 During this procedure, the fetus is actually rotated from a breech presentation all the way to a cephalic presentation.

    00:58 The reason we do this procedure is because the cephalic presentation is the safest for vaginal delivery.

    01:04 And so when the fetus presents in any other position, we have an opportunity to try to rotate the fetus to cephalic.

    01:13 Now, it's not without risks that we do that.

    01:16 So it's important that we understand what those are.

    01:19 When we do the cephalic version, it can cause rupture of the membranes.

    01:23 It might lead to bleeding. It can cause fetal distress.

    01:29 Cletus the fetus doesn't always like to be moved around too much.

    01:33 And it can also cause someone to go into spontaneous labor.

    01:37 So how should the nurse prepare the client for the external version? First, due to the risks that we just talked about, it's very important that a consent form is signed.

    01:48 The second thing to make sure that Cletus is doing okay, before we start this procedure, the nurse should obtain a baseline nonstress test.

    01:56 Remember, we're looking for a reactive strip.

    02:00 Hopefully you remember back in antepartum, when we talked about RhoGAM.

    02:04 It's the shot that we give for clients who are Rh-negative to protect them from sensitization from an Rh-positive fetus.

    02:11 So double check that chart and make sure that the client if they're Rh-negative, has received the RhoGAM.

    02:18 Also, it's important to make sure that an IV is established.

    02:22 In case there are any complications, labor starts, or we experienced fetal distress, that access is going to be really important.

    02:30 Also to calm the uterus down, because sometimes it's a little irritated.

    02:34 Even before, we start this procedure, the provider may order a tocolytic to help calm things down.

    02:41 And finally, after the procedure is done, the nurse is going to again, repeat that nonstress test and make sure that Cletus is a okay, before we move on.

    02:51 The next procedure is cervical ripening.

    02:53 Cervical ripening is a procedure done for a client who may be induced for their birth.

    02:59 So what it actually is, is a mechanical or pharmacological process to actually open and help soften the cervix and get it ready for labor.

    03:09 When do we do cervical ripening? If we have a client who's had a baby before, then we use a test called a Bishop score, which I'll explain in just a second.

    03:18 And if that score is less than eight, then we will need to consider cervical ripening.

    03:24 If the client has never delivered a baby before, then that Bishop score will be less than 10.

    03:31 So let's talk about what that Bishop score looks like.

    03:34 So this is a table that explains it pretty well.

    03:37 So let's break it down.

    03:39 They're going to be five elements that we want to consider in this assessment.

    03:42 The dilation of the cervix. How open it is? The position of the cervix.

    03:47 So this is in relationship to the vaginal opening.

    03:50 The cervix actually shifts as it labor's.

    03:53 And so the closer it gets, as it lines up to the vaginal opening, the more ripe it is.

    03:58 So, it's not the position of the patient.

    04:00 It's the position of the cervix.

    04:02 If you remember back from our discussion of the stages and phases of labor, we also want to think about effacement.

    04:09 So that's sort of the thinness or the shortness of the cervix.

    04:13 We want to think about the station.

    04:15 So how close is the presenting part to the cervix? And to the ischial spines? We also want to think about cervical consistency.

    04:24 So thinking about how something feels.

    04:26 So a cervix that's not really ready for labor is going to feel pretty firm like the tip of your nose.

    04:32 And as it gets more and more ready for labor, it's going to soften up and feel more mushy.

    04:37 So usually mushy things are bad, but in labor, actually a nice soft cervix is pretty good.

    04:44 So if you look across the top of this chart, you'll see numbers. 0, 1, 2, and 3.

    04:49 And depending on how the client scores on that assessment, we'll add those numbers together to come up with a Bishop score.

    04:56 So remember, if it's someone who's had a baby before, we're going to use a score of less than eight as an indicator for the need for cervical ripening.

    05:05 And if they've never been pregnant before, never had a baby before, then we'll use the number 10.

    05:11 So how do we do cervical ripening? How's it done? Well, there are two possibilities.

    05:17 It could be mechanical, where we actually use a device that's inserted into the cervix, and it helps to physically push open the cervix and apply pressure.

    05:27 Or we can use medication.

    05:28 And there's several different options such as Dinoprostone, Misoprostol, or low-dose oxytocin.

    05:35 So either one could be used depending on the provider, and the particular needs of the client.

    05:40 So what are the risks because there's certainly some? First of all, anytime we use any sort of mechanical device to open up something that's closed, there's a potential for trauma.

    05:51 We could also, as we begin to open the cervix send that oxytocin which is released from the cervix into the uterus, and it will start contracting too much and that's called hyperstimulation.

    06:03 There could also be bleeding.

    06:05 And finally, of course, if we overstimulate the uterus, there can be fetal distress.

    06:11 So how does the nurse prepare for cervical ripening? Well, the very first thing is you want to make sure those dates are correct.

    06:18 The last thing that needs to happen is that we ripen the cervix and then find out that the client is really not do.

    06:25 Finding out they're preterm after you've already tried to open the cervix is not a good day.

    06:31 The next thing because some of the medications may cause contractions, and therefore put some stress on poor Cletus the fetus, we want to do a baseline nonstress test to make sure, he's doing okay.

    06:43 The next thing is we want to make sure that the client and maybe the other people that are there with the client, the support team knows what to expect.

    06:51 Sometimes cervical ripening can take place over a few days and everyone needs to be ready for that.

    06:57 It's important to gather all the equipment that you need.

    06:59 So cervical ripening balloon or the medication or whatever might be needed in order to perform the cervical ripening.

    07:08 And then once the device is placed, or the medication has been placed on the cervix or around the cervix, then making sure there are no signs of fetal distress, or hyperstimulation.

    07:19 So that can be accomplished by continuous monitoring for just a little while.


    About the Lecture

    The lecture External Cephalic Version and Cervical Ripening (Nursing) by Jacquelyn McMillian-Bohler is from the course Procedures During Labor and Delivery (Nursing).


    Included Quiz Questions

    1. Monitor for fetal distress
    2. Ensure consent form is signed prior to the procedure
    3. Confirm if RhoGHAM was given at 28 weeks
    4. Complete the procedure when the fetus is in the breech position
    5. Administer oral fluids and medications during the procedure
    1. To prepare for vaginal delivery
    2. To induce labor
    3. To prepare for C-section delivery
    4. To enhance placental perfusion
    1. Cervical ripening increases the readiness of the cervix for labor.
    2. Indicated for multiparous clients with a Bishop score < 8
    3. The mechanical cervical ripening balloon is used in cervical ripening.
    4. Indicated for nulliparous clients with a Bishop score > 8
    5. Pharmacological methods are not used in cervical ripening.
    1. Stimulation of the cervix can induce contractions.
    2. Prior to the procedure, confirm fetal gestation.
    3. Monitor for bleeding and trauma
    4. Explain to the client that cervical ripening takes a few minutes.
    5. After the procedure do a nonstress test.

    Author of lecture External Cephalic Version and Cervical Ripening (Nursing)

     Jacquelyn McMillian-Bohler

    Jacquelyn McMillian-Bohler


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