Maternity - L&D, part 8: Vacuum/Forceps Assisted Delivery, Premature Rupture of Membranes, Preterm Labor
by Meris Shuwarger November 19, 2021 Updated: February 21, 2022 7 min read
Hi. I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about vacuum-assisted delivery, forcep-assisted delivery, premature rupture of membranes, and preterm labor. I'm going to be following along using our maternity flashcards, which are available on our website, leveluprn.com., if you want to get a set for yourself. If you already have a set of your own, I would invite you to follow along with me through this labor and delivery section of the deck. All right. Let's get started.
So first up, we are going to be talking about assisted deliveries, and we're talking about vacuum-assisted and forceps-assisted deliveries.
Before we even start, I want to say that forceps-assisted deliveries are very uncommon now, and many facilities have policies against them. So you may not actually see this in clinical practice as much as you would have, previously. And I was actually a forcep-assisted baby. So my mom used to make fun of me and my cone head when I was born because I had quite a cone head.
So let's talk about vacuum-assisted delivery first. So this is where it's exactly what it sounds like.
There's a cup-like suction applied to the fetal head or to the fetal presenting part, which is going to help to provide traction to pull the baby out and assist with that fetal descent. So this is going to leave a mark, right? This is going to leave a mark on the baby because we're putting suction onto the head. And think about if you were to put a vacuum cleaner attachment against your arm. You're going to end up with a big round circle, right, a big, red, sort of inflamed bruise area.
So you will see that that is referred to here as cephalohematoma. So cephalohematoma or a caput, both of those are going to be possible complications of an assisted delivery of any type.
And we also risk birth trauma, right? We can cause maternal or fetal lacerations. And we can even lead to an infant subdural hematoma, a brain bleed, right, as a result of assisted deliveries. But those are going to be those complications. Hopefully, none of those things happen.
Now, when do we do this?
This is going to be done with prolonged second stage of labor or if we have any sort of abnormal fetal presentation, fetal distress, maternal exhaustion, because if we've been in labor for a long time, we're going to be exhausted, right, or ineffective pushing. So all of those things could be indications for an assisted delivery.
So nursing care here is really going to be kind of standard nursing care. Make sure your patient is in lithotomy position if that's required per your hospital policy, make sure that their bladder is empty. And they have to have ruptured their membranes, right, and the fetal part must be engaged before we can do this. I can't vacuum or forcep-assist if I haven't ruptured membranes, right, because then I'm just grabbing the amniotic sac. So make sure that the membranes have been ruptured and that the fetal presenting part is engaged in the maternal pelvis. So that is assisted delivery. But I would say, probably, forceps you're not going to hear or see about too much nowadays.
Now, moving on to a premature rupture of membranes, which we abbreviate as PROM-- there's also pre-PROM, which is preterm PROM, right? So this is going to be the rupture of membranes that's happening in a preterm gestation.
So there's PROM and pre-PROM.
So premature rupture of membranes is going to be prior to the onset of true labor, meaning my water is broken, but I'm not really truly in labor, yet. That's going to be PROM.
Pre-PROM is my membranes have ruptured, and I am preterm, right? I am not full term yet, so that is going to be before 37 weeks gestation.
So lots of things can cause this. Maternal infection is going to be a big one. Incompetent cervix, which I always think is really insulting, right? My cervix isn't incompetent, but this means that the cervix is not doing a good job of staying close, high, and tight, right? That's going to be more so the pre-PROM. And then previous preterm birth, of course, predisposes you to another preterm birth.
So the signs and symptoms are going to be I'm leaking fluid.
Now, I'm going to tell you a true story that happened to me because it's going to tell you why we need to do this next thing. I went to labor and delivery when I was pregnant with my son and said, "I think my water broke." And I was pretty pregnant, like maybe 36 or 37 weeks. I said, "I think my water broke. I've been leaking fluid all day long." And they tested the fluid that was leaking out of me and said, "Well, good news. It's not amniotic fluid. Your membranes are intact. You're just really sweaty."
So if your patient reports that they are leaking fluid, we need to assess and see, "Are you leaking amniotic fluid?" So we can do that a couple of ways.
We can pH-test the fluid. That nitrosamine paper that we would use to test the fluid would turn blue in the presence of amniotic fluid, so that blue color would mean, yeah, that's amniotic fluid.
And then a positive ferning test, where the fluid is examined under a microscope, and if it has fern-like crystals, then that would be amniotic fluid as well.
Treatment here. We're going to give ampicillin to treat any possible infection, and then we're going to give betamethasone, which is a steroid to help promote fetal lung maturity. So if we're preterm and we think maybe we have a little bit of time, even if we can just get one dose in, we're going to help to promote fetal lung maturity with the betamethasone. If it's preterm, they're staying in the hospital to be observed. Or they can go home on bed rest, which would mean no intercourse. You're taking your temperature every four hours, and you've got to report any signs or symptoms of infection. But if they are near term or if they are at term, then they're probably just going to be induced so that we can get baby out and not be concerned about things like infection anymore.
So biggest risks here, again, infection, prolapsed umbilical cord. Any time those membranes have ruptured, we can end up with the cord being prolapsed, and we can end up with germs getting inside.
So let's move on to preterm labor. I see some big, bold, red stuff here, so I want to point that out.
So preterm labor is going to be any kind of uterine contractions that cause cervical changes between 20 and 37 weeks of gestation.
Remember, we have Braxton Hicks contractions. Those are not true contractions. They're not affecting the cervix. But we're talking here about contractions that really are affecting the cervix.
So risk factors, infection, diabetes, hypertension, smoking, multi-fetal pregnancy, PROM, placenta previa. There's so many, previous preterm delivery, like we said. There's a lot of risk factors.
But the signs and symptoms of preterm delivery or preterm labor, like we said, is going to be cervical dilation, vaginal discharge of amniotic fluid, and uterine contractions. Those are the big three there.
But there's a very special lab test that can be done if we think a patient could be in labor, or maybe we're concerned that they might go into preterm labor.
A test called fetal fibronectin can be done. And fetal fibronectin is an amniotic enzyme. And if it is detected in a swab of the vagina, then it can correlate to, yes, you are at risk for preterm delivery. If we do not detect it, if we have low levels based on gestational age, then we can say with pretty good confidence that you are unlikely to deliver in the coming days. So this is a really great test and can help to assess a patient's risk for preterm labor.
Now, if we were to give magnesium to our patients to relax the uterus, that's something that we can do to slow those contractions down.
We would need to be concerned about magnesium toxicity, so we should be assessing those deep tendon reflexes, assessing their respiratory effort and knowing that the antidote for magnesium is going to be calcium gluconate. So we need to be ready with that if we have any concern of magnesium toxicity.
Nifedipine is also a medication that's a calcium channel blocker, and it can be given because it's going to help to relax that muscle. That's how it works to decrease blood pressure. So it's going to help to relax muscle, including the muscle of the uterus. So that is an option as well.
Terbutaline we've talked about before is a tocolytic, so it's going to help to relax the uterus. Indomethacin, it's an NSAID, actually, that can help to suppress labor.
And as we discussed before, betamethasone to improve that fetal lung maturity. Now, if our patients are going to be on bed rest or anything like that, we need to explain to them what that means and that, also, they are on pelvic rest, so no sexual intercourse is going to be allowed during this time.
So I hope that review was helpful for you. I'm going to give you a quick quiz to help you assess your learning of some key points in this video. All right. So here is our quiz.
What color does nitrosamine paper turn in the presence of amniotic fluid? What color does it turn? What drug can be administered to promote fetal lung maturity? So we talked about a lot of drugs, but which one is given to promote fetal lung maturity? Next up, the presence of which substance in vaginal secretions may indicate an increased risk of preterm labor? What substance is it that we're checking for? And lastly, what is the antidote to magnesium?
All right. I hope you did well. Best of luck and happy studying.
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