Which of the following should be assessed first by the nurse immediately after Amniotomy has been performed?

In addition to basic intrapartum care, the nurse observes the woman and fetus for complications and takes corrective actions if abnormalities are noted. Nursing care is similar for the woman who has cervical ripening.

The nurse has a great responsibility when administering oxytocin or other uterine stimulants to a pregnant woman. The nurse must maintain safeguards to both mother and fetus when administering oxytocin and recognize when to start, change, or stop its infusion and when to notify the physician. Facility policies related to oxytocin must clearly support correct nursing and medical actions (Pearson, 2011).

Oxytocin (Pitocin)

Classification: Oxytocic

Action: Synthetic compound identical to the natural hormone from the posterior pituitary. Stimulates uterine smooth muscle, resulting in increased strength, duration, and frequency of uterine contractions. Uterine sensitivity to oxytocin increases gradually during gestation. Oxytocin has vasoactive and antidiuretic properties.

Indications: Induction or augmentation of labor at or near term. Maintenance of firm uterine contraction after birth to control postpartum bleeding. Management of inevitable or incomplete abortion.

Dosage and Route: Induction or Augmentation of Labor

Control of Postpartum Bleeding: Intravenous infusion: Dilute 10 to 40 units in 1000 mL of intravenous solution. The rate of infusion must control uterine atony. Begin at a rate of 20 to 40 mU/min, increasing or decreasing the rate according to uterine response and the rate of postpartum bleeding. Correcting any identifiable cause of the hemorrhage should also be done. Intramuscular injection: Inject 10 units after delivery of the placenta. (See Chapter 28 for other medications used to treat postpartum hemorrhage.)

Inevitable or Incomplete Abortion: Dilute 10 units in 500 mL of intravenous solution and infuse at a rate of 10 to 20 mU/min. Other dilutions are acceptable.

Absorption: Intravenous, immediate; intramuscular, 3 to 5 minutes.

Excretion: Liver and urine.

Contraindications and Precautions: Include, but are not limited to, placenta previa, vasa previa, nonreassuring fetal heart rate (FHR) patterns, abnormal fetal presentation, prolapsed umbilical cord, presenting part above the pelvic inlet, previous classic or other fundal uterine incision, active genital herpes infection, pelvic structural deformities, invasive cervical carcinoma.

Adverse Reactions: Most result from hypersensitivity to drug or excessive dosage. Adverse reactions include hypertonic uterine activity, impaired uterine blood flow, uterine rupture, and abruptio placentae. Uterine hypertonicity may result in fetal bradycardia, tachycardia, reduced FHR variability, and late decelerations. Fetal asphyxia may occur with diminished uterine blood flow. Fetal or maternal trauma, or both, may occur from rapid birth. Prolonged administration may cause maternal fluid retention, leading to water intoxication. Hypotension (seen with rapid intravenous injection), tachycardia, cardiac dysrhythmias, and subarachnoid hemorrhage are rare adverse reactions.

Drug interactions include vasopressors and the herb ephedra, causing hypertension.

Nursing Considerations: Intrapartum: Assess the FHR for at least 20 minutes before induction to identify reassuring or nonreassuring patterns. Perform Leopold’s maneuvers, a vaginal examination, or both to verify a cephalic fetal presentation. If nonreassuring FHR patterns are identified or if fetal presentation is other than cephalic, notify the physician and do not begin induction until an ultrasound is done to ascertain fetal presentation.

Observe uterine activity for establishment of effective labor pattern: contraction frequency every 2 to 3 minutes, duration of 40 to 90 seconds, intensity of 50 to 80 mm Hg (measured with an intrauterine pressure catheter). Observe for hypertonic uterine activity (also known as tachysystole): contractions less than 2 minutes apart or more than 5 contractions within 10 minutes; rest interval shorter than 30 seconds, duration longer than 90 to 120 seconds, or an elevated resting tone greater than 20 mm Hg (measured with an intrauterine pressure catheter).

Observe FHR for nonreassuring patterns such as tachycardia, bradycardia, decreased variability, and late decelerations.

If uterine hypertonicity (tachysystole) or a nonreassuring FHR pattern occurs, intervene to reduce uterine activity and increase fetal oxygenation: stop the oxytocin infusion; increase the rate of nonadditive solution; position the woman in a side-lying position; and administer oxygen by snug facemask at 8 to 10 L/min. Notify the physician of adverse reactions, nursing interventions, and response to interventions. Record the maternal blood pressure, pulse, and respirations every 30 to 60 minutes and with each dosage increase. Record intake and output.

Postpartum: Observe uterus for firmness, height, and deviation. Massage until firm if uterus is soft (“boggy”). Observe lochia for color, quantity, and presence of clots. Notify birth attendant if uterus fails to remain contracted or if lochia is bright red or contains large clots. Assess for cramping. Assess vital signs every 15 minutes or according to protocol. Monitor intake and output and breath sounds to identify fluid retention or bladder distention.

Inevitable or Incomplete Abortion: Observe for cramping, vaginal bleeding, clots, and passage of products of conception. Observe maternal vital signs, intake, and output as noted under postpartum nursing implications.

What nursing assessment should be reported immediately after amniotomy?

Which finding following an amniotomy should be assessed for first?

Which is the priority assessment when the membranes rupture?

What is a potential complication related to amniotomy?