Intrapartum Care Part 1

What Triggers Labor? fetal factors

- placenta ages and starts to deteriorate, triggering the initiation of contractions. -Prostaglandin synthesis by the fetal membranes and the decidua stimulates contx -Fetal cortisol ↑ and acts on the placenta to reduce progesterone that quiets the uterus, and ↑ prostaglandin that stimulates the uterus to contract.

Risk Factor Assessment notes

-Risk factors can be discovered at any stage of pregnancy or during the labor process. -risk factors can be found to originate in the patient's obstetrical hx, her medical hx and current OB status or psychosocial status. -if she have a hx of diabetes or heart disease -has she had a hx of poor pregnancy outcomes. is there a risk for preterm delivery or inner uterine growth restriction, is there some malformation that's going on either with the uterus or with the baby. -has she had a hx of a postpartum hemorrhage .

Cardinal movement third

-internal rotation is THIRD, the fetal head typically enters the pelvis with the anterior posterior head diameter in a transverse position. -this position is beneficial when entering the pelvis bc the diameter of the pelvis Inlet is the widest from right to left however if they had remained in the transverse position the shoulders are in a position where they are too wide to pass through the pelvic inlet.

Cardinal movement first

Descent: the FIRST of the Cardinal movement is a downward movement of the fetus. it determined when the Bi-primal diameter of the head passes the ischial spines and moves into the pelvic Inlet. the full descent is accomplished when the fetal head passes beyond the dilated cervix and contact supposterior vaginal floor

Cardinal movement sixth

Expulsion after the delivery of the shoulder the remainder of the body is delivered quickly and easily this step signifies the end of the second stage of Labor.

Cardinal movement steps

engagement, descent, flexion -> internal rotation -> extention begining (rotation complete) -> extension complete -> external rotation (restitution) -> external rotation (shoulder rotation) -> expulsion

types of contraction

there are three phases to contractions. -The Increment is the building up of intensity of a contraction -acnem is the peak of the contraction -the decrement is the releasing of the intensity of the contraction.

Fetal Membrane Statu

• Normal fluid is colorless and clear • Tests to assess rupture of the membranes • Nitrazine test, Fern test • Amnisure• Risk factors• Polyhydramnios • Oligohydramnios • Meconium • PROM, PPROM• Foul-smelling fluid (chorioamnionitis)

the transverse presentation (refer to pic on slide 11)

• the transverse (horizontal) presentation is basically it's a transverse lye where the shoulder is presenting and of course at the shoulder is presenting the fetus cannot travel through the birth canal and they are for the baby cannot be delivered vaginally with a shoulder presentation. • presentation shoulder ; presenting part scapula • attitude flexion

Risk Factor Assessment

•Preexisting medical diseases -Diabetes, hypertension, heart disease, infections, renal disease, anemia •Previous poor pregnancy outcome -Perinatal mortality, preterm delivery, IUGR, malformations, hemorrhage •Risk factors developing during the pregnancy -PIH, GDM, IUGR, multiple gestation, placenta previa, abnormal presentation, drug exposure, smoking, alcohol use •Inadequate maternal weight gain

complete breach (refer to pic on slide 11)

•complete breach: where the baby's head is up and the buttocks is down in the babies usually sitting cross legged position. •most as I said these babies are delivered via C-section. Sometimes you'll have a doctor who will deliver a second baby breech but they're hard to find these days. •longitudinal or vertical •breech (sacrum and feet presentation) • general flexion

What Triggers Labor? Maternal

(What triggers labor is still a mystery) -For maternal concerns its though Uterine muscles are stretched - leading to the release of prostaglandins that stimulate contractions. -There is ↑ pressure on the cervix that stimulates the neve plexus, causing a release of oxytocin by the maternal pituitary gland, which simulates contraction -Progesterone , which decrease the effects on contractions on the uterus starts to decrease - to allow estrogen to ↑ and cause contrx -Oxytocin and prostaglandins ↑ to inhibit calcium binding in muscle cells, and activates contractions.

Cardinal movement fourth

- (FOURTH) Extensions occurs after the internal rotation is complete as they head passes through the pelvis, the occiput emerges from the vagina and back of the neck stops under the pubic symphysis. further descent is temporarily halted bc of the fetus the shoulders are too wide to pass with the pelvis or under the pubic Arch.

assessment of contraction

- contx is followed by relaxation and relaxation is very important bc blood vessels that supply the placenta are compressed during a contraction and that decreases O flow to the fetus so it's important to know that our uterus is relaxing. -in order to assess a contraction it has to begin with direct palpation, you can't just look at the fetal monitor, unless there is IUPC present so if there isn't IUPC you have to palpate the contx and we frequently palpated at the Acme of the contx to see how strong the contx is - then we will palpate between contractions to see if the contraction is releasing or relaxing. -if there's an IUPC we document in "mmm" otherwise we document are contractions as strong or moderate or mild

Risk Factor Assessment that she may developed during pregnancy notes

- does she have on pregnancy-induced HTN or just gestational diabetes, are there twins, multiple gestation or triplets, does she have a placenta previa is there an abnormal presentation such as the baby is breech or the babies in a posterior position, is there any uterine growth restriction, -has mom been exposed to drugs whether they are legal or illegal, is there mom's been smoking did she drink during her pregnancy. -has there been an inadequate weight gain or has mom gained too much weight during her pregnancy.

Third Stage Placenta

- the third stage has delivery of the placenta as a uterus begins to shrink the placenta detaches from the wall of the uterus this causes an autotransfusion of blood into the mother's system to help the mother during postpartum this causes the mother's heart too slow in order to pump the additional blood volume through her system. -The Physician or Midwife will examine the placenta to make sure all the lobes are there and that nothing has been left inside the women bc if she has retained placenta still cause her to hemorrhage.

Cardinal movement fifth

-(FIFTH) external rotation that happens and it's also called restitution is necessary bc of the shoulders which previously turned fit through the pelvic Inlet must turn again to fit through the pelvic outlet and under the pubic Arch. -after the head is born, the face which is facing down after completion of extension is turned to face the mothers inner thighs. -the head rotates about 5° returning to the anterior posterior head diameter to the transverse position assume during descent. anterior shoulder is delivered first with possible assistance of a downward flexion on the head after the anterior shoulder is delivered a slight upward flexion may be necessary to deliver the posterior shoulder.

delivery /placenta

-After the delivery we are now having a big push to place the baby directly on mom's abd and not take the baby over to the warmer, you have better success in breastfeeding if you don't separate the baby from the mom, so many practitioners is pop the baby up onto the moms abd and suction and clamp the cord on the mom's abd, -they usually are waiting for the cord to stop pulsating before they cut the cord and many don't use the Bold suction anymore they let the fluid just drain out unless there's a lot of gurgling going on, they don't suction bc actually it causes a baby to get sore throats and an aversion to breastfeeding, so many not even suction the baby anymore -you want to gently stimulate the baby cry, clamp and cut the cord on some hcp again give the pitocin via the IV as soon as the baby is born to prevent postpartum Hemorrhage and some will wait until after placenta is delivered to start the pitocin.

brow and fece presentation (refer to slide 1)

-Brow presentation (poor flexion) the fetal head is partly extended and this is an unstable position that can convert to the vertex if the head decides to flex or to face presentation if the head decides to extend, this makes it difficult for the fetus to fit through the birth canal for a first-time Mom this is almost impossible, the second time mom has babies look pretty beat up their faces and browse is very swollen -face presentation where the head is fully extended. I've seen a couple babies be born this way vaginally but there with multips that usually a first-time mom cannot deliver a baby in this position it could be dangerous but I have seen at these babies look really beat up, their faces are very bruised lips or eyes are a very swollen when they're born in this position.

Positioning of the Laboring Woman

-Side line is better than supine to help O fetus and prevent maternal hypotension bc there is compression of IVC, aortic, and iliac arteries when pt lay supine. -If pt prefers to lie down left or right lateral position for Maternal-Fetal oxygen exchange at the placenta level and enhance is the fetal wellbeing. -Even with bed rest pt may be assisted to various positions for labor and birth. usually, they'll go to side to side every 30 to 40 mins and some will use what we called Peanut balls. -Studies have shown that ambulation during labor has shown to decrease the rate of operative births by 50% and ↓ use of anesthesia, Also pt are more mobile during labor and report greater Comfort and ability to tolerate labor -upright position shortens labor from both 1 + 2 stages

the process of birth

-The process of birth a baby begins to Crown meaning the head of the baby is at the introies and does not slip back -hcp will allow the head to stretch the perineum to allow for the baby to be delivered with minimal trauma at the perineum, hopefully without an episiotomy or laceration - if the mom doesn't have an epidural she may complain that her perineum feels like it's burning or what we call a ring of fire once the head delivers it will turn it over either to the right or to the left and then the shoulders and the body will be born.

today childbirth notes

-Today however hospitals remain the birthplace for moms in the US and midwives seem to be continuing in the practice. -Epidural are very common for pain management; however, there is a re-emergence of nitrous oxide which is an anesthetic which is used during labor. -med has accel to include safer techniques for both mom and her baby. -Pt care is different as technology allows for more ↑ monitoring and a higher survival rate for both the mom and newborn. There is some who are choosing to have their babies in alternative birth setting such as a clinic or their home, these alternative settings may give families more control over the birth experience by allowing them to become more involved in the process in response to the consumer demand for more relaxed family-friendly birthing areas -we see that many hospitals have revamped their labor and delivery units to create a more natural childbirth environment .

History of Childbirth Notes

-Up until the 20th Century a majority of the births took place at home assisted by a midwife, the birth was a social and emotional event shared by women and their families and friends. -Some women gave birth sitting up in a chair or even standing or squatting - the early 1900 women were encouraged to go to the hospital to give birth; it was considered safer and there was less pain is a doctor's implemented twilight sleep a combination of "Scopolamine" and "morphine" which put Mom's asleep to help her with the pain of childbirth. However usually the mom couldn't remember her birth at all and it would take several days for her to recover or some mom's became uncontrollable during her labor and they would need leather restraints to hold her down while she labored and delivered the baby.

boney pelvis

-We know that the gynecoid pelvis is most commonly shaped pelvis is for a female, is divided into the true pelvis which is that Boney inner pelvis for which the fetus must pass - the false pelvis is above the brim of that true pelvis, so above that plane of the the inlet of the midplane. - the ischial spines is the most narrow part of the pelvis, so we know we're doing good if that head makes a pass the ischial spines bc that is the widest part of the baby in the most difficult part to get through the pelvis. -Estrogen and relaxant during pregnancy help soften the cartilage in the pubic symphysis to and it also ↑ the elacity of the ligaments allowing room for the fetal head.

Passageway: Soft tissues

-passageway which consists of all the soft tissue. -the bottom part of the uterus the lower uterine segment stretches as the upper uterine segment pushes the baby down into the birth canal so the lower uterine segment stretches and yields to those contractions. -the cervix starts to open up or what we call dilate and it thins or what we call a effaces, So the cervix has to efface and has to dilate. -If the woman has delivered previously she's going to deliver faster than a first-time mom bc soft tissue yields more readily to the contraction in the push effort. -the cervix has to thin out to paper thin in order to have a baby

Psychological Response or Psyche culture

-pt values and our beliefs regarding sickness, health, and pregnancy will shape her identification of what childbirth experience should be. -other cultural factors that can affect mom's behavior during childbirth include the expectations about who should attend the birth. -Moms perception of and response to pain should be the pain be expressed openly or stoic -feelings about touch some don't like to be touched during labor and some want the closeness. -when facing labor weather for first time for fifth time women may have feelings of anxiety or fear about the process, the feelings of fear may center on anticipating the pain associated with labor or feel or fear of being out of control and not being able to cope. ***providing guidance regarding strategies to laboring women can use to cope with the stress and discomforts of labor **

Psychological Response or Psyche notes

-the woman's psyche or emotional stake in the term in her total response to labor and influence her physiological and psychological functioning. influencing factors include The mothers previous birth experience if there were complications with at birth; what was the outcome? Was it a good outcome or was it a bad outcome? We need to assess the mother's personal expectations, are they being met? -we need to know about this current pregnancy, Has there been any problems with pregnancy and how is she responded? we need to know about her age, her marital status, the number children she has had, as well as her current expectations for this pregnancy; these are all influencing factors.

what factors contribute to positioning laboring women

-unit culture, hcp preference and pt's cultural background often determine the position of women will assume during their labor and childbirth. -position changes can help the pt adapt to labor and can influence the frequency and strength of contrx but the position also has to accommodate the hcp to assist in the birth. -pt confine a bed during the majority of labors result of the use of electronic fetal monitoring, IV, oxytocin and Regional anesthesia

Fetal Membrane Status tests: A

Amnisure (most popular) : basically the sample is taken by a sterile swab which is inserted 2 to 3 in inside the vagina and some of the amnisure will have an indicator that says yes or no; yes bag of waters ruptured know the bag of waters or no ruptured. where I work we take a swab we put it in some fluid and we send it back to the lab so they can collect the revenue and they read it and they tell us whether the bag of water is broken or not or ruptured.

Cardinal movement second

flexion is the SECOND of the Cardinal movements it OCCURS DURING DESCENT . it is caused by the resistance of the fetal head against the pelvic floor. -the combined pressure of the resistance and the uterine abd muscle contractions force the heads of the fetus to Bend forward so that the chin is passed to the chest this allows the smallest diameter the fetal head to descend through the pelvis.

Cardinal Movements of Labor& Birth

the cardinal movement of labor are fetal position changes that occur during the second stage of labor, they help the fetus pass through the birth canal, these movements are necessary bc of size of the fetal head in relation to the irregular-shaped pelvis. -specific deliberate precise and various movements allow the smallest diameter of the fetus to pass through the corresponding diameter of the woman's pelvis.

Fundal Massage

to massage the fundus or massage the uterus the lower hand is placed in a cup position above the pubic symphysis, this help steady the uterus, the top hand is placed on the top of the fundus or the top of the uterus, the upper hand gently massage is the top of the uterus by rotating the hand in a circular motion; the lower hand supports the uterine segment upon massage the uterine segment starts to contract and feels very firm once the massage finish examine the perineum for bleeding and blood clots that may have been expelled.

Vaginal Exam: Cervical Status and Fetal Descent notes

we have to assess the cervix so we do vaginal exam and nurses can do this. -we check for the cervix to see how thin it is, Effacement of cervix, we express that in % so the cervix usually is from my knuckle to the tip of my thumb so it's about 3 cm or about an inch and so if it's a half an inch or halfway between my knuckle of my thumb to the tip of my thumb that would be 50% of effacing. -dilation usually it's from 0 to 10 cm, so if the cervix is I can't put my fingers inside the cervix then a cervix is closed, if I can put two fingers inserted in the cervix that's actually 3 cm dilated, and it goes from there. -whats presenting, do I feel your hard head when I do the vaginal exam, do I feel little fingers or feet, what do I feel when I put my hand in in the cervix -we want to check the relationship of the head with the ischial spines, is the baby's head right at 0 station or is below or above.

Engagement and station

• Engagement occurs when the presenting part of the fetus passes into the pelvis to the point where the cephalic presentation biparietal diameter of the fetal head is at the level of the bid pelvis or at the level of the ischial spine -we assess this by vaginal examination before and during labor. -if the fetus is at zero station the fetus is considered to be at the level of the Ischial spines and is considered being engaged. • station is relationship of the presenting part of the fetal head to the maternal ischial spine.

fetal positioning (refer to slide 10 for images)

• Fetal position is determined by what body part of the fetus engages into the pelvic Inlet first. • cephalic (vertex) which is head down, brow that is presenting; vertex is the most common •brow and face are difficult for the mom to deliver when the baby is presenting like that. •Fetal position by using 3 letters. -first letter designates whether the presenting part is facing the woman's right or left side so we use "R" for right and "L" for left -second letter refers the presenting part of the fetus "O" for the occiput the back of the fetus head and "M" for the mentum which stands for the baby's chin, "SA" for the sacrum which is the Triangular bone at the base of the spine or scapula or arachnid process is represented by "A", -third letter designates whether the presenting part is pointing to the anterior "A", posterior "P" or transverse "T" position of the mom; • the most common fetal positions are left occiput anterior or right occiput anterior.

Footling breech (refer to pic on slide 11)

• Footling breech : the baby head is up with one or both feet hanging down meaning the feet are coming first on through the birth canal; years ago we would deliver babies breech but now w/o practice, we now just find it safer and there's less complications if we do a C-section for breech babies • longitudinal or vertical • presenting Breech (incomplete) • presenting part: sacrum • attitude : flexion , except one leg extended at hip and knee (however once in a while you'll find one Doctor Who will go ahead and deliver a breech baby especially if it's the mother second baby.)

Frank breech (refer to pic on slide 11)

• Frank breech: that's the most common breech position the baby's bottom is down with the legs pointing upward towards the head. • With these babies are born after birth they stay sort of in this position for their feet are up by their ears and it takes several hours to a day for the legs finally to relax and to lay flat. • longitudinal or vertical • presentation : breech (incomplete) • presenting part : sacrom • attitude: flexion

comfort measure for first stage labor

• Frequent position change: really helping labor to progressed faster, she can get in the bathtub or the shower even if your water has broken studies have shown that it does not increase infection by getting in the tub •Hydrotherapy :can be very relaxing •Perineal care just keeping her clean •Clear fluids and Ice chips during this time, •Birthing ball: sitting on a birthing ball help so open up the pelvis more and also takes a lot of pressure off back •provide information : you just want to continue to give information and support tell her how good she's doing, keep everybody updated and informed who is in the room supporting her

Assessment of the Woman in Labor

• Gravidity and parity • Gestational age • Fetal heart beat/rate • Maternal vital signs • Contraction status • Cervical dilatation and effacement • Fetal presentation and station • Membrane status

comfort measure for first stage labor continue

• Relaxation between contractions: helping Mom relax between contractions with breathing techniques is very helpful, •Distraction: some people bringing cards play or they watch TV • Enfleurage is that massage on the belly that helps women relax,if they like to be touched. •Counter pressure which is firm pressure on the back or sacrum: really helps of moms having back labor •Visualization usually will do what's called Progressive relaxation tyrying relaxing muscles and then doing an imagery that's usually done with what we call hypnotherapy, it's usually something that needs to be practiced it just can't be done spontaneously, it would be very difficult but if you're somebody who wants to go natural the hypnotherapy •visualization actually works quite well •controlled breathing you don't want Mom to be hyperventilating said to give her some breathing techniques to use is very helpful you teach the family members and they get in her face and they breathe with her works really well.

Nursing Responsibilities in Labor: maternal assessment

• VS: depending where she is in a risk factors will depend on how frequently you will take them. •Hydration and nutrition, most moms will have an IV and they will be allowed to have clear liquids up until the point of getting an epidural placed •Elimination: moms need to get up and go to the bathroom frequently cuz the contractions are pushing on the bladder but if Mom has a epidural she may not be able to feel her bladder getting full so it's important for you to assess; that a full bladder can act like a balloon and can keep the fetus up into the pelvis and not allow it to descend into the birth canal.

what affect the ability of the fetus to navigate the birth canal

• passanger is the fetus or the baby •Size of fetal head •Fetal position •Fetal presentation •Fetal lie •Fetal attitude (all those affect the ability of the fetus to navigate the birth canal) •how the fetus is present in the pelvis will affect how the babies expelled through the birth canal to be born

the 5 P's of Labor (5 P's are intended to help you remember to consider)

• passenger: fetus •Passageway : pelvis •Position : baby •Power of the contractions •Psychology the maternal response (it is not important which one comes first just that you know you have to consider these factors in a laboring pt)

vertex and miliatary postion description (refer to slide 13)

• vertex (complete flexion) position is the best position for the baby to be into when it's delivered or for women to labor in bc it allows for the smallest diameter of the fetal head present through the pelvis. •military position (moderate flexion): the fetal head presents at more than neutral position which is neither Flex or extended; where the vertex position everything is flexed so that it makes a very narrow but a military position in a neutral position neither flexed or extended. -the occiput frontal diameter presents into the maternal pelvis and a top of the head is the presenting part so it's just not as flexible makes it much more difficult to fit through

Nursing Interventions: Fourth Stage part 1

•4 stage start after the delivery of the placenta and ends 4 hrs after the delivery when the mom is stable. -if Mom is had a repair of a laceration or episiotomy you're going to need to examine that, you may put ice on the episiotomy or lacerations to help with the swelling. •you're going to examine the perineum for any hematoma or bruising -you are gonna assess the uterus and make sure that it's firm, you're going to set asesse every 15 min for the first hr •Make sure that the uterus isn't boggy bc it becomes boggy then she's going to have some bleeding •assess the lochea she should have a moderate amount it's going to be rubra red and if she has a large amount of lochia that's worrisome you'll need to keep an eye on it and if she is saturating a pad in an hour or more than that's considered a hemorrhage and you'll need to implement the protocol for your postpartum Hemorrhage so assessing the bleeding every 15 min is also very important

Nursing Interventions: Active Phase

•4 to 7 cm •Palpate contractions every 15-30 minutes •Vaginal exams to assess cervical dilatation, effacement, and fetal station and position •Encourage client to void •Assess vital signs every hour -but depending on her status whether she has a pitocin going on or maybe an epidural you may be taking Vital Signs every 15 minutes

Nursing Interventions: Third Stage continue

•Assist with delivery of placenta •Medications given in delivery room after delivery of the placenta •Pitocin (oxytocin) •Methergine (methylergonovine maleate) •Cytotec (misoprostol) •Hemabate (carboprost Tromethamine) -You're going to administer medication in the delivery room after the placenta which is usually oxytocin, they need mathorgen if there is a problem with bleeding or misoprostol or hemabate in case there are any bleeding problems.

maternal abdications following birth:

•BP should return to pre-labor levels •pulse maybe slightly slower than in labor bc you had that influx of blood volume for the delivery of the placenta. • Uterine fundus: should stay midline at the umbilicus or 1-2 fingerbreadths below the umbilicus. -Right after delivery the fundus maybe halfway between pubic symphysis and umbilicus but then it will quickly move up in the next 12 hours to the umbilicus or 1 - 2 to below the umbilicus. •Lochia : should be rubra or red. it's small to moderate amount. -from spotting on pads it should be 1/4 to 1/2 of the pad covered in 15 minutes. -it doesn't exceed saturation of 1 pad in the first hour. •Bladder is nonpalpale •Perineum should be smooth, pink, without bruising or edema -Emotional state: Mom will have a wide variation of emotions; excited, exhilarated, smiling, could be crying she's so happy or she could be crying bc she's so tired, fatigued, verbal, quiet , pensive and they could be sleepy they may have gotten some pain med just before they delivered and now that they delivered the pain medicine has kicked in and is made they very sleepy or they could have been in labor for a couple days and they're just absolutely exhausted so emotional status quo will vary widely.

Signs and Symptoms of Impending Labor continue

•Back pain: some women will experience back aches due to the relaxation of the pelvic joints due to the hormone relaxin •Energy Sprout: it is not uncommon for women to experience weight loss during the last few weeks of her pregnancy -Some women will experience energy spurts or what we'll call nesting which may cause a ↓ in the placental progesterone production and this results in an ↑ in epinephrine that gives a woman extra energy for labor. •GI s/s: she may experience diarrhea, nausea, and indigestion that is common before Labor.

Nursing Responsibilities in Labor: fetal assessment

•Baseline FHR (between 110-160) •Variability •Accelerations •Periodic changes (decelerations) •Early (head compression) : -early deceleration bc that might be that she's getting close to delivering •Late (placental insufficiency): -late decelerations means that there may be something going on with a placenta it's not for perfusing correctly •Variable (cord compression)

Nursing Interventions: Third Stage

•Begins after the delivery of the placenta and typically ends within 4 hours of with the stabilization of the mother •Provide newborn care •Time of birth and delivery noted •Drying, stimulation, suctioning of the newborn if needed •Respiratory effort, heart rate, color, tone noted •One- and five-minute Apgar scores assigned •Cord blood obtained •Identification of the baby -the baby should never leave the room unless its identified prior to leaving

Brief History of Childbirth

•Birth was viewed as a normal process •Birth most often took place in the home •Birth was a social and emotional event shared by the woman with her family and friends (-be sure to comment on something she did or say in her labor -play positive interpretation in her role, especially if there were negative aspect at birth, latter if she reflects on the negative; she may recall your kind words)

Signs and Symptoms of Impending Labor "C"

•Braxton Hicks contractions which are mild contractions of the uterus that occur throughout pregnancy. -they may become extremely strong a few days before labor begins and it may cause some women especially primiparous to interpret them as true labor. -Braxton Hicks contractions are usually irregular, may diminished when a woman ↑ or decreases her activity usually will tell the woman to do the opposite of whatever she was doing when the contraction patterns started and if it changes and stops and we know those were Braxton Hicks contractions and not true labor. -Most of the time Braxton Hicks contractions are commonly painless, many feel only a tightening of the abd usually not in the back. -The most important differentiation between Braxton Hicks contractions and true labor is that Braxton Hicks contractions do not cause Progressive effacement and dilation of the cervix.

Assessment of the Woman in Labor notes part 2

•Contraction status -assessment of contractions is important most women have contractions as early as the 2nd trimester however these contractions result in cervical change prior to 38 weeks gestation is considered preterm labor •Cervical dilatation and effacement - after 38 weeks the cervix starts to dilate + efface, thins then we can consider this a normal progression of Labor. -Prior to 38 weeks the patient may be experiencing preterm labor if the cervix dilates and it efface in the first trimester the cervix may be considered incompetent and she might need circulus to so the cervix up so that she doesn't deliver prematurely. •Fetal presentation and station •Membrane status -we need to check the membrane status whether the membranes are intact or ruptured.

Psychological Response or Psyche

•Culture and Birth traditions -cultural values are another influencing factor; woman's culture can give us a clue about how she's going to act or respond during pregnancy, l&d . •Expectations •Support Systems •Labor Support

false labor

•Discomfort localized in abd and No lower back pain •Contx irregular and Contx ↓ in intensity and frequency with ambulation •Cervix may soften but no significant change in dilatation -contx feel diff in each women and may feel diff from one pregnancy to the next -most hospitals will have a two-hr triage women window, where the woman will come in and we'll assess her to see if she's in labor. if everything looks good on the fetal monitor, there is acceleration on the monitor, theres nothing that contraindicating or any risk factors, we will usually allow the mom to get up for an hr or two walk around the unit and then we will have her get back in bed and recheck her. And if there's no cervical change which means the cervix didn't dilate then we consider that she is not in labor and we send her home with instruction. But if shes in labor that means her cervix has dilated and then we go ahead and admit her for labor.

Vaginal Exam: Cervical Status and Fetal Descent

•Effacement •Thinning of the cervical canal •Expressed in % •Dilation •Opening of the cervix •Closed to 10 cm (complete) •Presenting part •Vertex most common •Station •Expressed in cm above or below the ischial spines

Fetal Membrane Status tests: F

•Fernie where we would actually take some of the fluid and we put it on a slide and we would let it dry and look at it under a microscope and we would see almost crystallizing snowflakes, it would look like ferns on the slide and that would tell us that the fluid was ruptured and that was amniotic fluid. well our lab took away our microscope because they said it was too far to come to do the quality controls on the microscope and all we had to do competencies for the nurse but also with the loss of revenue for the lab so we don't do fernie anymore,

Assessment of the Woman in Labor notes part 1

•Gravidity and parity -Gravity indicates # of times a woman is or has been pregnant regardless of the pregnancy outcomes, a current pregnancy if any is included in this count, - parity/para indicates # of pregnancy reaching 20 weeks including live and stillbirths. •Gestational age •Fetal HR -an ultrasound can routinely detect a heartbeat in the baby as early as 6-7 weeks, -Doppler can't reliably detect the baby's heartbeat until 10 to 12 weeks. •Maternal vital signs -we look at maternal VS when assessing pt, we know during the 2nd trimester that BP usually decrease due to the vasodilation of the maternal blood vessels due to ↑ in progesterone during pregnancy, during the 3rd trimester the BP returns to normal and elevation in the blood pressure during the 2nd + 3rd trimester is of concern and would require further evaluation.

Hands & knees positions continue

•Gravity can promote descent of the fetus!! •Hands & knees position may assist in rotation of an OP fetus!! -for at least 30 mins during labor may be beneficial to promote rotation from a baby that's in the occiput posterior position to the occiput anterior position. -there was less use of oxytocin -fewer mechanical assisted births -Pushing during 2nd stage of labor was ↓ when women were in their squatting position -less severe lacerations and episiotomy compared to semi-recumbent births. -Also may reduce back pain for women who are experiencing back pain in labor.

Engagement presentation

•In primiparous non-engagement of the presenting part on the onset of labor is considered worrisome; may indicate there is a complication such as cephalopelvic disproportion or maybe an abnormal presentation or position for an abnormality of the fetal head •engagement of the presenting part is described as floating if it is NOT at that zero station -in the mult-parous, the non-engagement of the fetus is not uncommon; it can occur at the during the labor as it progresses or just at the onset of Labor •bc the ischial spines are the narrowest part of the fetal female pelvis an engagement indicates that the pelvic Inlet is large enough for the fetal head to pass through because the widest part of the fetus has already passed through the narrow part of the pelvis.

Signs and Symptoms of Impending Labor

•Lightening: is descend of the fetal head into the pelvis, the uterus lowers the muse more interior and the contour of the abd also changes. -Sometimes you can see this on women one day the baby is sitting up higher and the next day you'll see that the baby looks lower in her pelvis and primiparous women these changes usually occur 2 weeks before birth and multiparous these changes can occur on the day of Labor or It can start after labor begins. -Lightning↑ the pressure on the bladder which causes urinary frequency, there may be extra pressure on the sciatic nerve which may cause leg pain, breathing may become easier for the woman after lightning bc the pressure on the diaphragm is decreased. •Cervical changes: the cervix will start to soften and what we will call ripening of the cervix it will start to thin out and dilate and there may be a brownish or bloodtinge cervical mucus discharge referred to as BLOODY SHOW and this allows the mucus plug that seals cervical Canal during pregnancy to become discharged.

Fetal Membrane Status tests: N

•Nitrazine. years ago we used to have nitrazine paper on the unit and we place it inside vagina and a normal pH of the vagina is about 4.5 to 6 and amniotic fluid is a higher pH for basic and it will turn the nitrazine paper usually up blueish color. problem with that is that the lab needed to test all the nurses to see if they were color blind before nurse was confident to do a nitrazine test and also the lab was losing Revenue when the nurse did the nitrazine test so most hospitals now had taken away the nitrazine paper from the units

true labor

•Pain in lower back that radiates to abdomen •Pain accompanied by regular contractions •Contractions intensify with ambulation •Progressive cervical dilatation and effacement will progress in other words the contractions will come closer together and will become stronger and then they will cause a cervix to start to dilate and efface.

Nursing Interventions: Transition Phase (8 to 10cm)

•Palpate contractions every 15 minutes •Sterile vaginal exams to assess labor progress •Assess maternal vs every 30 mins •Assess fetal HR every 30 min (may be assessing every 15 mins) •Assist with breathing •Keep woman from pushing until fully dilated -if mom doesn't have an epidural she may feel a lot of pressure in the urge to push and you really don't want to push until she's 10 cm dilated.

Preparation for Delivery notes part 2

•Pitocin available for administration after delivery -some hcp will start the Pitocin early right after the delivery of the infant and some hcp still go with the traditional way of waiting till the placenta is delivered and then they start the pitocin, some studies are showing that if you start your pitocin early it decrease is postpartum hemorrhage. •Positioning of mother for birth -you're responsible for positioning the mother for birth traditionally mother's deliver in the lithotomy position: her feet are in a foot pedals instead of Leg stirrups, •Gown, gloves, and PPE (make sure that everyone in the room who needs PPE have them) •Cleansing of the perineum -was a long tradition we used to use Betadine or chlorhexidine to wipe the perineum in case they cut an episiotomy but in the last several years bc we don't routinely cut episiotomies the practice of preparing the perineum has sort of gone to the Wayside so I'm not sure if you'll see this in your or hospitals or not but they used to clean the area.

Fetal Membrane Status tests continue....

•Polyhydramnios •PROM : refers to pts who are beyond 37 weeks gestation and present with rupture of membranes prior to the onset of labor -PPROM is rupture of membranes prior to 37 weeks gestation. •Foul-smelling fluid (chorioamnionitis): Any foul-smelling oldor may indicate that there's an infection ascending from the vagina, the risk of developing chorioamnionitis ↑ with each vaginal exam that is performed in the final month of pregnancy so it's really important to LIMIT vaginal exams on these women.

Preparation for Delivery notes part 1

•Prepare instrument table -need a table in the room which has instruments for delivery. needs to be a sterile table and we usually set up the table around the active stage of Labor. if it's first-time mom I usually wait until about 6 or 7 cm to make sure things are going well cuz it's expensive the instruments I hate to waste them so I usually wait until they're really in a good labor. If their second time is usually around 4 cm I go ahead and and set up the table. •Adequate lighting (so the hcp will be able to see when they're delivering) •Oxygen and suction equipment for both the mother and the newborn. •Radiant warmer, blankets, identification for newborn (radian warmer in the room is on preheat or on warm and then they put some blankets under there so they get warm, you want to make sure that there's identification bands for the newborn to be completed.)

Preparation for Delivery

•Prepare instrument table •Adequate lighting •Oxygen and suction equipment •Radiant warmer, blankets, identification for newborn •Pitocin available for administration after delivery •Positioning of mother for birth •Gown, gloves, and protective equipment for personnel •Cleansing of the perineum

primary and secondary power

•Primary powers: contractions -the primary power is involuntary power which equals uterine contractions •Secondary powers: bearing down efforts - the secondary power is voluntary power which demonstrates the bearing down of the woman to push (-power determines the effectiveness of a contraction. -Power is responsible for the effacement and shortening of the cervix in the first stage of Labor.)

Nursing Interventions: Fourth Stage PPT

•Repair of the laceration and/or episiotomy •Assess the uterus - palpate the fundus every 15 minutes for one hour •Assess lochia - Vaginal bleeding •Medication - oxytocin; pain med •Warm Blankets •Food and drink •Maternal Vital signs q. 15 min •Monitor perineum •Ice packs to perineum •Monitor bladder distention •Encourage bonding and breastfeeding •Promote rest; monitor visitors

Comfort Measures: Second Stage

•Same as first stage •Cool cloths (she may want a cool cloth cuz she's hot) •Encourage rest between contractions •Assist into pushing position -some people with count with her if she does holding breath, we're trying to change to what we call open glottis pushing where you don't have to count but traditionally it has been the breath-hold pushing •Sips of fluids or ice chips bc she gets very dry •Reassurance -reassure her tell her she's doing great and baby's almost here, if you start seeing the head you want to tell her I can start saying that had the baby has lots of hair looks like he's bald whatever but just give her lots of encouragement and reassurance.

Stages of labor

•Stages of labor begin with true labor and consists of four stages. •first stage the onset of Labor to complete dilation of cervix; in the first stage of Labor there are three phases: -there is latent phase which starts at 0 cm dilated to 3 cm dilated. -active phase is 4 cm to 7 cm dilated -transition is 8 cm to 10 cm dilated. • second stage: complete dilation to birth ( 10 cm dilated to birth) • third stage: birth to placental expulsion; which is a delivery of the placenta, •fourth stage is the 4 hours following delivery of the placenta.

station grading (slide 12)

•Station is documented in grade ranges so if the fetus is above zero station in the pelvis we're going to document that in negative numbers . -in primiparous non-engagement of the presenting part on the onset of Labor is considered worrisome it may indicate there is a complication such as cephalopelvic disproportion or there maybe an abnormal presentation or position for an abnormality of the fetal head • the highest part is considered a -5 and the part just before 0 station is a -1. •if the baby is below the Ischial spine we're going to document that in + numbers; so +1 will just be below the Ischial spine, a +4 is going to be right at the opening of the introitus and +5 the perineum is going to be bulging in the the fetus's head is going to be almost bulging out of the of the vaginal canal

Nursing Interventions: Second Stage

•Sterile vaginal exams to assess fetal descent •Assess maternal vital signs •Provide support and information about labo' •Assist with pushing progress: when Mom gets to the pushing stage one-on-one, the nurse needs to be in the room at all times with her •Assist the physician or CNM with the birth

If a Mother and Fetus Are Doing Well . . .

•The best care we can provide is expectant management: If a mom + her fetus are doing well the best care we can provide is expected management. •Watchful assessment: making sure Mom and a fetus are stable •Encouraging mother that labor will occur: -we want to encourage mother that labor will occur especially if she's come into a triage room and she's having Braxton-hicks and she thinks this is the real thing that her cervix hasn't dilated and so we're going to be sending her home and she'll be very discouraged so we need to give her the appropriate support telling her that labor will occur soon •Providing appropriate support: if she is in labor the cervix has dilated then we're going to tell her all about the admission process and what to expect here in the hospital.

Molding

•The fetus's head needs to mold to fit through the pelvis and birth canal. •The fetal skull bones are connected by membranes sutures but are not fused allowing them to mold and shift to help permit the fetus passage through the birth canal. •Where the sutures connect are membranes frontale there is the anterior fontanelle it's large and it's shaped like a diamond • they're posterior frontale at the occiput the back of the head and it's shaped like a triangle.

Indicator of normal labor

•Uterine contractions:-uterine contractions is tightening and shortening of the uterine muscles during a contraction and the contractions accomplish two things: cause the cervix to thin and dilate and they help the baby to send into the birth canal. During the contractions the nurse palpates the abd to assess the firmness of those contractions. •Uterine relaxation between contractions •Fetal HR Baseline 110 - 160, + variability, no late deceleration. •Maternal vital signs •BP < 140/90 or less than +30/+15 above baseline BP •Pulse 60 -100 •Temperature 97.8 F and 99.6F •If membranes are ruptures and Fluid should be clear without odor -what time the bag of water ruptured, was the bag of water clear was there any odor with that.

genereal assessment

•Vs(BP, P, R, T) -take VS and depending on the acuity of the pt in the stage of labor will depend on how often vital signs are taken. •Abd: •make sure others no Rash, lesion, scars, •Leopold's maneuvers to help decide where and what position the baby is in •Bladder: that is not distended •Lower extremities •Edema •DTR and Clonus - check reflexes , we want to check the clonus you know the involuntary rhythmic muscle contractions when we have a pt with eclampsia. preeclampsia we may have some neurologic involvement depending on how serious it is and you could have some clonus with that.

Third Stage of Labor

•Watch for signs of placental separation -during 3rd stage they'll be a gush of blood as a placenta separates from the uterus and the umbilical cord will lengthen. •Palpate fundus - after the delivery of the placenta, the fundus is palpated; it's usually halfway between the pubic symphysis and the umbilicus right after delivery. •Encourage breathing and abdominal relaxation during delivery of placenta •Possible administration of Pitocin •Obtain cord blood after delivery of placenta -After deliver there's the administration of the pitocin if it wasn't already done •Possible cord blood collection for storage for parents delivery of placenta - the cord blood is attained for blood typing and if the parents are going to bank for Cord Blood for stem cells they may go ahead and do that at that time.

Nursing Interventions: Fourth Stage notes part 3

•administer med such as oxytocin if needed •any pain med it's always nice to give some Motrin to help with the uterine cramping •pt may want some warm blankets bc Mom's tend to shake or shiver after the delivery or have chills and that's very common but it can be upsetting to the mom or to fam, who are watching but it's very common is caused by excessive epinephrine production during labor and then there's sudden release of the in delivery of the baby so she doesn't need all that epinephrine anymore in and causes her to shake or some people believe that there's a sudden release of pressure on the pelvic nerve and that also causes shaking so warm blankets are more helpful than I can cure it but they're helpful • give her some food and drink bc she's very thirsty and she's hungry cuz she probably hasn't eaten for the last time

Nursing Interventions: Fourth Stage part 3

•assessing her VS every 15 minsfor that first hour •monitor the perineum again making sure there aren't any hematomas putting ice packs on - monitor the bladder to make sure that it's not distended bc if it bc of distended bladder is going to cause a postpartum Hemorrhage. -you want to encourage mom to breastfeed the baby if breastfeeding bc she's going to be the most successful as she breastfeeds early + encourage bonding for both the bottle-fed mom and the breastfeeding mom -you want to promote rest; monitor visitors you don't want the baby to be passed around from person to person because actually the baby shuts down and doesn't want to breastfeed when he gets passed around a lot so it's really important for you to monitor the visitors and make sure that the baby stays with Mom under the covers skin-to-skin bc the baby's going to warm up nicely if you do that but once you start passing the baby around the room then you were sort of sabotaging her breastfeeding and also running the risk of the baby getting cold

position of the head during birth

•fetal skull usually is the largest structure of the baby - it is the less flexible part of the fetus however bc of the sutures in the fontanelles there is some flexibility in the fetal skull •the sutures allow the cranial Bones the capability of moving and overlapping in response to the power of Labor. •the size of the position of fetal head affects the ability for the fetus to travel the birth canal and the location of fetal head helps determine the presentation -another words if a fetus comes to the birth canal and the momentum or chin is presenting that is the largest part of the head and it's very difficult to almost impossible for a mom to deliver vaginally if the chin or the face is presenting first. •also Sinciput is also a very large area and doesn't allow for the field head to maneuver into the birth canal very easily but if the vertex position is presenting that's the best position for had to be in to come through the birth canal

Admission Assessment

•is pt in labor: she must make cervical change to be considered in labor. are there factors that put the women or the fetus at risk? such as just gestational diabetes and BP issues. •Should we encourage the woman to ambulate or does she need to stay in bed. •is there more frequent monitoring needed or can she be monitored intermittently? •what does the woman or the couple want during labor and birth? do they have a birth plan: Are they banking their cord blood? do they want delayed cord clamping? all this needs to be determined. •Who will be with the laboring women for social support: we need to find out if theres people she doesn't want in the room, we have to realize labor isn't a spectator sport, people just can't be in the room to watch the labor, they didn't earn the right to be there so we need to find out from the woman privately who she'd like have in the room with her.

Nursing Interventions: Latent Phase

•latent phase of Labor that 0 -3cm •Anticipatory guidance •Encourage ambulation -we know mom's usually are in the least amount of pain during this time, she's usually can be up and moving around as long as everything is good on the fetal monitor, •Offer fluids -we can offer her fluids so that she doesn't get dehydrated during this stage.

Fetal Membrane Status tests continue

•oligohydramnios is it the AFI level is less than 5 cm or the absence of the fluid pocket or the fluid volume is less than 500 mL at 32 to 36 weeks gestation, that a diagnosis of oligohydramnios would be suspected. •meconium means that the baby's feces was passed in utero before birth and in some cases this happens bc of the fetus being under stress, may be due to a ↓ in blood supply and O, may be prob with the placenta (placenta getting old) or the umbilical cord, or diabetes have ↑ incidence, or may be she have had a diff delivery or prolonged labor or HTN have high risk -once meconium has passed in the surrounding AF. the baby may breathe in the meconium into the lungs and if this happens the baby can have inflammation of the lungs and there could be breathing problems, we call this aspiration meconium. -some babies just have meconium-stained on their fingers and on their skin and the umbilical cord and they don't swallow any meconium or breathe in any of the meconium, so we just don't know how much of a problem meconium was going to be in until the baby is born

Assess Everything

•psychosocial status: we need to know when we send Mom home does she have a place to stay, does she have running water , does she have electricity, what's going on is she in an abusive relationship, will she be safe, will the baby be safe, •risk factors: may be with previous pregnancies, she's had problems may be postpartum Hemorrhage or she's had risk factors with this pregnancy high BP problems or gestational diabetes. •hx during this pregnancy, did she have any problems with the pregnancy. •past pregnancy hx: did she have maybe a postpartum Hemorrhage the last time she delivered cuz that's going to put her at risk for this next pregnancy, did she have large for gestational age babies •past medical and surgical hx: does she have cardiac issues, has she had a myomectomy we know somebody who's had a myomectomy can't deliver vaginally bc we cut through their uterine wall and she has a higher incidence of rupturing so we need to take a very thorough in-depth history

Family Expectations

•unrealistic expectations can ↑ anxiety: if fam don't know what to expect they may be very anxious themselves and ↑ the anxiety of pt. •Nurses have to be advocates for pt and family: you have to maybe tell the hcp that the fam wants something that's not usually something we would do on the unit, ex: I had a pt with a full-term baby that had died and she was a previous c-section so they were going to go ahead and use general anesthesia and deliver her well the dad wanted to be in the room with pt when they delivered dead baby, so I had to intervene and say you can't use general dad wants to be there with his pt and support her •Experiences in labor are dependent on cultural norms: Be sure that you give culturally sensitive care and pts who are religiously observant, you need to find out what they prefer and not impose your personal religious views bc if you do, sometimes it causes great emotional distress on the fam. •beliefs and norms •Variation in issues of modesty and pain: you want to find out the variations in issues of modesty, some pts really want to be covered when they deliver and they don't want to be exposed, some pt obviously don't care. some pts feel that their failure if they take pain medicine and some patients you know want their pain medicine right away

Lab Assessment for woman in labor

•we continue to assess the woman, assess the urine for protein, ketones, glucose, and leukocytes. -protein may indicate that there are problems with her BP she may be developing pregnancy -induced HTN such as pre-eclampsia. -ketones may indicate poor nutrition or dehydration or uncontrolled diabetes. -spilling glucose may indicate gestational diabetes. •check the woman's hgb and h&h values to make sure that she's not anemic, many doctors do not treat anemia until the hemoglobin drops below 11. •serology test for syphilis •hiv screening with consent •comfort level and support personal/preparation -Check the Comfort level of the woman, we want to make sure that there is a support person and what the preparation has been and we want to make sure that it's really labor and not false labor.