Maternal Child- Exam 2 (Chapter 13-17)

Pushing before full cervical dilation may cause what?

It may cause impede expulsion and cause the cervix to swell which may result in cervix not reaching full dilation.

Signs preceding labor

Lightening, return of urinary frequency, backache, stronger Braxton Hicks contractions, weight loss of 0.5 to 1.5 kg, surge of energy, increased vaginal discharge, bloody show, cervical ripening, possible rupture of membranes.

Preparation for Regional Anesthesia

Nurse/Epidural►Assess knowledge and concerns ►Watch video or consult with anesthesia dept. ►Make sure there is a consent form ►Maternal VS & FHR pattern ►Review laboratory values- CBC w PLT ►Review OB history ►Assess for hypersensitivity to drugs ►Administer 1 Liter bolus to offset hypotension.

First Stage of Labor (Cont.)

Nursing Interventions ►General hygiene ►Nutrient & fluid intake ►Limited oral intake (Ice Chips) ►IVF ►Elimination ►Distended bladder can impede descent of baby ►May have bowel movement during pushing ►Upright position encouraged ►If baby is posterior: squatting can help baby's head rotate more anterior

Fourth Stage- Golden Hour

►Immediate recovery period, last about 2 hours ►Homeostasis is re-established ►Period of close observation of mother and infant ►Time to facilitate maternal-infant bonding and breastfeeding.

►Rupture of the uterus (cont.)

►Increased risk ►Multiple cesarean births ►No previous vaginal births ►Augmented or induced labor ►Macrosomia ►Infection

Zero (0) station at level of ischial spaces

(Stations)

Relationship of presenting part to ischial spines of pelvic midplane.

+4-+5 Station: delivery Zero (0) station at level of ischial spaces

Warning signs to report to the HCP

-Vaginal bleeding - Acute abdominal pain - Temperature of ≥100° - Preterm labor - Preterm SROM - Hypertension - Non-reassuring fetal heart rate tracing - Other alterations in patient's condition

►Meconium-stained amniotic fluid

►Indicates that the fetus has passed the first stool before birth ►Places the infant at risk for meconium aspiration syndrome ►Requires the team skilled in neonatal resuscitation

Dysfunctional Labor (Cont.)

►Precipitous labor- fast labor ►Labor that lasts less than 3 hours ►Hypertonic uterine contractions ►Associated conditions: placental abruption, uterine tachysystole, recent cocaine use ►Risks: uterine rupture, lacerations of birth canal, amniotic fluid embolus, postpartum hemorrhage

►Prolapsed umbilical cord

►Prolapsed umbilical cord ►When cord lies below presenting part of fetus, visible or occult ►Most common directly after ROM ►Contributing factors include ►Long cord (longer than 100 cm) ►Malpresentation (breech) ►Transverse lie ►Unengaged presenting part ►Care management

►Uterine Tachysystole: stress on baby

►Reduce or discontinue dose of any uterine stimulants in use Pitocin ►Administer ►Uterine Relaxant (Tocolytic) ►Terbutaline (Brethine) is the number one given.

Gate-control theory of pain:

►limited number of messages travel through nerve pathways at one time

Pharmacological Pain management: Opioid (narcotic) agonist analgesics

►Fentanyl: rapid onset, short-acting, less neonatal side effects than Demerol.

Obesity

►Increasingly serious problem for pregnant women ►Likely to begin their pregnancy with pre-existing conditions ►Hypertension ►Diabetes ►Increased risk of postdate pregnancy and complications ►Nursing care has many challenges

Effacement

►Thinning & shortening of the cervix ►Cervix is "taken in or obliterated ►With 100% effacement only may palpate thin edge if the cervix

The 5 P's affecting labor

Passenger (fetus and placenta) Passageway (birth canal) Powers (contractions): the physiological forces of labor Position of mother: the relationship of the fetus to the mother Psychology: women's psychosocial considerations

Pain During Labor and Birth

►Visceral pain: from cervical changes, distention of lower uterine segment, and uterine ischemia ►Located over lower portion of abdomen ►Referred pain: originates in uterus, radiates to abdominal wall, lumbosacral area of back, iliac crests, gluteal area, and down thighs ►Somatic pain: pain described as intense, sharp, burning, and localized ►Stretching and distention of perineal tissues and pelvic floor to allow passage of fetus from distention and traction on peritoneum and uterocervical supports during contractions and lacerations of soft tissue

5th P= Psychology

►Women's expectation can influence response to the childbirth experience ►Past personal experience as previous birth experiences can influence labor ►Anxiety should be assessed ►Cultural factors should also be evaluated

Second Stage of Labor-Delivery

❖Begins with complete cervical dilation and ends with the birth of the fetus ❖Usually completed in about two hours ►As long as progress is being made there is no need for rigid time limit ❖Contractions occur about every 2-3 mins Last about 60-90 sec Are strong by palpation

Physiologic Adaptation to Labor

►Fetal adaptation ►These changes occur in: ►Fetal heart rate: variability ►Fetal circulation: contractions decrease circulation ►Fetal respiration: chemoreceptor changes to stimulate breathing

first stage of labor

3 phases: 1. Latent: Frequency-5-10 minutes. Duration- 30-45 seconds. (0-3 cm) 2. Active: Frequency- 2-5 minutes. Duration- 45-60 seconds. (4-7 cm) 3. Transition: Frequency-2-3 minutes. Duration-60-90 seconds. (8-10cm)

Interventions for Specific Problems

Maternal Hypotension -Can become an Emergency -Increase the rate of the primary IV infusion Change to lateral or Trendelenburg Positioning Administer Ephedrine or Phenylephrine if other measures are unsuccessful in increasing blood pressure. Monitor the BP.

Normal attitude : Moderate flexion with chin flexed on the chest and extremities flexed on the abdomen.

Moderate flexion with chin flexed on the chest and extremities flexed on the abdomen.

Fetal position:

Presenting part, indicates that portion of the fetus that overlies the pelvic inlet.

Frequent changes in position?

Relieve fatigue Increase comfort Improve circulation

SROM

Time, color, amount, and odor needs to be documented.

Fetal presentation:

cephalic, breech, shoulder- the part of the fetus's body that leads through the birth canal. We want cephalic first.

The size of the fetal head

cranial sutures and fontanels

Secondary powers

involuntary bearing down efforts (pushing) assists in expelling the fetus.

Fetal lie:

relation of baby's (spine) to mom's spine

Fetal attitude:

relation of fetal body parts to each other

Primary powers

► Effacement: thinning ► Dilation: opening

Care Management

►Abnormal ►Fetal monitoring standards of care ►Categorizing FHR tracings ►Category 1 is a happy baby! ►Normal (Baseline: 110-160,Moderate variability) ►Category 2►Indeterminate (Minimal variability).... Maybe the medicine causing but will continue to monitor. ►Category III (Absent baseline variability, Recurrent late decels, Bradycardia. May have to have a C-section!

Nonpharmacologic Pain Management

►Alternative therapies ►Relaxation: imagery and visualization ►Breathing techniques: Box 14.3 on P. 339 ►May have had childbirth prep class ►Should not exceed twice the normal RR ►Patterned-paced breathing during dilation from 8-10 cm ►Effleurage (light stroking of abdomen) and counterpressure: firm pressure on sacrum, both hips, or knees with firm object, fist, or hands ►Counterpressure when occiput is posterior (back labor) lifts head off of spinal nerves

Nonpharmacologic Pain Management

►Alternative therapies ►Touch and massage- hand holding, massage ►Mother may become more sensitive to touch as labor progresses ►Applications of heat and cold ►Heat for pain & relaxation ►Cold for pain & relieving feeling of overheating ►Acupressure and acupuncture ►Pressure applied with contractions initially, then continuously ►Acupuncture by trained professional only

Nonpharmacologic Pain Management (Cont.)

►Alternative therapies ►Transcutaneous electrical nerve stimulation ►Electrodes on either side of spine ►Water therapy (hydrotherapy) ►Some may labor in water ►ACOG does not recommend water birth ►Midwives Alliance of North America reports no evidence of any subsequent neonatal risk for adverse outcome

►Dystocia of fetal origin

►Anomalies: ascites, hydrocephalus, etc ►Large size baby ►Malposition: posterior: back labor ►Malpresentation: breech ►Breech vaginal delivery: higher risk for cord prolapse, trapping of fetal head, trauma to baby

Care Management (Cont.)

►Basic Intervention 1.Administer oxygen rate of 10ml/min for approx. 15 to 30 min 2.Assist patient to side lying position 3.Increase maternal blood volume by increasing the Rate of Primary IV infusion

First Stage of Labor

►Begins with onset of regular uterine contractions ►Ends with full cervical effacement and dilation

Physiologic Adaptation to Labor

►Cardiovascular: During each contraction, an average of 300 to 500 mL of blood is shunted from the uterus into the maternal vascular system. By the end of the first stage of labor cardiac output during contractions has increased by 51% ►Respiratory: oxygen consumption can almost double in unmedicated labor ►Renal: Edema causes issue with voiding ►Neurologic: Euphoria, seriousness, amnesia, elation, fatigue ►GI: decreased motility-N/V after birth ►Endocrine: Decrease of Progesterone/Increase in Estrogen, Oxytocin and Prostaglandins.

Third Stage- Placenta delivery

►Care Management ►Begins with birth of the infant and ends with delivery of the placenta ►Separation of placenta may occur with 3rd or 4thcontraction after birth of infant (15-30 mins) ►Duration of third stage may be from 5 to 7 minutes up to 1 hour ►As length of third stage increases, risk of hemorrhage increases ►Placenta cannot detach from a flaccid uterus

Labor and Birth at Risk (Cont.)

►Crucial for nurses to: ►Understand normal birth process ►Prevent and detect deviations from normal labor and birth ►Implement nursing measures if complications arise ►Nurse and obstetric team must use knowledge and skills in a concerted effort to provide care in event of complications

Dysfunctional Labor

►Defined as long, difficult, or abnormal labor ►Ineffective uterine contractions (powers) ►Alterations in pelvic structure (passage) ►Fetal causes (passenger) ►Maternal position during labor and birth ►Psychologic response of the woman

Fourth Stage of Labor

►Delivery of placenta until mother is stable in postpartum period, usually first hour after birth ►Care Management ►Assessment: risk for hemorrhage ►Postanesthesia recovery ►Epidural or spinal anesthesia: lift legs, raise buttocks off of bed

Fetal Assessment During Labor

►Electronic fetal monitoring is a useful tool for visualizing fetal heart rate (FHR) patterns on a monitor screen or printed tracing ►First used in 1970s ►Anticipated effect was a decrease in cerebral palsy; however, the rate has not declined. Increased C-sections because abnormalities are seen. ►Primary mode of intrapartum assessment in the United States

Mechanisms of Labor

►Engagement ►Descent ►Flexion ►Internal rotation ►Extension ►Restitution and external rotation ►Expulsion (birth)

Pharmacologic Pain Management (Cont.)

►Epidural ►Catheter in epidural space in the spine, continuous infusion of medication ►Disadvantages►Cannot move freely ►High spinal anesthesia (respiratory depression) ►Hypotension ( Baby will also be hypotensive) ►Longer second stage of labor ►Higher risk for operative vaginal birth

Narcotics commonly used in L&D

►Fentanyl citrate (Fentanyl) 50-100 mcg IV q1 hour onset 1-2 min peak 3-5 mins

Basis for Monitoring

►Fetal response ►Labor is a period of physiologic stress for fetus ►Frequent monitoring of fetal status is part of nursing care during labor ►Fetal oxygen supply must be maintained during labor to prevent fetal compromise

Basis for Monitoring (Cont.)

►Fetal well-being during labor measured by response of FHR to uterine contractions (UCs) ►Reassuring FHR patterns are: ►Baseline FHR in normal range of 110 to 160 beats/min, with no periodic changes and a moderate baseline variability ►In the preterm infant, baseline FHR may be higher

pharmacological pain management: Opioids

►Given IV, IM, ►Provide sedation & euphoria but limited pain control ►Can cause respiratory depression, sedation, N/V, dizziness, altered mental status, decreased GI motility, delayed gastric emptying, & urinary retention ►Cross the placenta

Basis for Monitoring (Cont.)

►Goals of intrapartum FHR monitoring are to identify non-reassuring patterns indicative of fetal compromise ►If uncorrected can progress to fetal hypoxia

►Oxytocin

►Hormone normally produced by posterior pituitary gland ►Stimulates uterine contractions ►Used to induce labor or augment a labor progressing slowly because of inadequate uterine contractions ►Drug most commonly associated with adverse events during labor & birth

Side Effects of Anesthesia

►Hypotension ►Transient alteration in fetal heart tones ►N&V ►Itching (with opioids) ►Urinary retention ►Maternal temperature elevation ►Inadequate pain relief ►Post-dural puncture headaches (spinal headache) They will treat with a blood patch.

Dysfunctional Labor (Cont.)

►Increased risk for uterine dystocia includes: ►Overweight or short stature ►Advanced maternal age ►Infertility ►Uterine abnormalities ►Malpresentation and position of the fetus ►Cephalopelvic disproportion (CPD) ►Uterine overstimulation with oxytocin

Monitoring techniques

►Intermittent Auscultation ►Doppler, stethoscope ►Not for high-risk patients ►Electronic Fetal Monitoring ►External, Fig.15.2 on P. 363 ►US transducer-fetal HR ►Tocotransducer- uterine activity; Does not tell contraction intensity!! You will palpate for intensity. ►Internal, Fig. 15.5 on P. 365 ►More accurate, invasive ►Membranes must be ruptured, must be dilated 2-3 cm, baby be low enough to place electrode ►Spiral electrode applied to presenting part-tells HR ►Intrauterine pressure catheter (IUPC)- measures uterine activity

Care and Management of Preterm Labor

►Interventions Suppression of uterine activity Tocolytics: Magnesium Sulfate- to stop contractions Brethine- to stop contractions

►Cesarean birth

►Intraoperative care ►Disclosure of confidential information ►Partner in room unless emergent ►Immediate postoperative care ►Oxytocin for fundal tone ►Can breastfeed ►Postoperative/postpartum care ►New mother first, surgical patient second ►Sips & chips until bowel sounds return

First Stage of Labor (Cont.)

►Laboratory and diagnostic tests ►Analysis of urine specimen: hydration ►Blood tests: CBC, type & screen. What kind of blood do mother and baby have! ►Other tests: Group B Streptococci (GBS) ►Assessment of amniotic membranes and fluid ►May have amniotomy (AROM) ►Should be clear in color ►Signs of potential problems ►Prolapsed cord ►Infection: limit vag exams, monitor temp\

First Stage of Labor (Cont.)

►Latent phase: up to 3 cm of dilation ►Active phase: 4 to 7 cm of dilation ►Transition phase: 8 to 10 cm of dilation

Second Stage of Labor- Delivery

►Latent: relatively calm with passive descent of baby through birth canal ►Active Pushing Phase: active pushing and urges to bear down

Preparing for birth

►Maternal position: change frequently ►Bearing-down efforts: spontaneous, open-glottis pushing for 6-8 seconds ►Panting breaths during crowning ►FHR and pattern

Advantages of Upright positioning

►May increase pelvic diameter ►May enhance uterine contraction strength ►Promotes descent of the fetus ►Helps minimize discomfort ►May shorten the second stage of labor ►May decrease incidence of perineal trauma

Pharmacologic Pain Management (Cont.)

►Nerve block analgesia and anesthesia ►Local perineal ►Lidocaine into skin & subQ ►Pudendal nerve block ►Given late in second stage for operative vaginal delivery. may use if there is a need for vacuum or forceps. ►Fig 14.9 on p. 348

Nonpharmacologic Pain Management and Support

►Nonpharmacologic measures often simple, safe, few adverse reactions, and inexpensive ►Provide sense of control over childbirth ►Methods require practice for best results ►Try variety of methods and seek alternatives, including pharmacologic methods, if measure used is not effective

Narcotics commonly used in L&D

►Nubain 5-10 mg IV q 90 mins onset 2-3 mins peak 30 mins. This is our choice of drug.

►Opioid (narcotic) agonist-antagonist analgesics

►Nubain: adequate analgesia with no respiratory depression in mom or baby ►Do not use in opioid dependent mother-can cause withdrawal. (More commonly used) No respiratory depression for mother/baby!

Onset of Labor

►Onset of true labor cannot be ascribed to single cause. Many factors involved, including changes in maternal uterus, cervix, and pituitary gland

►Abnormal fetal heart rate pattern during second stage of labor

►Open-glottis pushing ►Use fewer pushing efforts during each contraction ►Make individual pushing efforts shorter ►Push only with every other or every third contraction ►Push only with perceived urge to push

Dilation

►Opening of the cervix ►Diameter ⇧ to 10 cm ►With 10cm cervix is usually not felt.

►Oxytocin

►Oxytocin—high alert medication ►Placental abruption ►Uterine rupture ►Unnecessary cesarean birth ►Postpartum hemorrhage ►Infection ►Fetal hypoxemia and acidemia ►Uterine tachsystole: > 5 uterine contractions in 10 minutes over a 30 minute window

►Alterations in pelvic structure

►Pelvic dystocia ►Contractures of pelvic diameters that reduce capacity of bony pelvis, inlet, midpelvis, or outlet ►Congenital or from injury/trauma ►Soft tissue dystocia ►Results from obstruction of birth passage by an anatomic abnormality other than bony pelvis ►Cervical edema

First Stage of Labor (Cont.)

►Physical examination (Cont.) ►Assessment of uterine contractions ►Frequency: how often. in minutes! ►Intensity: how strong ►Duration: time between onset & end. No longer than 90 seconds! ►Resting tone: tension of uterus between contractions ►Palpation: P. 387

Factors influencing pain response

►Physiologic factors: fatigue, contraction strength/duration, endorphins ►Culture: response to pain may not accurately reflect pain intensity ►Anxiety: increased muscle tension

Third Stage- Placenta delivery

►Placental Separation & Expulsion ►Signs: lengthening of umbilical cord, gush of blood from vagina ►Immediately begin fundal massage & Pitocin infusion after delivery of placenta ►Be sure there are no retained portions of the placenta

Nonpharmacologic Pain Management

►Relaxation: imagery and visualization ►Breathing techniques: Box 14.3 on P. 339 ►May have had childbirth prep class ►Should not exceed twice the normal RR ►Patterned-paced breathing during dilation from 8-10 cm ►Effleurage (light stroking of abdomen) and counterpressure: firm pressure on sacrum, both hips, or knees with firm object, fist, or hands ►Counterpressure when occiput is posterior (back labor) lifts head off of spinal nerves

Pharmacologic Pain Management

►Sedatives: relieve anxiety, induce sleep ►Mostly avoided ►Analgesia and anesthesia ►Anesthesia: amnesia, relaxation, reflex activity ►Analgesia: alleviation of pain or raising the pain threshold without loss of consciousness

Maternal physical status

►Signs of potential problems ►Excessive blood loss ►Alteration in vital signs and consciousness ►Care of placenta after delivery ►Cultural traditions

VEAL CHOP

►Variable ►Early ►Accelerations ►Late ►Cord compression ►Head compression ►Ok ►Placental Insufficiency

►Rupture of the uterus

►Very serious obstetric injury, most often with VBAC ►Most frequent cause ►Scarred uterus as a result of previous cesarean births ►Signs and symptoms ►Abnormal FHR tracing ►Loss of fetal station ►Abdominal pain ►Shock