OB/GYN Exam 2

Monitoring Techniques:

Monitoring Techniques: Intermittent auscultation: -Intermittent auscultation involves listening to fetal heart sounds at periodic intervals to assess the FHR. IA of the fetal heart can be performed with a Pinard stethoscope, Doppler ultrasound, an ultrasound stethoscope or a DeLee-Hillis fetoscope. -IA is easy to use, inexpensive, and less invasive than EFM. It is often more comfortable for the woman and gives her more freedom of movement. -Listening to fetal heart sounds at periodic intervals to assess FHR -Easy to use, inexpensive, less invasive than EFM Difficult to perform on women who are obese Does not provide a permanent record Electronic fetal monitoring: The purpose of electronic FHR monitoring is the ongoing assessment of fetal oxygenation. FHR tracings are analyzed for characteristic patterns that suggest fetal hypoxic events and metabolic acidosis during labor. When hypoxia or metabolic acidosis is suspected in labor, interventions to resolve the problem can be implemented in a timely manner before permanent damage or death occurs Two forms of EFM: External: External transducers placed on the mothers abdomen to detect FHR. Internal: Placed on the presenting part of the fetus to detect FHR. External monitoring: -The ultrasound transducer works by reflecting high-frequency sound waves off a moving interface: in this case, the fetal heart and valves. -The tocotransducer (tocodynamometer) measures UA transabdominally. The device is placed over the fundus above the umbilicus and held securely in place using an elastic belt Advantages of External Fetal Monitoring -Noninvasive; reduces the risk of infection -Membranes do not have to be ruptured -Cervix does not have to be dilated -Placement of transducers can be performed by the nurse. This provides a permanent record of FHR and uterine contraction tracing. Disadvantages of External Fetal Monitoring -Contraction intensity is not measurable -Movement of the client requires frequent repositioning of transducers -Quality of recording is affected by client obesity and fetal position Internal Monitoring: -Spiral electrode -Intrauterine pressure catheter (IUPC) -Display: displayed on the monitor paper or computer screen, with the FHR in the upper section and UA in the lower section -The technique of continuous internal FHR or UA monitoring provides a more accurate appraisal of fetal well-being during labor than external monitoring because it is not interrupted by fetal or maternal movement or affected by maternal size. -For this type of monitoring, the membranes must be ruptured, the cervix sufficiently dilated (at least 2 to 3 cm), and the presenting part low enough to allow placement of the spiral electrode or intrauterine pressure catheter or both -Internal monitoring of the FHR is accomplished by attaching a small spiral electrode to the presenting part. For UA to be monitored internally an IUPC is introduced into the uterine cavity. The catheter has a pressure-sensitive tip that measures changes in intrauterine pressure. As the catheter is compressed during a contraction, pressure is placed on the pressure transducer. This pressure is then converted into a pressure reading in millimeters of mercury (mm Hg). The IUPC can objectively measure the frequency, duration, and intensity of UC, as well as uterine resting tone.

Preterm Labor Care Management

Assessment Patient teaching Interventions Prevention Early recognition and diagnosis Lifestyle modifications Activity restriction: -Activity Restriction. Activity restriction, including bed rest and limited work, is a commonly prescribed intervention for the prevention of preterm birth -Research indicates that bed rest causes adverse physical effects, including risk of thrombus formation, muscle atrophy, osteoporosis, and cardiovascular deconditioning Restriction of sexual activity Restriction of sexual activity is frequently recommended for women at risk for preterm birth. This intervention has not been shown to be effective at preventing preterm birth. Home care: Women who are at high risk for preterm birth commonly are told that it would be best for them to "take it easy" at home for weeks or months Nursing Care of a Patient in Preterm Labor (includes focus on stopping uterine contractions) Activity restriction Instruct the patient on modifying her environment to allow for bed rest, yet have the ability to fulfill daily role responsibilities. Strict bed rest has been found to have adverse effects. Encourage the patient to rest in the left lateral position to increase blood flow to the uterus and decrease uterine activity. Tell the patient to avoid sexual intercourse. Treatment: Hospitalization Hydration. Tocolytics. Administration of systemic corticosteroids to promote fetal lung maturity if delivery imminent. Suppression of uterine activity: Tocolytic medications: Tocolytics are medications given to arrest labor after uterine contractions and cervical change have occurred. Tocolytic therapy usually will not prolong the pregnancy long enough for further fetal growth or maturation to occur; rather, the goal is to delay birth long enough to institute interventions that reduce neonatal morbidity and mortality -Magnesium sulfate is the most commonly used tocolytic agent because maternal and fetal or neonatal adverse reactions are less common than with the beta-adrenergic agonists. -Beta2-adrenergic agonists (e.g., ritodrine and terbutaline [Brethine]) have been widely used in the past as tocolytics. They have many maternal and fetal adverse reactions, however, including beta1-stimulated cardiopulmonary (e.g., tachycardia) effects and beta2-stimulated metabolic (e.g., hyperglycemia) effects. Terbutaline: -Terbutaline, the most commonly administered beta-adrenergic agonist used for tocolysis, works by relaxing uterine smooth muscle as a result of stimulation of beta2-receptors in the uterine smooth muscle. A single dose of terbutaline given subcutaneously may help diagnose preterm labor. Nifedipine: -Nifedipine (Adalat, Procardia), a calcium channel blocker, is another tocolytic agent that can suppress contractions. It works by inhibiting calcium from entering smooth muscle cells, thus reducing uterine contractions -Because of ease of administration and low incidence of significant maternal and fetal side effects, nifedipine's use is increasing. Indomethacin (Indocin), a nonsteroidal antiinflammatory drug (NSAID), has been shown in some trials to suppress preterm labor by blocking the production of prostaglandins. Serious maternal side effects are uncommon and indomethacin is usually well tolerated. However, three serious fetal or neonatal side effects have caused major concerns about its use as a tocolytic Promotion of fetal lung maturity: Antenatal glucocorticoids: significantly reduce the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in neonates Management of inevitable preterm birth: -Labor that has progressed to a cervical dilation of 4 cm or more is likely to lead to inevitable preterm birth. If birth appears imminent, preparations to care for a small, immature neonate should be made. -Therefore, nurses must be prepared to handle the emergency birth of a preterm infant, from either cephalic or breech presentation, without the woman's primary health care provider being present. Fetal and early neonatal loss: -Preterm birth or the presence of congenital anomalies or genetic disorders incompatible with life are major reasons for intrauterine fetal demise (stillbirth) or early neonatal death. -In many of these situations the parents will have already been told that the fetus has died or that the baby has a condition that is incompatible with life and will most likely die very soon after birth. -Sometimes, however, the fetal death will be unexpected, diagnosed only after the woman has been admitted to the labor and birth unit. Whatever the case, labor and birth nurses must be prepared to provide sensitive care to these women and their families.

Maternal Adaptations

Cardiovascular Changes: -During each contraction an average of 400 mL of blood is emptied from the uterus into the maternal vascular system. This increases cardiac output by about 12% to 31% in the first stage and by about 50% in the second stage of labor. The heart rate increases slightly. -Changes in blood pressure also occur. Blood flow, which is reduced in the uterine artery by contractions, is redirected to peripheral vessels. As a result, peripheral resistance increases, and blood pressure increases -Supine hypotension -The woman should be discouraged from using the Valsalva maneuver (holding one's breath and tightening abdominal muscles) for pushing during the second stage because fetal hypoxia may occur. Respiratory Changes: -Increased physical activity with greater oxygen consumption is reflected in an increase in the respiratory rate. Hyperventilation may cause respiratory alkalosis (an increase in pH), hypoxia, and hypocapnia (decrease in carbon dioxide). In the unmedicated woman in the second stage of labor, oxygen consumption almost doubles. Anxiety also increases oxygen consumption. Renal Changes: -During labor, spontaneous voiding may be difficult for various reasons: tissue edema caused by pressure from the presenting part, discomfort, analgesia, and embarrassment. Proteinuria of 1+ is a normal finding because it can occur in response to the breakdown of muscle tissue from the physical work of labor. Integumentary Changes: -The integumentary system changes are evident, especially in the great distensibility (stretching) in the area of the vaginal introitus. The degree of distensibility varies with the individual. Despite this ability to stretch, even in the absence of episiotomy or lacerations, minute tears in the skin around the vaginal introitus do occur. Musculoskeletal Changes: -The musculoskeletal system is stressed during labor. Diaphoresis, fatigue, proteinuria (1+), and possibly an increased temperature accompany the marked increase in muscle activity. Backache and joint aches (unrelated to fetal position) occur as a result of increased joint laxity at term. The labor process itself and the woman's pointing her toes can cause leg cramps Neurologic Changes: Sensorial changes occur as the woman moves through the phases of the first stage of labor and as she moves from one stage to the next. Initially she may be euphoric. Euphoria gives way to increased seriousness, then to amnesia between contractions during the second stage, and finally to elation or fatigue after giving birth. Endogenous endorphins (morphine-like chemicals produced naturally by the body) raise the pain threshold and produce sedation. In addition, physiologic anesthesia of perineal tissues, caused by pressure of the presenting part, decreases perception of pain. Gastrointestinal Changes: During labor, gastrointestinal motility and absorption of solid foods are decreased, and stomach-emptying time is slowed. Nausea and vomiting of undigested food eaten after onset of labor are common. Nausea and belching also occur as a reflex response to full cervical dilation. The woman may state that diarrhea accompanied the onset of labor, or the nurse may palpate the presence of hard or impacted stool in the rectum. Endocrine Changes: The onset of labor may be triggered by decreasing levels of progesterone and increasing levels of estrogen, prostaglandins, and oxytocin Metabolism increases, and blood glucose levels may decrease with the work of labor. Accurate assessment of the mother and fetus during labor and birth depends on knowledge of these expected adaptations so that appropriate interventions can be implemented

Factors Influencing Pain Response:

Factors Influencing Pain Response: Pain perception or intensity is unique to every woman Physiologic factors: A variety of physiologic factors can affect the intensity of childbirth pain. Women with a history of dysmenorrhea may experience increased pain during childbirth as a result of higher prostaglandin levels. -Back pain associated with menstruation also may increase the likelihood of contraction-related low back pain. -Other physical factors that affect pain intensity include fatigue, the interval and duration of contractions, fetal size and position, rapidity of fetal descent, and maternal position. -More endorphins, the higher the pain tolerance threshold. Culture: -Women with strong religious beliefs often accept pain as a necessary and inevitable part of bringing a new life into the world -The nurse can provide appropriate, culturally sensitive care by using pain relief measures that preserve the woman's sense of control and self confidence once he or she is culturally aware. Anxiety: -Anxiety and fear heighten, muscle tension increases, the effectiveness of uterine contractions decreases, the experience of discomfort increases, and a cycle of increased fear and anxiety begins. Ultimately this cycle will slow the progress of labor. Previous experience: Childbirth, for a healthy young woman, may be her first experience with significant pain, and as a result she may not have developed effective pain coping strategies. She may describe the intensity of even early labor pain as pain "as bad as it can be." The nature of previous childbirth experiences also may affect a woman's responses to pain. For women who have had a difficult and painful previous birth experience, anxiety and fear from this past experience may lead to increased pain perception. Gate-control theory of pain: -Even particularly intense pain stimuli can at times be ignored. This is possible because certain nerve cell groupings within the spinal cord, brainstem, and cerebral cortex have the ability to modulate the pain impulse through a blocking mechanism. This gate-control theory of pain helps explain the way hypnosis and the pain relief techniques taught in childbirth preparation classes work to relieve the pain of labor. -Using distraction techniques such as massage or stroking, music, focal points, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain. Comfort : Although the predominant medical approach to labor is that it is painful, and the pain must be removed, an alternative view is that labor is a natural process, and women can experience comfort and transcend the discomfort or pain to reach the joyful outcome of birth. Support: -Current evidence indicates that a woman's satisfaction with her labor and birth experience is determined by how well her personal expectations of childbirth were met and the quality of support and interaction she received from her caregivers. -In addition, satisfaction is influenced by the degree to which she was able to stay in control of her labor and to participate in decision making regarding her labor, including the pain relief measures to be used Environment: -Environment includes the individuals present (e.g., how they communicate, their philosophy of care including a belief in the value of nonpharmacologic pain relief measures, practice policies, and quality of support) and the physical space in which the labor occurs. -Women usually prefer to be cared for by familiar caregivers in a comfortable, homelike setting which is safe and private. -Stimuli such as light, noise, and temperature should be adjusted according to her preferences

Reproductive System and Associated Structures

Lochia: Uterine discharge after childbirth, commonly called lochia, is initially bright red (lochia rubra) and may contain small clots. For the first 2 hours after birth the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time the lochial flow should steadily decrease. lochia rubra is red (first 1-3 days) . lochia serosa is pink (day 3 to 10). lochia alba yellow-white (10-14 or 28 days). Rubra: Lochia rubra consists mainly of blood and decidual and trophoblastic debris. The flow pales, becoming pink or brown (lochia serosa) after 3 to 4 days Serosa: Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. The median duration of lochia serosa discharge is 22 to 27 days Alba: Lochia alba consists primarily of leukocytes and decidual cells but also contains epithelial cells, mucus, serum, and bacteria. Lochia alba usually continues for 10 to 14 days but may last longer and still be normal. Changes in Lochia that Cause Concern: CHANGE: Presence of clots POSSIBLE PROBLEM: Inadequate uterine contractions that allow bleeding from vessels at the placental site NURSING ACTION: -Assess location and firmness of fundus -Assess voiding pattern -Record and report findings CHANGE: Persistent lochia rubra POSSIBLE PROBLEM: -Inadequate uterine contractions, retained placental fragments, infection; undetected cervical laceration NURSING ACTION: -Assess location and firmness of fundus -Assess activity pattern -Assess for signs of infection -Record and report findings Cervix: -The cervix is soft immediately after birth. The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has some small lacerations—optimal conditions for the development of infection. Over the next 12 to 18 hours it shortens and becomes firmer. The cervical os, which dilated to 10 cm during labor, closes gradually. Within 2 to 3 days postpartum it has shortened, become firm, and regained its form. The cervix up to the lower uterine segment remains edematous, thin, and fragile for several days after birth. By the second or third postpartum day the cervix is dilated 2 to 3 cm, and by 1 week after birth it is approximately 1 cm dilated. -The external cervical os never regains its prepregnancy appearance; it no longer has a circular shape but appears as a jagged slit often described as a "fish mouth" -Lactation delays the production of cervical and other estrogen-influenced mucus and mucosal characteristics. -Cervix is spongy, flabby and may appear bruised. -Cervix may have lacerations. Vagina and perineum: Postpartum estrogen deprivation is responsible for the thinness of the vaginal mucosa and the absence of rugae. The greatly distended smooth-walled vagina gradually decreases in size and regains tone, although it never completely returns to its pre pregnancy state. Rugae reappear within 3 to 4 weeks, but they are never as prominent as they are in the nulliparous woman. -Vagina may be edematous, bruised with small superficial lacerations. Episiotomy and laceration assessments: Most episiotomies and laceration repairs are visible only if the woman is lying on her side with her upper buttock raised or if she is placed in the lithotomy position Hemorrhoids: -Commonly can be seen -Internal hemorrhoids can evert while the woman is pushing during birth -Symptoms such as itching, discomfort, and bright red bleeding with defecation. Pelvic muscular support: -The supporting structure of the uterus and vagina may be injured during childbirth and contributes to later gynecologic problems. Supportive tissues of the pelvic floor that are torn or stretched during childbirth may require up to 6 months to regain tone. Kegel exercises, which help to strengthen perineal muscles and encourage healing, are recommended after childbirth. -Later in life, women can experience pelvic relaxation, the lengthening and weakening of the fascial supports of pelvic structures. These structures include the uterus, the upper posterior vaginal wall, the urethra, the bladder, and the rectum. Although pelvic relaxation can occur in any woman, it is usually a direct but delayed complication of childbirth.

Pharmacologic Pain Management

Pharmacologic measures for pain management should be implemented before pain becomes so severe that catecholamines increase and labor is prolonged. It is unacceptable for women in labor to endure severe pain when safe and effective relief measures are available. Sedatives: relieve anxiety and induce sleep; typically used for women in a prolonged latent phase of labor when there is a need to lessen the intensity of the contractions, decrease anxiety, or promote sleep. May also be given to augment analgesics and reduce nausea when an opioid is used. -Barbituates should be avoided if birth is anticipated within 12 to 24 hours. -The depressant effects are increased if a barbiturate is administered with another CNS depressant such as an opioid analgesic. However, pain will be magnified if a barbiturate is given without an analgesic to women experiencing pain because normal coping mechanisms may be blunted. -Phenothiazines (e.g., promethazine [Phenergan], hydroxyzine [Vistaril]) do not relieve pain but are often given with opioids to decrease anxiety and apprehension, increase sedation, and reduce nausea and vomiting. Promethazine is probably the most widely used drug in this class. It causes significant sedation and has been shown to impair the analgesic efficacy of opioids. Using opioids with less potential to cause nausea and vomiting should make the routine use of promethazine unnecessary. -Metoclopramide (Reglan) is an antiemetic that causes little sedation and may potentiate the effects of analgesics. -Ondansetron (Zofran) is another very effective antiemetic that has few side effects. Whenever possible, it should be used instead of promethazine -Includes analgesia and local/ regional analgesics. To avoid slowing labor progress, prior to administering analgesics, the nurse should verify that labor is well established. A vaginal exam and uterine contraction pattern evaluation are done. -Benzodiazepines (e.g., diazepam [Valium], lorazepam [Ativan]), when given with an opioid analgesic, seem to enhance pain relief and reduce nausea and vomiting. Because benzodiazepines cause significant maternal amnesia, however, their use should be avoided during labor. Major disadvantage of diazepam is that it disrupts thermoregulation in newborns. Opioid Analgesics: Opioid analgesics, such as Demerol, Fentanyl, Stadol and Nubain act on the CNS to decrease pain perception without loss of consciousness -Because opioids can inhibit uterine contractions, they should not be administered until labor is well established unless they are being used to enhance therapeutic rest during a prolonged latent phase of labor. -Decrease gastric emptying, increase nausea and vomiting and decrease bladder and bowel emptying. -Should be used cautiously in women with respiratory or cardiac problems. -Butorphanol (Stadol) and Nalbuphine (Nubain) provide pain relief without significant respiratory depression in the mother or fetus. -Meperidine hydrochloride (Demerol) used to be the most commonly used opioid agonist analgesic for women in labor, but is no longer the preferred choice because other medications have fewer side effects. -Fentanyl citrate (Sublimaze) and sufentanil citrate (Sufenta) are potent short-acting opioid agonist analgesics. Sufentanil use is increasing because it has a more potent analgesic action than fentanyl when given through an epidural catheter. Also less sufentanil will cross the placenta, resulting in reduced fetal exposure. Opioid (narcotic) agonist antagonist analgesics: -In the doses used during labor, these mixed opioids provide adequate analgesia without causing significant respiratory depression in the mother or neonate. They are less likely to cause nausea and vomiting, but sedation may be as great or greater when compared with pure opioid agonists. As a result of these effects, parenteral opioid agonist-antagonist analgesics are used more commonly during labor than the opioid agonist analgesics Opioid (narcotic) agonists: -Opioids such as hydromorphone, meperidine, and fentanyl can cause excessive CNS depression in the mother, the newborn, or both, although the current practice of giving lower doses of opioids intravenously has reduced the incidence and severity of opioid-induced CNS depression. Opioid (narcotic) antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect. -Administration opioid analgesics can be IM or IV Adverse Effects of Opioid Analgesics: Sedation Tachycardia Hypotension Decreased FHR variability Allergic reaction -Anesthesia encompasses analgesia, amnesia, relaxation, and reflex activity. Anesthesia abolishes pain perception by interrupting the nerve impulses to the brain. The loss of sensation may be partial or complete, sometimes with the loss of consciousness. -Analgesia: the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness -The type of analgesic or anesthetic chosen is determined in part by the stage of labor of the woman and by the method of birth planned. Systemic Analgesia: Use of systemic analgesia for relieving the pain of labor has been declining, although it still remains the major pharmacologic method for relieving the pain of labor when personnel trained in regional analgesia (e.g., epidural analgesia) are not available. Systemic analgesics cross the maternal blood-brain barrier to provide central analgesic effects, also cross the placenta. Nerve block analgesia and anesthesia: -A variety of local anesthetic agents are used in obstetrics to produce regional analgesia (some pain relief and motor block) and anesthesia (complete pain relief and motor block). Most of these agents are related chemically to cocaine and end with the suffix -caine. This helps to identify a local anesthetic. -Interrupts of the conduction of nerve impulses, notably pain. Local Perineal Infiltration Anesthesia: -Local perineal infiltration anesthesia may be used when an episiotomy is to be performed or when lacerations must be sutured after birth in a woman who does not have regional anesthesia. Pudendal Nerve Block. -Pudendal nerve block, administered late in the second stage of labor, is useful if an episiotomy is to be performed or if forceps or a vacuum extractor are to be used to facilitate birth. It can also be administered during the third stage of labor if an episiotomy or lacerations must be repaired. Spinal anesthesia (block): Spinal Anesthesia. In spinal anesthesia (block), an anesthetic solution containing a local anesthetic alone or in combination with an opioid agonist analgesic is injected through the third, fourth, or fifth lumbar interspace into the subarachnoid space where the anesthetic solution mixes with cerebrospinal fluid (CSF). The use of this technique has increased for both elective and emergent cesarean births and is more common than epidural anesthesia for these types of births. -Spinal anesthesia (block) used for cesarean birth provides anesthesia from the nipple (T6) to the feet. If it is used for vaginal birth, the anesthesia level is from the hips (T10) to the feet. - Post-dural puncture headaches Leakage of CSF from the site of puncture of the dura mater (membranous covering of the spinal cord) is thought to be the major causative factor in postdural puncture headache (PDPH), commonly referred to as a spinal headache. Spinal headache is much more likely to occur when the dura is accidentally punctured during the process of administering an epidural block. The needle used for an epidural block has a much larger gauge than the one used for spinal anesthesia and thus creates a bigger opening in the dura, resulting in a greater loss of CSF. Epidural blood patch: Epidural blood patch is the most rapid, reliable, and beneficial relief measure for PDPH. The woman's blood (i.e., 20 ml) is injected slowly into the lumbar epidural space, creating a clot that patches the tear or hole in the dura mater. Treatment with a blood patch is considered if the headache is severe or debilitating or does not resolve after conservative management. The blood patch is remarkably effective and is nearly complication free. Epidural and spinal regional analgesia consists of using analgesics such as Fentanyl (Sublimaze) and Marcaine, short-acting opioids administered as a motor block into the epidural or intrathecal space without anesthesia. These opioids produce regional analgesia. They provide rapid pain relief while still allowing the patient to sense contractions and maintain the ability to bear down. Epidural anesthesia or analgesia (block): -Currently the most effective pharmacologic pain relief method for labor -Relief from the pain of uterine contractions and birth (vaginal and cesarean) can be achieved by injecting a suitable local anesthetic agent (e.g., bupivacaine, ropivacaine), an opioid analgesic (e.g., fentanyl, sufentanil), or both into the epidural (peridural) space. Injection is made between the fourth and fifth lumbar vertebrae for a lumbar epidural block. -For relieving the discomfort of labor and vaginal birth, a block from T10 to S5 is required. For cesarean birth, a block from at least T8 to S1 is essential. Combined spinal-epidural (CSE) analgesia: -Sometimes referred to as a "walking epidural," although women often choose not to walk because of sedation and fatigue, abnormal sensations in and weakness of the legs, and a feeling of insecurity Epidural and intrathecal (spinal) opioids -An epidural needle is inserted into the epidural space. Before the epidural catheter is placed, a smaller-gauge spinal needle is inserted through the bore of the epidural needle into the subarachnoid space. A small amount of opioid or combination of opioid and local anesthetic is then injected intrathecally to rapidly provide analgesia. Afterward the epidural catheter is inserted as usual. -Used to block pain transmission without blocking motor ability. Epidural and Intrathecal (Spinal) Opioids: Opioids also can be used alone, eliminating the effect of a local anesthetic altogether. The use of epidural or intrathecal opioids without the addition of a local anesthetic agent during labor has several advantages. Opioids administered in this manner do not cause maternal hypotension or affect vital signs. The woman feels contractions but not pain. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost, and her motor power remains intact. Adverse Effects of Epidural and Spinal Analgesia -The woman's ability to move freely and to maintain control of her labor is limited -Occurrence of orthostatic hypotension and dizziness, sedation, and weakness of the legs -Decreased gastric emptying, resulting in nausea and vomiting -Inhibition of bowel and bladder elimination sensations -Bradycardia or tachycardia -Hypotension Contraindications to subarachnoid and epidural blocks Active or anticipated serious maternal hemorrhage Maternal hypotension Maternal coagulopathy Infection at the injection site Increased intracranial pressure Allergy to the anesthetic drug Maternal refusal or inability to cooperate Some types of maternal cardiac conditions Abnormal FHR and pattern requiring immediate birth.

Postpartum Care Management

Routine laboratory tests: -Several laboratory tests may be performed in the immediate postpartum period. Hemoglobin and hematocrit values are often evaluated on the first postpartum day to assess blood loss during childbirth, especially after cesarean birth. In some hospitals a clean-catch or catheterized urine specimen may be obtained and sent for routine urinalysis or culture and sensitivity -In addition, if the woman's rubella and Rh status are unknown, tests to determine her status and need for possible treatment should be performed at this time. Prevention of excess bleeding: A moderate amount of vaginal bleeding (lochia) is expected in the immediate postpartum period. Nurses need to assess and prevent excessive bleeding, the most frequent cause of which is uterine atony, failure of the uterine muscle to contract firmly. -The two most important interventions for preventing excessive bleeding are maintaining good uterine tone and preventing bladder distention. Maintenance of uterine tone: -A major intervention to alleviate uterine atony and restore uterine muscle tone is stimulation by gently massaging the fundus until firm Prevention of bladder distention: Uterine atony and excessive bleeding after birth can be the result of bladder distention. A full bladder causes the uterus to be displaced above the umbilicus and well to one side of midline in the abdomen. It also prevents the uterus from contracting normally. Prevention of infection: -Maintaining a clean environment. -Wear shoes when walking about to prevent contamination of the linens when they return to bed -Staff and visitors with colds, coughs, diarrhea should be urged to stay away. Promotion of comfort: Most women experience some degree of discomfort during the postpartum period. Common causes of discomfort include pain from uterine contractions (afterpains), perineal lacerations or episiotomy, hemorrhoids, sore nipples, and breast engorgement. Promotion of ambulation: Early ambulation is associated with a reduced incidence of venous thromboembolism (VTE); it also promotes the return of strength. Free movement is encouraged once anesthesia wears off unless a narcotic analgesic has been administered Promotion of exercise: Postpartum exercise can begin soon after birth, although the woman should be encouraged to start with simple exercises and gradually progress to more strenuous ones. -Kegel exercises to strengthen muscle tone are extremely important Promotion of nutrition: -Prenatal vitamins and iron supplements are often continued until 6 weeks after childbirth or until the ordered supply has been used. Promotion of normal bladder and bowel function: -The mother should void spontaneously within 6 to 8 hours after giving birth. The first several voidings should be measured to document adequate emptying of the bladder. -150mL expected for each voiding. -After birth, women may be at risk for constipation related to side effects of medications (narcotic analgesics, iron supplements, magnesium sulfate), dehydration, immobility, or the presence of episiotomy, perineal lacerations, or hemorrhoids. The woman may fear pain with the first bowel movement. -Nursing interventions are to educate on preventing constipation, alert about side effects, stool softeners or laxitives. Promotion of breastfeeding: -The ideal time to initiate breastfeeding is within the first 1 to 2 hours after birth. -At this time, most infants are alert and ready to nurse. Breastfeeding aids in the contraction of the uterus and prevention of maternal hemorrhage. -The first hour after birth is also an opportune time to assist the mother with breastfeeding, assess her basic knowledge of breastfeeding, and assess the physical appearance of the breasts and nipples Lactation suppression: Suppression of lactation is necessary when the woman has decided not to breastfeed or in the case of neonatal death. Wearing a well-fitted support bra continuously for at least the first 72 hours after giving birth is important. Women should avoid breast stimulation, including running warm water over the breasts, newborn suckling, or pumping of the breasts. Some nonbreastfeeding mothers experience severe breast engorgement (swelling of breast tissue caused by increased blood and lymph supply to the breasts as the body produces milk, occurring at about 72 to 96 hours after birth). Breast engorgement can usually be managed satisfactorily with nonpharmacologic interventions. Breast care during lactation: -Cleanse breast daily -Air dry nipples after breast feeding -Encourage patient to wear well-fitted support bra

Integumentary System:

-Melasma (mask of pregnancy) disappears -Vascular abnormalities regress -Hair loss often reported during the first 3 months postpartum

First Stage of Labor

Begins with regular uterine contractions Ends with full cervical effacement and dilation Obstetric triage Prenatal data The nurse reviews the prenatal record to identify the woman's individual needs and risks Three phases of the first stage of labor Latent phase (up to 3 cm of dilation) Active phase (4 to 7 cm of dilation) Transition phase (8 to 10 cm of dilation) Assessment and nursing diagnosis Determination of whether the woman is in true labor or false labor, nurses often don't make decision because of legal liability, will often say come if you feel like you need to be checked or contact pcp. Contractions must be felt Cervix must be dilating Fetus Obstetric triage A woman is considered to be in true labor until a qualified provider determines that she is not Admission to the labor unit Admission data Prenatal data: If the woman has had no prenatal care or her prenatal records are unavailable, the nurse must obtain certain baseline information. If the woman is having discomfort, the nurse should ask questions between contractions when the woman can concentrate more fully on her answers -Knowing the womans age is important because different age groups have different needs. -Other important data found in the prenatal record include patterns of maternal weight gain; physiologic measurements such as maternal vital signs (blood pressure, temperature, pulse, respirations); fundal height; baseline fetal heart rate (FHR); and laboratory and diagnostic test results. -If this labor and birth experience is not the woman's first, the nurse needs to note the characteristics of her previous experiences. Interview: -Reason for coming to the hospital. -The woman may have come in for an obstetric check, which is a period of observation reserved for women who are unsure about the onset of their labor Spontaneous rupture of membranes -The woman is asked to recall the events of the previous days and to describe the following: Time and onset of contractions and progress in terms of frequency, duration, and intensity Location and character of discomfort from contractions (e.g., back pain, abdominal or suprapubic discomfort) Persistence of contractions despite changes in maternal position and activity (e.g., walking or lying down) Presence and character of vaginal discharge or "show" The status of amniotic membranes -Assessing the woman's respiratory status -Allergy status -The nurse obtains any information not found in the prenatal record during the admission assessment. -Formulate birthplan Bloody or pink show: Bloody show is distinguished from bleeding by the fact that it is pink and feels sticky because of its mucoid nature. There is very little bloody show in the beginning, but the amount increases with effacement and dilation of the cervix. Psychosocial factors -The woman's general appearance and behavior (and that of her partner) provide valuable clues to the type of supportive care she will need. Women with history of sexual abuse: Labor can trigger memories of sexual abuse, especially during intrusive procedures such as vaginal examinations. Stress in labor Discuss the feelings a woman has about her pregnancy and fears regarding childbirth. This discussion is especially important if the woman is a primigravida who has not attended childbirth classes or is a multiparous woman who has had a previous negative childbirth experience. Admission data Cultural factors -Woman may have a preconceived idea of the "right" way to behave, these behaviors can range from total silence to moaning or screaming -Culture and father participation -Non-English-speaking woman in labor -The woman's cultural and religious background influences her choice of birth companion as do trends in the society in which she lives Physical examination: The initial physical examination includes a general systems assessment and an assessment of fetal status. During the examination uterine contractions are assessed and a vaginal examination is performed. The findings of the admission physical examination serve as a baseline for assessing the woman's progress from that point General systems assessment: On admission, the nurse should perform a brief systems assessment. This includes an assessment of the heart, lungs, and skin and an examination to determine the presence and extent of edema of the face, hands, sacrum, and legs. It also includes testing of deep tendon reflexes and for clonus if indicated. Also note the woman's weight Vital signs: Assess vital signs (temperature, pulse, respirations, and blood pressure, using a correct-size cuff) on admission. The initial values are used as the baseline for comparison for all future measurements. If the blood pressure is elevated, reassess it 30 minutes later, between contractions, to obtain a reading after the woman has relaxed. Encourage the woman to lie on her side to prevent supine hypotension and fetal distress. Monitor her temperature so that you can identify signs of infection or a fluid deficit (e.g., dehydration associated with inadequate intake of fluids). Leopold maneuvers (abdominal palpation): Leopold maneuvers are performed with the woman briefly lying on her back. These maneuvers help identify the (1) number of fetuses; (2) presenting part, fetal lie, and fetal attitude; (3) degree of the presenting part's descent into the pelvis; and (4) expected location of the point of maximal intensity (PMI) of the FHR on the woman's abdomen. Assessment of FHR and pattern: The PMI of the FHR is the location on the maternal abdomen at which the FHR is heard the loudest. It is usually directly over the fetal back. In a vertex presentation, you can usually hear the FHR below the mother's umbilicus in either the right or the left lower quadrant of the abdomen. In a breech presentation you usually hear the FHR above the mother's umbilicus. The Nursing Process Box: First Stage of Labor summarizes assessments recommended for determining fetal status. In addition, you must assess the FHR after ROM because this is the most common time for the umbilical cord to prolapse, after any change in the contraction pattern or maternal status, and before and after the woman receives medication or a procedure is performed Assessment of uterine contractions: A general characteristic of effective labor is regular uterine activity (i.e., contractions becoming more frequent with increased duration), but uterine activity is not directly related to labor progress. Uterine contractions are the primary powers that act involuntarily to expel the fetus and the placenta from the uterus. Several methods are used to evaluate uterine contractions, including the woman's subjective description, palpation and timing of contractions by a health care provider, and electronic monitoring. Frequency: How often uterine contractions occur; the time that elapses from the beginning of one contraction to the beginning of the next contraction Intensity: The strength of a contraction at its peak Duration: The time that elapses between the onset and the end of a contraction Resting tone: The tension in the uterine muscle between contractions; relaxation of the uterus The woman's description and palpation are more subjective and less precise ways of determining the intensity of uterine contractions and resting tone than is the electronic fetal monitor. Mild: Slightly tense fundus that is easy to indent with fingertips (feels like touching finger to tip of nose) Moderate: Firm fundus that is difficult to indent with fingertips (feels like touching finger to chin) Strong: Rigid boardlike fundus that is almost impossible to indent with fingertips (feels like touching finger to forehead) You must consider uterine activity in the context of its effect on cervical effacement and dilation and on the degree of descent of the presenting part. Vaginal examination -The vaginal examination reveals whether the woman is in true labor and enables the examiner to determine whether the membranes have ruptured -Test is often stressful and uncomfortable for the woman. -For example, you should perform a vaginal examination on admission, prior to administering medications (e.g., analgesics, increasing oxytocin infusion), when significant change has occurred in uterine activity, on maternal perception of perineal pressure or the urge to bear down, when membranes rupture, or when you note variable decelerations of the FHR. A full explanation of the examination and support of the woman are important in reducing the stress and discomfort associated with the examination -Cervical effacement, dilation, fetal descent Laboratory and diagnostic tests: Analysis of urine specimen: A clean-catch urine specimen may be obtained to gather further data about the pregnant woman's health. Analysis of the specimen is a convenient and simple procedure that can provide information about her hydration status (e.g., specific gravity, color, amount), nutritional status (e.g., ketones), infection status (e.g., leukocytes), or the status of possible complications such as preeclampsia, shown by finding protein in the urine. Blood tests: -Hematocrit -Complete blood count (CBC) -Human immunodeficiency virus (HIV) status is undocumented -Type and screen: to determine the woman's blood type and Rh status. -Assessment of amniotic membranes and fluid -Other Tests. If the woman's group B streptococci status is not known, a rapid test may be done on admission. The rapid test results are usually available within an hour or so and will determine if the woman must be given antibiotics during labor. Assessment of Amniotic Membranes and Fluid. Labor is initiated at term by SROM in approximately 25% of pregnant women. A lag period, rarely exceeding 24 hours, may precede the onset of labor. Membranes (the BOW) also can rupture spontaneously any time during labor, but most commonly in the transition phase of the first stage of labor. The Procedure box: Tests for Rupture of Membranes explains how to determine if membranes are ruptured. If the membranes do not rupture spontaneously, the BOW will likely be ruptured artificially at some time during labor. Artificial rupture of membranes (AROM), called an amniotomy, is performed by the physician or certified nurse-midwife using a plastic AmniHook or a surgical clamp. Signs of potential problems

Nonpharmacologic Pain Management

Nonpharmacologic Pain Management: -With increasing use of epidural analgesia, nurses may be less likely to encourage women to use nonpharmacologic measures, in part because these methods may be viewed as more complex and time consuming than monitoring a woman receiving an epidural. Additionally, new nurses may not have had the opportunity to develop skill in the implementation of these methods, imperative for patient to have practice and nurse to have expertise in teaching. -Drinking herbal tea, relaxing of muscles stroked by coach, quiet and relaxed environment. Childbirth preparation methods: Relaxing and breathing techniques Focusing and relaxation: By reducing tension and stress, focusing and relaxation techniques allow a woman in labor to rest and to conserve energy for the task of giving birth. Focus on object or image in their head to take away from the feeling of pain or distract. Breathing techniques: -Different approaches to childbirth preparation stress varying breathing techniques to provide distraction, thereby reducing the perception of pain and helping the woman maintain control throughout contractions. -In the first stage of labor such breathing techniques can promote relaxation of the abdominal muscles and thereby increase the size of the abdominal cavity. -In the second stage, breathing is used to increase abdominal pressure and thereby assist in expelling the fetus. Breathing also can be used to relax the pudendal muscles to prevent precipitate expulsion of the fetal head -All patterns begin with a deep, relaxing, cleansing breath to "greet the contraction" and end with another deep breath exhaled to "gently blow the contraction away." These deep breaths ensure adequate oxygen for mother and baby and signal that a contraction is beginning or has ended. As the breath is exhaled, respiratory and voluntary muscles relax. Effleurage and counterpressure: -Effleurage (light massage) and counterpressure have brought relief to many women during the first stage of labor. The gate control theory may supply the reason for the effectiveness of these measures. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions, distracts the woman from pain. -Counterpressure is steady pressure applied by a support person to the sacral area with a firm object (e.g., tennis ball) or the fist or heel of the hand. Application of counterpressure helps the woman cope with the sensations of internal pressure and pain in the lower back. -Counterpressure lifts the occiput off these nerves, thereby providing pain relief. Touch and massage: Touch and massage have been an integral part of the traditional care process for women in labor. A variety of massage techniques have been shown to be safe and effective during labor. Therapeutic touch: Application of heat and cold: -Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad can enhance relaxation and reduce pain during labor. Heat relieves muscle ischemia and increases blood flow to the area of discomfort. Heat application is effective for back pain caused by a posterior presentation or general backache from fatigue. -Cold application such as cold cloths, frozen gel packs, or ice packs applied to the back, the chest, and/or the face during labor may be effective in increasing comfort when the woman feels warm. -Heat and cold may be used alternately for a greater effect. Neither heat nor cold should be applied over ischemic or anesthetized areas because tissues can be damaged Acupress and Acupuncture: Acupressure and acupuncture can be used in pregnancy, in labor, and postpartum to relieve pain and other discomforts. Pressure, heat, or cold is applied to acupuncture points called tsubos. These points have an increased density of neuroreceptors and increased electrical conductivity. Acupressure is said to promote circulation of blood, the harmony of yin and yang, and the secretion of neurotransmitters, thus maintaining normal body functions and enhancing well-being. Transcutaneous electrical nerve stimulation Water therapy (hydrotherapy): -Bathing, showering, and jet hydrotherapy (whirlpool baths) with warm water (e.g., at or below body temperature) are nonpharmacologic measures that can promote comfort and relaxation during labor. -The warm water stimulates the release of endorphins, relaxes fibers to close the gate on pain, promotes better circulation and oxygenation and helps to soften the perineal tissues. Music: Music, recorded or live, can provide a distraction, enhance relaxation, and lift spirits during labor, thereby reducing the woman's level of stress, anxiety, and perception of pain. It can be used to promote relaxation in early labor and to stimulate movement as labor progresses. Transcutaneous Electrical Nerve Stimulation: Electrodes provide continuous low-intensity electrical impulses or stimuli from a battery operated device. During a contraction the woman increases the stimulation from low to high intensity by turning control knobs on the device. Intradermal water block: An intradermal water block involves the injection of small amounts of sterile water (e.g., 0.05 to 0.1 ml) by using a fine needle (e.g., 25 gauge) into four locations on the lower back to relieve low back pain. It is a simple procedure that can be performed by the nurse and is effective in early labor and in an effort to delay the initiation of pharmacologic pain relief measures. Aromatherapy: Aromatherapy uses oils distilled from plants, flowers, herbs, and trees to promote health and to treat and balance the mind, body, and spirit. These essential oils are highly concentrated, complex essences, and are mixed with lotions or creams before they are applied to the skin. Certain essential oils can tone the uterus, encourage contractions, reduce pain, relieve tension, diminish fear and anxiety, and enhance the feeling of well-being. -Lavender, rose, and jasmine oils can promote relaxation and reduce pain. -Rose oil also acts as an antidepressant and uterine tonic, while jasmine oil strengthens contractions and decreases feelings of panic in addition to reducing pain. -Essential oils of bergamot or rosemary can be diffused or used in a massage oil to relieve exhaustion Hypnosis: Hypnosis is a form of deep relaxation, similar to daydreaming or meditation. While under hypnosis women are in a state of focused concentration and the subconscious mind can be more easily accessed. Hypnosis techniques used for labor and birth place an emphasis on enhancing relaxation and diminishing fear, anxiety, and perception of pain. Current evidence suggests that hypnosis seems to reduce fear, tension, and pain during labor and to raise the pain threshold Biofeedback: Biofeedback may provide another relaxation technique that can be used for labor. Biofeedback is based on the theory that if a person can recognize physical signals, certain internal physiologic events can be changed (i.e., whatever signs the woman has that are associated with her pain). For biofeedback to be effective, the woman must be educated during the prenatal period to become aware of her body and its responses and how to relax.

Obstetric Procedures: Induction of Labor

The chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about birth Labor may be induced either electively or for indicated reasons. -Induction of labor is indicated if continuing the pregnancy could be dangerous for either the woman or the fetus, and if no contraindications exist to artificial rupture of the membranes (amniotomy) or augmenting uterine contractions with oxytocin. Elective induction of labor -Labor is initiated without a medical indication. -Many are for the convenience of the woman or her primary health care provider. Risks: Increased rates of cesarean birth Increased neonatal morbidity Increased cost Elective induction of labor should not be initiated until the woman reaches 39 completed weeks of gestation. Bishop's score -A rating system used to evaluate inducibility or cervical ripeness Cervical ripening methods Chemical agents: Chemical Agents. Preparations of prostaglandins E1 (PGE1) and E2 (PGE2) have been shown to be effective when used before induction to "ripen" (soften and thin) the cervix. Mechanical and physical methods -Mechanical dilators ripen the cervix by stimulating the release of endogenous prostaglandins. Balloon catheters (e.g., Foley catheter) can be inserted through the intracervical canal to ripen and dilate the cervix. The catheter balloon is inflated above the internal cervical os with 30 to 50 ml of sterile water. This process results in pressure and stretching of the lower uterine segment and the cervix, as well as the release of endogenous prostaglandins. -Hydroscopic dilators (substances that absorb fluid from surrounding tissues and then enlarge) also can be used for cervical ripening. Laminaria tents (natural cervical dilators made from desiccated seaweed) and synthetic dilators containing magnesium sulfate. -Hydroscopic dilators compare favorably with prostaglandins in terms of their effectiveness in ripening the cervix but are associated with increased discomfort at insertion and during expansion and with a higher incidence of postpartum maternal and newborn infections -Physical methods such as sexual intercourse (prostaglandins in the semen and stimulation of contractions with orgasm), nipple stimulation (release of endogenous oxytocin from the pituitary gland), and walking (gravity applies pressure to the cervix, which stimulates the secretion of endogenous oxytocin) may be used by women to "self-induce" labor in an effort to "get it over with." Alternative methods -Blue cohosh and castor oil can be used for their labor stimulation effects and black cohosh and evening primrose oil can ripen the cervix. -Acupuncture Amniotomy Amniotomy (i.e., artificial rupture of membrane [AROM]) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if progress begins to slow. Labor usually begins within 12 hours of the rupture. Amniotomy can decrease the duration of labor by up to 2 hours, even without oxytocin administration Oxytocin Hormone normally produced by the posterior pituitary gland, which stimulates uterine contractions and aids in milk let-down Synthetic oxytocin (Pitocin) may be used either to induce labor or to augment labor that is progressing slowly because of inadequate uterine contractions.

Postpartum Depression

Disorders of Mood: Postpartum Depression -A depressive illness, usually manifested after 2 weeks of delivery. -Decreased interest/pleasure in previously enjoyed activities. Signs and Symptoms -decreased appetite -Insomnia -fatigue -confusion -withdrawal -decreased self-esteem -suicidal thoughts Collaborative management -Selective Serotonin reuptake inhibitors are first line agents. -Hospitalization as needed. -Assess mother/infant interaction -Assess child neglect/social needs

Maternal Psychological Adjustment

Rubin described maternal postpartum changes in 3 phrases: taking in taking hold letting go

Musculoskeletal System

-Adaptations of system are reversed, these adaptations include the relaxation and subsequent hypermobility of the joints and the change in the mother's center of gravity in response to the enlarging uterus. -Joints are stabilized 6 to 8 weeks after birth.

Neurologic System

-Changes result from reversal of maternal adaptations to pregnancy and from trauma during labor and childbirth. -Pregnancy-induced neurologic discomforts abate after birth. -Headaches are common in the first postpartum week.

Respiratory System

-Immediate decrease in intraabdominal pressure at birth -Decreased pressure on the diaphragm -Reduced pulmonary blood flow -Chest wall compliance increases -The decline in progesterone that occurs with loss of the placenta causes Paco2 levels to rise.

Nursing Care of the Postpartum Woman

-Nurse provides family-centered care that focuses on assessment and support of a woman's physiologic and emotional adaptation after birth -Care is wellness oriented -Typical hospital stay is 1 to 2 days after vaginal birth, much needs to be taught in a short period of time. -The greatest risk associated with early discharge is for the infant who may develop jaundice, feeding difficulties, infection, or unrecognized respiratory or cardiac problems.

Reproductive Systemand Associated Structures

-Postpartum (PP) period is the interval between birth and return of the reproductive organs to their nonpregnant state. -This period is sometimes known as the puerperium, or fourth trimester of pregnancy. Although the puerperium has traditionally been considered to last 6 weeks, this time frame varies among women. Uterus Involution process Contractions Afterpains Placental site

Obstetric Procedures:Cesarean Birth Overview

Birth of a fetus through a transabdominal incision of the uterus to preserve the well-being of the mother and her fetus Cesarean birth rate in the United States has been over 32% since the early 2000s VBAC = Vaginal birth after cesarean TOLAC = Trial of labor after cesarean -A trial of labor (TOL) is the observance of a woman and her fetus for a reasonable period (e.g., 4 to 6 hours) of spontaneous active labor to assess the safety of vaginal birth for the mother and infant. It may be initiated if the mother's pelvis is of questionable size or shape or if the fetus is in an abnormal presentation or position. Elective Cesarean Birth: Cesarean birth on demand for reasons such as previous vaginal bad experiences, fear. Scheduled cesarean birth: Cesarean birth is scheduled or planned if labor and vaginal birth are contraindicated (e.g., complete placenta previa, active genital herpes, positive HIV status with a high viral load), Unplanned cesarean birth: The psychosocial outcomes of unplanned or emergency cesarean birth are usually more pronounced and negative when compared with the outcomes associated with a scheduled or planned cesarean birth. Forced cesarean birth: If the woman continues to refuse surgery, then health care providers must decide if it is ethical to get a court order for the surgery. Every effort, however, should be made to avoid this legal step Complications and risks: -Possible maternal complications related to cesarean birth include aspiration, hemorrhage, atelectasis, endometritis, abdominal wound dehiscence or infection, urinary tract infection, injuries to the bladder or bowel, and complications related to anesthesia. -Longer recovery period -More expensive Anesthesia: -Spinal, epidural, and general anesthetics are used for cesarean births. Epidural blocks are popular because women want to be awake for and aware of the birth experience. However, the choice of anesthetic depends on several factors. The mother's medical history or present condition, such as a spinal injury, hemorrhage, or coagulopathy, may rule out the use of regional anesthesia -In an emergency, general anesthesia will most likely be used unless the woman already has an epidural block in effect. The woman herself is a factor. Either she may not know all the options or may have fears about having "a needle in her back" or about being awake and feeling pain Prenatal preparation: No woman can be guaranteed a vaginal birth, even if she is in good health and no indication of danger to the fetus exists before the onset of labor. Therefore, every woman needs to be aware of and prepared for the possibility of having a cesarean birth Preoperative care: Family-centered care is the goal for the woman who is to undergo cesarean birth and for her family. The preparation of the woman for cesarean birth is the same as that for other elective or emergency surgery. The primary health care provider discusses, with the woman and her family, the need for the cesarean birth and the prognosis for the mother and infant. A member of the anesthesia care team assesses the woman's cardiopulmonary status and describes the options for anesthesia. Women who are scheduled for an elective cesarean are often told to remain NPO (nothing by mouth) for at least 8 hours prior to the surgery. Immediate postoperative care: Once surgery is completed, the mother is transferred to a postanesthesia recovery area. After a cesarean birth, women have postoperative and postpartum needs that must be addressed. They are surgical clients as well as new mothers. Postoperative postpartum care: The caregivers should stress that the woman is a new mother first and a surgical client second. This attitude helps the woman perceive herself as having the same problems and needs as other new mothers, while requiring supportive postoperative care. Nursing interventions Trial of labor Vaginal birth after cesarean

Postpartum Hemorrhage (PPH)

Definition and incidence Traditionally defined as follows: -Loss of 500 ml of blood after vaginal birth -Loss of 1000 ml after cesarean birth -A 10% change in hematocrit between labor and postpartum -Leading cause of maternal morbidity and mortality -Often unrecognized until mother has profound symptoms -Often as much as 50% of blood loss. -PPH is classified as early or late with respect to the birth. -Early, acute, or primary PPH occurs within 24 hours of the birth -Late or secondary PPH occurs more than 24 hours but less than 6 weeks after the birth.

Fetal Lie, Fetal Attitude, Fetal Position

Fetal Lie: Lie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. -The two primary lies are longitudinal, or vertical, in which the long axis of the fetus is parallel with the long axis of the mother and transverse, horizontal or oblique in which the long axis of the fetus is at a right angle diagonal to the long axis of the mother. -Longitudinal lies are either cephalic or breech presentation. -Vaginal births cannot occur if the fetus stays in a transverse lie. -An oblique lie, one in which the long axis of the fetus is lying at an angle to the long axis of the mother, is less common and usually converts to a longitudinal or transverse lie during labor. Fetal Attitude: Fetal flexion - chin flexed to chest, extremities flexed into the torso(Occiput or Vertex) Fetal extension - chin extended away from the chest, extremities extended -Attitude is the relation of the fetal body parts to each other. General Flexion: Normally the back of the fetus is rounded so that the chin is flexed on the chest, the thighs are flexed on the abdomen, and the legs are flexed at the knees. The arms are crossed over the thorax, and the umbilical cord lies between the arms and the legs. This attitude is termed general flexion. -Deviations from the normal attitude may cause difficulties in childbirth. For example, in a cephalic presentation, the fetal head may be extended or flexed in a manner that presents a head diameter that exceeds the limits of the maternal pelvis, leading to prolonged labor, forceps or vacuum-assisted birth, or cesarean birth Critical measurements of fetal head: -The biparietal diameter, which is about 9.25 cm at term, is the largest transverse diameter and an important indicator of fetal head size. -Of the several anteroposterior diameters, the smallest and the most critical one is the suboccipitobregmatic diameter. When the head is in complete flexion, this diameter allows the fetal head to pass through the true pelvis easily. As the head is more extended, the anteroposterior diameter widens, and the head may not be able to enter the true pelvis Fetal Position: -Position is the relationship of a reference point on the presenting part (occiput, sacrum, mentum [chin], or sinciput [deflexed vertex]) to the four quadrants of the mother's pelvis. -The first letter of the abbreviation denotes the location of the presenting part in the right (R) or left (L) side of the mother's pelvis. The middle letter(s) stands for the specific presenting part of the fetus (O for occiput, S for sacrum, M for mentum [chin], and Sc for scapula [shoulder]). The final letter stands for the location of the presenting part in relation to the anterior (A), posterior (P), or transverse (T) portion of the maternal pelvis. -For example, ROA means that the occiput is the presenting part and is located in the right anterior quadrant of the maternal pelvis, LSP, Left Sacral Posterior Quadrant. -Station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines and is a measure of the degree of descent of the presenting part of the fetus through the birth canal. When the lowermost portion of the presenting part is 1 cm above the spines, it is noted as being minus (−) 1. At the level of the spines, the station is 0. When the presenting part is 1cm below the spines, +1. -Birth is imminent when the presenting part is at +4 to +5 cm. -Engagement is the term used to indicate that the largest transverse diameter of the presenting part (usually the biparietal diameter) has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station 0.

Dysfunctional Labor (Dyscotia)

Long, difficult, or abnormal labor Most common indication for c-section. Five factors affect labor -Ineffective uterine contractions or maternal bearing-down efforts (the powers) -Alterations in the pelvic structure (the passage) -Fetal causes, including abnormal presentation or position, anomalies, excessive size, and number of fetuses (the passenger) -Maternal position during labor and birth -Psychologic responses of the mother to labor related to past experiences, preparation, culture and heritage, and support system. Dyscotia Causes: Abnormal uterine activity: -Can be further described as being hypertonic or hypotonic. Contractions may be frequent and painfully strong with hypertonic uterine activity, but ineffective at promoting cervical effacement and dilation. With hypotonic uterine activity, the rise in uterine pressure generated during contractions is insufficient to promote cervical effacement and dilation. Hypertonic uterine dysfunction: -Hypertonic uterine dysfunction, or primary dysfunctional labor, often is an anxious first-time mother who is having painful and frequent contractions that are ineffective in causing cervical dilation or effacement to progress. -These contractions usually occur in the latent phase of first stage labor. Therapeutic rest: Achieved with a warm bath or shower and the administration of an analgesic such as morphine, to inhibit uterine contractions, reduce pain, and encourage sleep, is usually prescribed to manage hypertonic uterine dysfunction. Hypotonic Uterine Dysfunction: Hypptonic uterine dysfunction or secondary uterine inertia. The woman initially makes normal progress into the active phase of first stage labor but then the contractions become weak and inefficient or stop altogether Secondary powers: -Secondary powers, or bearing-down efforts, are compromised when large amounts of analgesia are given. Anesthesia may also block the bearing-down reflex and, as a result, alter the effectiveness of voluntary bearing-down efforts. -Exhaustion resulting from lack of sleep or long labor, and fatigue resulting from inadequate hydration and food intake reduce the effectiveness of the woman's voluntary bearing-down efforts. -Maternal position can work against the forces of gravity and decrease the strength and efficiency of the contractions. Abnormal labor patterns: -Friedman's classification of "normal" labor patterns Updated, evidence-based awareness of "normal" labor -These patterns include: (1) prolonged latent phase (2) protracted active phase dilation (3) secondary arrest: no change (4) protracted descent (5) arrest of descent (6) failure of descent Precipitous labor: -Precipitous labor is defined as labor that lasts less than 3 hours from the onset of contractions to the time of birth. This abnormal labor pattern occurs in approximately 2% of all births in the United States. Precipitous birth alone is not usually associated with significant maternal or infant morbidity or mortality -Maternal complications can include uterine rupture, lacerations of the birth canal, anaphylactoid syndrome of pregnancy (amniotic fluid embolism), and postpartum hemorrhage. Fetal complications include hypoxia caused by decreased periods of uterine relaxation between contractions and, in rare instances, intracranial trauma related to rapid birth. Alterations in pelvic structure: Pelvic dystocia Pelvic dystocia can occur whenever there are contractures of the pelvic diameters that reduce the capacity of the bony pelvis, including the inlet, the midpelvis, outlet, or any combination of these planes. Pelvic contractures may be caused by congenital abnormalities, maternal malnutrition, neoplasms, or lower spinal disorders. Soft-tissue dystocia Results from obstruction of the birth passage by an anatomic abnormality other than that of bony pelvis such as placenta previa. Fetal causes: Dystocia of fetal origin may be caused by anomalies, excessive fetal size (macrosomia), malpresentation, malposition, or multifetal pregnancy. Complications associated with dystocia of fetal origin include neonatal asphyxia, fetal injuries or fractures, and maternal vaginal lacerations. Although spontaneous vaginal birth is possible in these instances, a forceps-assisted, vacuum-assisted, or cesarean birth often is necessary. Anomalies: Gross ascites, large tumors, open neural tub defects (e.g., myelomeningocele), and hydrocephalus are examples of fetal anomalies that can cause dystocia. The anomalies affect the relationship of the fetal anatomy to the maternal pelvic capacity, with the result that the fetus is unable to descend through the birth canal. Cephalopelvic disproportion (CPD), also called fetopelvic disproportion (FPD): -Cephalopelvic disproportion (CPD), also called FPD, is disproportion between the size of the fetus and the size of the mother's pelvis. -With CPD, the fetus cannot fit through the maternal pelvis to be born vaginally. Although CPD is often related to excessive fetal size, or macrosomia (i.e., 4000 g or more), the problem in many cases is malposition of the fetal presenting part rather than true CPD Malposition: The most common fetal malposition is persistent occipitoposterior position (i.e., right occipitoposterior [ROP] or left occipitoposterior [LOP]; -Women often complains of extreme back pain as a result of the pressure of the fetal head (occiput) pressing against her sacrum. Malpresentation: -Malpresentation (the fetal presentation is something other than cephalic or head first) is another commonly reported complication of labor and birth. Breech presentation is the most common form of malpresentation, occurring in 3% to 4% of all labors -Diagnosis is made by abdominal palpation (e.g., Leopold maneuvers) and vaginal examination and usually confirmed by ultrasound scan. Criteria for attempting a breech presentation birth are as follows: • Frank or complete breech presentation • Estimated fetal weight between 2000 and 3800 g • Normal (gynecoid) maternal pelvis • Flexed fetal head -External cephalic version (ECV) may be tried to turn the fetus to a vertex presentation Multifetal pregnancy: -Multifetal pregnancy is the gestation of twins, triplets, quadruplets, or more infants -Multiple births are associated with more complications (e.g., dysfunctional labor) than single births. Position of the woman Maternal position alters relationship between uterine contractions, fetus, and mother's pelvis Psychologic responses Hormones and neurotransmitters released in response to stress can cause dystocia (dysfunctional labor) -Anxiety increases stress related hormone levels. Sources of stress and anxiety vary

Factors Affecting Labor: Passageway

Passageway: Birth canal Process of Labor: Labor: process of moving fetus, placenta, and membranes out of the uterus and through the birth canal Signs preceding labor: In first-time pregnancies the uterus sinks downward and forward about 2 weeks before term, when the fetus's presenting part (usually the fetal head) descends into the true pelvis. This settling is called lightening, or "dropping," and usually happens gradually. -Lightening allows easier breathing and less feeling of congestion but more pressure on the bladder causing urinary frequency. -In a pregnancy in a multiparous woman, lightening may not take place until after uterine contractions are established and true labor is in progress. -She may identify strong and frequent but irregular uterine (Braxton Hicks) contractions or lower back pain. -The vaginal mucus becomes more profuse -The thick mucus that has obstructed the cervical canal since conception is passed (commonly referred to as the mucous plug) -Weight loss due to water loss. -Burst of energy -Diarrhea, nausea, vomiting, indigestion. Bloody show: -Brownish or blood-tinged cervical mucus may be passed Onset of labor: -The onset of true labor cannot be ascribed to a single cause. Many factors, including changes in the maternal uterus, cervix, and pituitary gland, are involved -Hormones produced by the normal fetal hypothalamus, pituitary, and adrenal cortex probably contribute to the onset of labor. -Coordinated effects of these factors result in the occurrence of strong, regular, rhythmic uterine contractions. Stages of labor First stage Latent phase Active phase Transition phase Second stage Third stage Fourth stage First Stage of Labor: -The first stage of labor is considered to last from the onset of regular uterine contractions to full effacement and dilation of the cervix. -Much longer than second or third stage combined. -Parity has a strong effect on the duration of first stage labor. -Full dilation may occur in less than 1 hour in some multiparous pregnancies. In first-time pregnancy, complete dilation of the cervix can take 20 hours or more. -The first stage of labor is divided into three phases: a latent phase, an active phase, and a transition phase. During the latent phase there is more progress in effacement of the cervix and little increase in descent. During the active phase and the transition phase, there is more rapid dilation of the cervix and increased rate of descent of the presenting part. Maternal prepregnancy overweight and obesity can cause the active phase of labor to be longer than for women of normal weight. Latent: 0-3 cm Active: 4-7 cm Transition: 8-10 cm Second Stage of Labor: -The second stage of labor lasts from the time the cervix is fully effaced and dilated to the birth of the fetus. -The second stage takes an average of 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman, labor for up to 2 hours is considered normal. Latent Phase: Passive decent of the fetus, rotates to an anterior position as a result of ongoing uterine contractions. Active Phase: Active decent with maternal pushing efforts. Transition Phase: expulsion of fetus Third Stage of Labor: -Delivery of Infant Through Delivery of Placenta -Placenta is usually delivered after the third or fourth strong contraction after the infant has been born. -Usually no longer than 30 minutes -Placenta usually delivered 10-15 minutes after the baby. -Signs of placental separation; gush of blood, lengthening of the umbilical cord, a change in shape of the uterine fundus from discoid to globular with elevation of the fundal height -Patient is relieved and bonding with infant -Uterus should be firm and bleeding controlled Fourth Stage of Labor: -First Two Hours After Delivery of Placenta -Patient is focused on infant -Involution begins -Patient is usually happy -Vital signs, fundal/ lochia checks every 15 minutes for a minimum of 2 hours -Commonly see bradycardia related to sudden increase in circulating blood volume that is no longer perfusing the placenta Mechanism of labor -The turns and other adjustments necessary in the human birth process are termed the mechanism of labor -Fetus must adapt to the birth canal. Seven cardinal movements of mechanism of labor: Engagement: -When the biparietal diameter of the head passes the pelvic inlet, the head is said to be engaged in the pelvic inlet. In most nulliparous pregnancies, this occurs before the onset of active labor because the firmer abdominal muscles direct the presenting part into the pelvis. In multiparous pregnancies, in which the abdominal musculature is more relaxed, the head often remains freely movable above thepelvic brim until labor is established. -Asynclitism. The head usually engages in the pelvis in a synclitic position— one that is parallel to the anteroposterior plane of the pelvis. Descent: Descent refers to the progress of the presenting part through the pelvis. Descent depends on at least four forces: (1) pressure exerted by the amniotic fluid (2) direct pressure exerted by the contracting fundus on the fetus (3) force of the contraction of the maternal diaphragm and abdominal muscles in the second stage of labor (4) extension and straightening of the fetal body. The effects of these forces are modified by the size and shape of the maternal pelvic planes and the size of the fetal head and its capacity to mold. -The degree of descent is measured by the station of the presenting part -Little descent occurs during the latent phase of the first stage of labor. Descent accelerates in the active phase when the cervix has dilated to 4 to 7 cm. It is especially apparent when the membranes have ruptured. -First time pregnancy descent is usually slow. -Progress in descent of the presenting part is determined by abdominal palpation (Leopold maneuvers) and vaginal examination until the presenting part can be seen at the introitus. Flexion: As soon as the descending head meets resistance from the cervix, pelvic wall, or pelvic floor, it normally flexes, so that the chin is brought into closer contact with the fetal chest. Flexion permits the smaller suboccipitobregmatic diameter (9.5 cm) rather than the larger diameters to present to the outlet. Internal rotation: -The maternal pelvic inlet is widest in the transverse diameter; therefore the fetal head passes the inlet into the true pelvis in the occipitotransverse position. The outlet is widest in the anteroposterior diameter; for the fetus to exit, the head must rotate. Internal rotation begins at the level of the ischial spines but is not completed until the presenting part reaches the lower pelvis. As the occiput rotates anteriorly, the face rotates posteriorly. With each contraction the fetal head is guided by the bony pelvis and the muscles of the pelvic floor. Eventually the occiput will be in the midline beneath the pubic arch. The head is almost always rotated by the time it reaches the pelvic floor. Both the levator ani muscles and the bony pelvis are important for achieving anterior rotation. A previous childbirth injury or regional anesthesia may compromise the function of the levator sling. Extension: When the fetal head reaches the perineum for birth, it is deflected anteriorly by the perineum. The occiput passes under the lower border of the symphysis pubis first, and then the head emerges by extension: first the occiput, then the face, and finally the chin. Restitution and external rotation: After the head is born it rotates briefly to the position it occupied when it was engaged in the inlet. This movement is referred to as restitution Expulsion: After birth of the shoulders, the head and shoulders are lifted up toward the mother's pubic bone and the trunk of the baby is born by flexing it laterally in the direction of the symphysis pubis. When the baby has completely emerged, birth is complete, and the second stage of labor ends. Cardinal Movements Summary: Engagement: passage of the widest diameter of the presenting part to a level below the plane of the pelvic inlet Descent: the downward passage of the presenting part through the pelvis Flexion: occurs passively as the head descends owing to the shape of the bony pelvis and the resistance offered by the soft tissues of the pelvic floor Internal rotation: rotation of the presenting part from its original position as it enters the pelvic inlet (usually OT) to the anteroposterior position as it passes through the pelvis Extension: once the fetus has descended to the level of the introitus External rotation or restitution: the return of the fetal head to the correct anatomic position in relation to the fetal torso Expulsion: refers to delivery of the rest of the fetus

Plan of care and interventions

Plan of care and interventions Standards of care Physical nursing care during labor General hygiene: -Offer women in labor the use of showers or warm water baths, if they are available, to enhance the feeling of well-being and to minimize the discomfort of contractions. -Offer hand cleansing foam - Nutrient and fluid intake: Oral intake: -Only clear liquids or ice chips -Nothing by mouth during the active phase of labor when concern arose regarding the risk of anesthesia complications and their secondary effects if general anesthesia were required in an emergency. -These secondary effects include the aspiration of gastric contents and resultant compromise in oxygen perfusion, which could endanger the lives of the mother and fetus -Withholding food and fluids in labor is unlikely to be beneficial, and offering oral fluids is demonstrably useful and should be encouraged. Nurses should follow the orders of the woman's primary health care provider when offering the woman food or fluids during labor. As advocates, however, nurses can facilitate change by informing others of the current research findings that support the safety and effectiveness of the oral intake of food and fluid during labor and by initiating such research themselves. Intravenous intake: -Fluids are administered intravenously to the laboring woman to maintain hydration, especially when a labor is long and the woman is unable to ingest a sufficient amount of fluid orally or if she is receiving epidural or intrathecal anesthesia. -In most cases an electrolyte solution without glucose (e.g., Ringer's lactate or normal saline) is adequate and does not introduce excess glucose into the bloodstream. -Excessive maternal glucose level results in fetal hyperglycemia and fetal hyperinsulinism. After birth the neonate's high level of insulin will reduce his or her glucose stores, and hypoglycemia will result. Elimination Voiding: -Encouraged atleast every 2 hours. -A distended bladder may impede descent of the presenting part, slow or stop uterine contractions, and lead to decreased bladder tone or uterine atony after birth. Catheterization: If the woman is unable to void and her bladder is distended, she may need to be catheterized. Many hospitals have protocols that rely on the nurse's judgment concerning the need for catheterization. Before performing the catheterization, clean the vulva and perineum because vaginal show and amniotic fluid may be present. If an obstacle that prevents advancement of the catheter is present, this obstacle is most likely the presenting part. If you cannot advance the catheter, stop the procedure and notify the primary health care provider of the difficulty. Bowel elimination: Most women do not have bowel movements during labor because of decreased intestinal motility. Stool that has formed in the large intestine often moves downward toward the anorectal area as a result of pressure exerted by the fetal presenting part as it descends. This stool is often expelled during second-stage pushing and birth. However, the passage of stool with bearing-down efforts increases the risk of infection and may embarrass the woman, thereby reducing the effectiveness of her pushing efforts Ambulation and positioning: Confinement to bed is the norm for labor management in the United States. The increased use of epidurals during childbirth accompanied by multiple medical interventions (e.g., monitors, intravenous infusions) and reduced motor control contribute to this practice, thereby interfering with a woman's freedom of movement. Upright positions and mobility during labor, however, may be more pleasant for laboring women. These practices have also been associated with improved uterine contraction intensity and shorter labors, less need for pain medications, reduced rate of operative birth (e.g., cesarean birth, forceps- and vacuum assisted birth), increased maternal autonomy and control, distraction from labor's discomforts, and an opportunity for close interaction with the woman's partner and care provider as they assist her to assume upright positions and remain mobile. Supportive care during labor and birth: emotional support, physical care and comfort measures, and advice/information: Women who have continuous support beginning in early labor are less likely to use pain medication or epidurals, more likely to have a spontaneous vaginal birth, and less likely to report dissatisfaction with their birth experience. No harmful effects from continuous labor support have been identified. Nurse: -Helping the woman maintain control and participate to the extent she wishes in the birth of her infant -Providing continuity of care that is nonjudgmental and respectful of her cultural and religious values and beliefs -Meeting the woman's expected outcomes for her labor -Listening to the woman's concerns and encouraging her to express her feelings -Acting as the woman's advocate, supporting her decisions and respecting her choices as appropriate, and relating her wishes as needed to other health care providers -Helping the woman conserve her energy and cope effectively with her pain and discomfort by using a variety of comfort measures that are acceptable to her -Helping control the woman's discomfort -Acknowledging the woman's efforts during labor including her strength and courage, as well as those of her partner, and providing positive reinforcement -Protecting the woman's privacy, modesty, and dignity Father or partner: When the woman becomes focused on her pain, sometimes the partner can persuade her to try nonpharmacologic variations of comfort measures. In addition, he usually is able to interpret the woman's needs and desires for staff members. Doulas: The primary role of the doula is to focus on the laboring woman and to provide physical and emotional support by using soft, reassuring words of praise and encouragement; touching; stroking; and hugging. The doula also administers comfort measures to reduce pain and enhance relaxation and coping, walks with the woman, helps her to change positions, and coaches her bearing-down efforts. Doulas provide information about labor progress and explain procedures and events. Grandparents: They may have a way to deal with pain relief based on their experience. Grandparents should be encouraged to help as long as their actions do not compromise the status of the mother or the fetus Siblings during labor and birth: Preparing siblings for acceptance of the new child helps promote the attachment process and may help the older children accept this change Emergency interventions: Emergency conditions that require immediate nursing intervention can arise with startling speed. The

Powers, Position of the Laboring Woman

Powers: Involuntary and voluntary powers combine to expel the fetus and the placenta from the uterus. Involuntary uterine contractions, called the primary powers, signal the beginning of labor. Once the cervix has dilated, voluntary bearing-down efforts by the woman, called the secondary powers, augment the force of the involuntary contractions. Primary Powers: -The involuntary contractions originate at certain pacemaker points in the thickened muscle layers of the upper uterine segment. -Terms used to describe these involuntary contractions include frequency (the time from the beginning of one contraction to the beginning of the next), duration (length of contraction), and intensity (strength of contraction at its peak). -The primary powers are responsible for the effacement and dilation of the cervix and descent of the fetus. -Effacement of the cervix means the shortening and thinning of the cervix during the first stage of labor. -The cervix, normally 2 to 3 cm long and about 1 cm thick, is obliterated or "taken up" by a shortening of the uterine muscle bundles during the thinning of the lower uterine segment that occurs in advancing labor. -Effacement degree is usually expressed in percentages. Dilation: -The enlargement or widening of the cervical opening and the cervical canal that occurs once labor has begun. The diameter of the cervix increases from less than 1 cm to full dilation (approximately 10 cm) to allow birth of a term fetus. Full dilation marks the end of the first stage of labor. Secondary Powers: -Valsalva maneuver -As soon as the presenting part reaches the pelvic floor, the contractions change in character and become expulsive. -The laboring woman experiences an involuntary urge to push. -The woman aids in expulsion of the fetus as she contracts her diaphragm and abdominal muscles and pushes, adds to the power of contraction forces. -The secondary powers have no effect on cervical dilation, but they are of considerable importance in the expulsion of the infant from the uterus and vagina after the cervix is fully dilated. Position of the Laboring Woman: -An upright position (walking, sitting, kneeling, or squatting) offers a number of advantages. Gravity can promote the descent of the fetus. Uterine contractions are generally stronger and more efficient in effacing and dilating the cervix, resulting in a shorter labor. -An upright position also is beneficial to the mother's cardiac output, increased blood flow to uteroplacental unit and the maternal kidneys, CO is compromised if the vena cava and descending aorta are obstructed, so a lateral position is suggested if the woman wishes to lay down. -The "all fours" position (hands and knees) may be used to relieve backache if the fetus is in an occipitoposterior position and may assist in anterior rotation of the fetus and in cases of shoulder dystocia. -The predominant position in the United States in physician-attended births is the lithotomy position. -A woman who pushes in a semirecumbent position needs adequate body support to push effectively because her weight will be on her sacrum, moving the coccyx forward and causing a reduction in the pelvic outlet. In a sitting or squatting position, abdominal muscles work in greater synchrony with uterine contractions. -The lateral position can be used by the woman to help rotate a fetus that is in a posterior position

Lactation

Teach lactation. Success strategies: by IBCLC. Facilitate latching on proper positioning. Demonstration. -Mothers progress from exploratory touching to enfolding the infant. Pleasure is enhanced by skin-to-skin contact. -Normal everted nipple and other types of nipples that may cause the infant difficulty in latching on. -Nipples shown after stimulation -Rolling helps flat nipples become erect in preparation for latch-on

Postpartum Hemorrhage (PPH): Care Management

-Early recognition and treatment of PPH are critical. Hypotonic Uterus: -The initial intervention is firm massage of the uterine fundus. -Expression of any clots in the uterus -Elimination of bladder distention -Continuous intravenous (IV) infusion of 10 to 40 units of oxytocin added to 1000 ml IV fluid -Additional uterotonic medications if the uterus fails tto respond to oxytocin.

Assessment of Lochia and Perineum

Assess lochia for: -Amount, color and odor -Presence of any clots -Wound is assessed for approximation, redness, edema, ecchymosis and discharge -Presence of hemorrhoids -Level of comfort or discomfort -Efficacy of any comfort measures

Fetal Assessments During Labor:

Fetal Assessments During Labor: Indications for Monitoring Active labor Meconium stained amniotic fluid Abruption placenta - suspected or actual Abnormal non-stress test or contraction stress test Abnormal uterine contractions Fetal distress Multiple gestations, oxytocin (Pitocin) infusion Placenta previa Fetal bradycardia Maternal complications (diabetes mellitus, gestational hypertension, kidney disease) Intrauterine growth restriction Postdate Evaluating Fetal Heartrate: Fetoscope with head attachment to enhance faint fetal heart sounds. Transmission gel improves clarity of fetal heart movement sensed by the Doppler ultrasound transducer. Evaluating Fetal Heartrate During Labor: -This is a low intervention method for evaluating FHR during labor. Fetoscope with a head attachment to enhance faint fetal heart sounds. Transmission gel improves clarity of fetal heart movement sensed by the Doppler ultrasound transducer. -The uterine activity transducer is applied to the woman's upper abdomen, in the fundal area. The Doppler transducer for sensing FHR is placed on the lower abdomen when the fetus is in the cephalic presentation. Fetal Heartrate Patterns Baseline fetal heart rate: -The intrinsic rhythmicity of the fetal heart, the central nervous system (CNS), and the fetal autonomic nervous system control the FHR. An increase in sympathetic response results in acceleration of the FHR, whereas an increase in parasympathetic response produces a slowing of the FHR. -The baseline fetal heart rate is the average rate during a 10-minute segment that excludes periodic or episodic changes, periods of marked variability, and segments of the baseline that differ by more than 25 beats/min. There must be at least 2 minutes of interpretable baseline data in a 10-minute segment of tracing in order to determine the baseline FHR Average rate during a 10-minute segment that excludes: -Periodic or episodic changes -Periods of marked variability -Segments of the baseline that differ by more than 25 beats/min -There must be at least 2 minutes of interpretable data Characteristics of Fetal Heart Rate: Changes in FHR patterns are categorized as episodic or periodic changes Episodic changes are not associated with uterine contractions Periodic changes occur with uterine contractions; they include accelerations and decelerations Baseline fetal heart rate Variability: -Fetal heart rate baseline variability is described as fluctuations in the FHR baseline that are irregular in frequency and amplitude. -Variability of the FHR can be described as irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater -It is a characteristic of the baseline FHR and does not include accelerations or decelerations of the FHR. Classification of variability is as follows: 4 possible categories of variability: Absence Minimal Moderate Marked -Absent or minimal variability is classified as either abnormal or indeterminate, It can result from fetal hypoxemia and metabolic acidemia. Other possible causes of absent or minimal variability include congenital anomalies and preexisting neurologic injury, CNS depressant medications, tachycardia, extreme prematurity, or when the fetus is temporarily in a sleep state. -Absent or undetectable variability; considered non-reassuring -Minimal variability; greater than undetectable but less than 5/min -Moderate variability, however, is considered normal, Its presence is highly predictive of a normal fetal acidbase balance, indicates that FHR regulation is not significantly affected by fetal sleep cycles, tachycardia, prematurity, congenital anomalies, preexisting neurologic injury, or CNS depressant medications. -Moderate variability; 6 to 25/min -Marked variability is an uncommon pattern which classically occurs with severe fetal anemia. -Marked variability; greater than 25/min Heart Rate Patterns Tachycardia: >160 beats/min 10 minutes or more Bradycardia: <110 beats/min 10 minutes or more Changes in FHR Changes in FHR from the baseline are categorized as periodic or episodic. -Periodic changes are those that occur with UCs. -Episodic changes are those that are not associated with UCs. Fetal Tachycardia: -FHR more than 160/ min for 10 min or more. It can be considered an early sign of fetal hypoxemia, especially when associated with late decelerations and minimal or absent variability. Fetal tachycardia can result from maternal or fetal infection, such as prolonged rupture of membranes with amnionitis; from maternal hyperthyroidism or fetal anemia; or in response to medications such as atropine, hydroxyzine (Vistaril), terbutaline (Brethine), or illicit drugs such as cocaine or methamphetamines. Causes: -Maternal infection, chorioamnionitis -Fetal anemia -Fetal heart failure -Fetal cardiac dysrhythmias -Maternal use of cocaine or methamphetamines -Maternal dehydration Interventions for Fetal Tachycardia -Administer prescribed antipyretics for maternal fever, if present -Administer oxygen by mask at 8-10 L/min -Administer IV fluid bolus Fetal bradycardia: -FHR less than 110/ min for 10 min or more, true bradycardia occurs rarely and is not specifically related to fetal oxygenation. True bradycardia must be distinguished from a prolonged deceleration because the causes and management of these two conditions are very different. Bradycardia is often caused by some type of fetal cardiac problem such as structural defects involving the pacemakers or conduction system or fetal heart failure. Other causes of bradycardia include viral infections (e.g., cytomegalovirus), maternal hypoglycemia, and maternal hypothermia. Causes: -Uteroplacental insufficiency -Prolapsed umbilical cord -Maternal hypotension -Prolonged umbilical cord compression -Fetal congenital heart block -Anesthetic medications Interventions -Discontinue oxytocin (Pitocin) if being administered -Assist the patient to a side-lying position -Administer oxygen by mask at 8 to 10 L/min -Insert an IV catheter if one is not in place -Administer a tocolytic medication as prescribed -Notify the provider Accelerations -Accelerations can be periodic or episodic. They may occur in association with fetal movement or spontaneously. If accelerations do not occur spontaneously, they can be elicited by fetal scalp stimulation or vibroacoustic stimulation. Similar to moderate variability, accelerations are considered an indication of fetal well-being. Their presence is highly predictive of a normal fetal acid-base balance (absence of fetal metabolic acidemia) Decelerations -A deceleration (caused by dominance of a parasympathetic response) may be benign or abnormal (nonreassuring). FHR decelerations are categorized as early, late, variable, or prolonged. They are described by their visual relation to the onset and end of a contraction and by their shape. -Early deceleration of the FHR is a visually apparent gradual (onset to lowest point ≥30 seconds) decrease in and return to baseline FHR associated with UCs. -Early decelerations may occur during uterine contractions, during vaginal examinations, as a result of fundal pressure, and during placement of the internal mode of fetal monitoring. -Early decelerations in response to fetal head compression and considered normal and benign finding, so intervention is not necessary. -When present, they usually occur during the first stage of labor when the cervix is dilated 4 to 7 cm. -Often considered the mirror image of a contraction. -Variable decelerations due to umbilical cord compression Late Decelerations -Late deceleration of the FHR is a visually apparent gradual decrease in and return to baseline FHR associated with UCs, deceleration begins once the contraction has started and the lowest point of the deceleration is after the peak of contraction, deceleration usually doesnt go back to baseline until after the contraction is over. -Late decelerations due to uteroplacental insufficiency, persistent late decelerations usually mean inadequate placental perfusion resulting in fetal hypoxemia. -Require nursing intervention to improve placental blood flow and fetal oxygen supply -Late deceleration of FHR is slowing of FHR after a contraction has started, with return of FHR to baseline well after contraction has ended -Maternal hypotension, abruptio placentae, uterine hyperstimulation with oxytocin (Pitocin) Variable Decelerations: -Defined as a visually abrupt (onset to lowest point less than 30 seconds) decrease in FHR below the baseline. -Caused by reduced flow through umbilical cord (cord compression) and occur at any time during the uterine contraction phase. -The shape, duration and degree of fall below baseline rate are variable -The fall and rise in rate is abrupt and require nursing intervention -Occasional variables have little clinical significance. Recurrent variable decelerations, however, indicate repetitive disruption in the fetus's oxygen supply. This can result in hypoxemia and metabolic acidemia -Most commonly found during the transition phase of first stage labor or the second stage of labor as a result of umbilical cord compression and stretching during fetal descent. Prolonged Decelerations: -A prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) in FHR of at least 15 beats/min below the baseline and lasting more than 2 minutes but less than 10 minutes. -Prolonged decelerations are caused by a disruption in the fetal oxygen supply. They usually begin as a reflex response to hypoxia. If the disruption continues, however, the fetal cardiac tissue itself will become hypoxic, resulting in direct myocardial depression of the FHR. -Prolonged decelerations may be caused by prolonged cord compression, profound uteroplacental insufficiency, or perhaps sustained head compression. -Significant stimuli that may result in prolonged decelerations are a prolapsed umbilical cord or other forms of prolonged cord compression, prolonged uterine tachysystole, hypotension after spinal or epidural anesthesia or analgesia, placental abruption, eclamptic seizure, and rapid fetal descent through the birth canal. FHR Monitoring: -Care Management: -Category I: normal Category I FHR tracings are normal and strongly predictive of normal fetal acidbase status at the time of observation. These tracings may be followed in a routine manner and do not require any specific action. -Category II: indeterminate This category includes all tracings that do not meet category I or category III criteria. Category II tracings require continued observation and evaluation. -Category III: abnormal -Immediate evaluation and prompt intervention is required when these patterns are identified. -Fetal monitoring standards -Nursing management of nonreassuring patterns

Key Points

The onset of labor may be difficult to determine for both nulliparous and multiparous women. The familiar environment of her home is most often the ideal place for a woman during the latent phase of the first stage of labor. The nurse assumes much of the responsibility for assessing the progress of labor and for keeping the nurse-midwife or physician informed about that progress and deviations from expected findings. The fetal heart rate and pattern reveal the fetal response to the stress of the labor process. Assessing the laboring woman's urinary output and bladder is critical to ensure her progress and to prevent bladder injury. Regardless of the actual labor and birth experience, the woman's or couple's perception of the birth experience is most likely to be positive when events and performances are consistent with expectations, especially in terms of maintaining control and adequacy of pain relief. The woman's level of anxiety may increase when she does not understand what is being said to her about her labor because of the medical terminology used or because of a language barrier. Coaching, emotional support, and comfort measures assist the woman to use her energy constructively in relaxing and working with the contractions. The progress of labor is enhanced when a woman changes her position frequently during the first stage of labor. Doulas provide a continuous, supportive presence during labor that can have a positive effect on the process of childbirth and its outcome. The cultural beliefs and practices of a woman and her significant others, including her partner, can have a profound influence on their approach to labor and birth. Siblings present for labor and birth need preparation and support for the event. Women with a history of sexual abuse often experience profound stress and anxiety during childbirth. Inability to palpate the cervix during vaginal examination indicates that complete effacement and full dilation have occurred, and they are the only certain, objective signs that the second stage has begun. Women may have an urge to bear down at various times during labor; for some it may be before the cervix is fully dilated, and for others it may not occur until the active phase of the second stage of labor. When encouraged to respond to the rhythmic nature of the second stage of labor, the woman normally changes body positions, bears down spontaneously, and vocalizes (open-glottis pushing) when she perceives the urge to push (Ferguson reflex). Women should bear down several times during a contraction using the open-glottis pushing method. They should avoid sustained closed-glottis pushing because this will inhibit oxygen transport to the fetus. Nurses can use the role of advocate to prevent routine use of episiotomy and reduce the incidence of lacerations by empowering women to take an active role in the birth and by educating health care providers about approaches to managing childbirth that reduce the incidence of perineal trauma. Objective signs indicate that the placenta has separated and is ready to be expelled; excessive traction (pulling) on the umbilical cord before the placenta has separated can result in maternal injury. During the fourth stage of labor, the woman's fundal tone, lochial flow, and vital signs should be assessed frequently to ensure that she is physically recovering well after giving birth. Most parents and families enjoy being able to hold, explore, and examine the baby immediately after the birth.

Key Points

Preterm birth is any birth that occurs between 20 0/7 and 36 6/7 weeks of gestation. Preterm labor is generally diagnosed clinically as regular contractions along with a change in cervical effacement or dilation or both or presentation with regular uterine contractions and cervical dilation of at least 2 cm. The incidence of preterm birth varies considerably by race. In the United States, non-Hispanic black women have the highest rate of preterm birth. The cause of preterm labor is unknown and is assumed to be multifactorial; therefore, it is not possible to predict with certainty which women will experience preterm labor and birth. Because the onset of preterm labor is often insidious and can be mistaken for normal discomforts of pregnancy, nurses should teach all pregnant women how to detect the early symptoms of preterm labor and to call their primary health care provider when symptoms occur. The best reason to use tocolytic therapy is to achieve sufficient time to administer glucocorticoids in an effort to accelerate fetal lung maturity. Additionally, time is allowed for transport of the woman prior to birth to a center equipped to care for preterm infants. If fetal or early neonatal death is expected, the parents and members of the health care team need to discuss the situation before the birth and decide on a management plan that is acceptable to everyone. Vigilance for signs of infection is an essential component of the care management for women with preterm PROM. Dysfunctional labor results from differences in the normal relationships among any of the five factors affecting labor and is characterized by differences in the pattern of progress in labor. Obese women are at risk for several pregnancy complications, including cesarean birth. Even routine procedures require more time and effort to accomplish when the client is obese. Uterine contractility is increased by the effects of oxytocin and prostaglandin and is decreased by tocolytic agents. Labor should not be induced electively until the woman has reached at least 39 weeks of gestation. Cervical ripening using chemical or mechanical measures can increase the success of labor induction. Expectant parents benefit from learning about operative obstetrics (e.g., forceps-assisted, vacuum-assisted, or cesarean birth) during the prenatal period. The basic purpose of cesarean birth is to preserve the well-being of the mother and her fetus. Unless contraindicated, vaginal birth is possible after a previous cesarean birth. Labor management that emphasizes one-to-one support of the laboring woman by another woman (e.g., doula, nurse, nurse-midwife) can reduce the rate of cesarean birth and increase the VBAC rate. Obstetric emergencies (e.g., meconium-stained amniotic fluid, shoulder dystocia, prolapsed cord, rupture of the uterus, and amniotic fluid embolism) occur rarely but require immediate intervention to preserve the health or life of the mother and fetus or newborn.

Obstetric Procedures: Operative Vaginal Birth

Operative Vaginal Birth: -Operative vaginal births are performed using either forceps or a vacuum extractor -Forceps-assisted birth -Vacuum-assisted birth Maternal indications for forceps-assisted birth include a prolonged second stage of labor and the need to shorten the second stage of labor for maternal reasons (e.g., maternal exhaustion or maternal cardiopulmonary or cerebrovascular disease)

Urinary System:

-The hormonal changes of pregnancy (i.e., high steroid levels) contribute to an increase in renal function; diminishing steroid levels after birth may partly explain the reduced renal function that occurs during the puerperium. -Kidney function returns to normal within one month after birth. Urine components: -Renal glycosuria disappears by 1 week postpartum, lactosuria may remain. -Fluid loss -BUN levels increase result of breakdown of protein, returns to non pregnant level by 2 to 3 months after childbirth. Postpartal diuresis of extracellular fluid: -Within 12 hours of birth, women begin to lose the excess tissue fluid accumulated during pregnancy. Profuse diaphoresis often occurs, especially at night, for the first 2 or 3 days after childbirth. -Postpartal diuresis, caused by decreased estrogen levels, removal of increased venous pressure in the lower extremities, and loss of the remaining pregnancy-induced increase in blood volume, also aids the body in ridding itself of excess fluid. Urethra and bladder -Immediately after birth, excessive bleeding can occur if bladder becomes distended -A full bladder displaces and prevents contraction of the uterus

Gastrointestinal System:

Appetite: -Mothers usually hungry after childbirth -Hungry once anesthesia wears off Bowel evacuation: -A spontaneous bowel evacuation may not occur for 2 to 3 days after childbirth as a result of decreased muscle tone of intestines, dehydration, lack of food during labor. -Anal sphincter lacerations are associated with postpartum incontinence.

Nursing Care Following Cesarean Birth

Assessment Pain relief Respirations Abdomen Intake and output Interventions First 24 Hours: Pain relief Overcoming effects of immobility Providing comfort After 24 hours Resuming normal activities Assisting mother with infant feeding Preventing abdominal distention

Obstetric Procedures: Augmentation of Labor

Augmentation of Labor: -Stimulation of uterine contractions after labor has started spontaneously and progress is unsatisfactory -Common augmentation methods include oxytocin infusion and amniotomy. -Augmentation is usually implemented for the management of hypotonic uterine dysfunction, resulting in a slowing of the labor process (protracted active phase). Active management is augmentation of labor to establish efficient labor with the aggressive use of oxytocin so that the woman gives birth within 12 hours of admission to the labor unit.

Breasts

Breastfeeding mothers: -Promptly after birth a decrease occurs in the concentrations of hormones (i.e., estrogen, progesterone, hCG, prolactin, cortisol, and insulin) that stimulated breast development during pregnancy. The time required for these hormones to return to prepregnancy levels is determined in part by whether the mother breastfeeds her infant. -First 24 hours colostrum develops and the breasts gradually become fuller and heavier as the colostrum turns into milk. -Transitions to milk in 72 to 96 hours -Engorgement comfort measures for lactating mothers Nonbreastfeeding mothers: -The breasts generally feel nodular in contrast to the granular feel of breasts in nonpregnant women. The nodularity is bilateral and diffuse. Prolactin levels drop rapidly. Colostrum is present for the first few days after childbirth. -Engorgement resolves in 24 to 36 hours after milk comes in

Postpartum

Definition & Physiologic Considerations of the Postpartum Period The postpartum period is the 6 weeks following delivery. It is a time of recovery and stabilization for the new family. Changes during postpartum are abrupt.

PROM and PPROM Management

Determined individually for each woman Full-term birth is the best option. PPROM <32 weeks is managed expectantly and conservatively. Vigilance for signs of infections Fetal assessment Antenatal glucocorticoids

Cardiovascular System

Blood volume: -Dependent on how much blood is lost during labor. -Many times, the pregnancy induced hypovolemia allows the woman to tolerate considerable blood loss during labor. -The average blood loss for a vaginal birth of a single fetus ranges from 300 ml to 500 ml (10% of blood volume). -The typical blood loss for women who give birth by cesarean is 500 ml to 1000 ml (15% to 30% of blood volume). Factors that contribute to protecting the mother by increasing the circulating blood volume: (1) elimination of uteroplacental circulation reduces the size of the maternal vascular bed by 10% to 15%, (2) loss of placental endocrine function removes the stimulus for vasodilation (3) mobilization of extravascular water stored during pregnancy occurs Cardiac output: -Pulse rate, stroke volume, and cardiac output increase throughout pregnancy. -Cardiac output remains increased for at least the first 48 hours postpartum because of an increase in stroke volume. -Cardiac output decreases by 30% by 2 weeks after childbirth and then gradually decreases to nonpregnant values by 6 to 12 weeks in most women. -Stroke volume, end diastolic volume, cardiac output, and systemic vascular resistance remain elevated in some women over nonpregnant values for up to 12 weeks or longer. Vital signs: -Few alterations in vital signs are seen under normal circumstances. Heart rate and blood pressure return to nonpregnant levels within a few days -Respiratory function rapidly returns to nonpregnant levels after birth Blood components: Hematocrit and hemoglobin: After childbirth the total blood volume decreases by approximately 16% from its prebirth value, resulting in a transient anemia. After 8 weeks, however, the number of red blood cells has increased and the majority of women have a normal hematocrit. White blood cell count: Normal leukocytosis of pregnancy averages approximately 12,000/mm3. During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm3 are common. Neutrophils are the most numerous white blood cells. Leukocytosis, coupled with the normal increase in erythrocyte sedimentation rate, can obscure the diagnosis of acute infection at this time. Coagulation factors: Clotting factors and fibrinogen are normally increased during pregnancy and remain elevated in the immediate puerperium. Varicosities: varicosities of legs, anus (hemorrhoids) are common during pregnancy

Chorioamnionitis

Chorioamnionitis: -Bacterial infection of the amniotic cavity -Chorioamnionitis most often occurs after membranes rupture or labor begins, as organisms that are part of the normal vaginal flora ascend into the amniotic cavity. -Many of the risk factors for chorioamnionitis are associated with a long labor, such as prolonged membrane rupture, multiple vaginal examinations, and use of internal FHR and contraction monitoring modes. -Major cause of complications for mothers and newborns at any gestational age -Diagnosed by the clinical findings of maternal fever, maternal and fetal tachycardia, uterine tenderness, and foul odor of amniotic fluid -They are also more likely to have dysfunctional labor, which can result in the need for cesarean birth. -In order to prevent maternal and neonatal complications, prompt treatment with intravenous broad-spectrum antibiotics and birth of the fetus are necessary. -Neonatal risks -Treatment

FHR Categories

FHR Categories: Indeterminate FHR patterns Category II Bradycardia not accompanied by absence of baseline variability Tachycardia Minimal or absence of baseline variability not accompanied by recurrent decelerations Marked baseline variability No accelerations in response to fetal stimulation Periodic or episodic decelerations Abnormal FHR patterns described as nonreassuring Category III Nonreassuring FHR patterns associated with fetal hypoxemia Hypoxemia can deteriorate to severe fetal hypoxia Absence of baseline variability Recurrent or late decelerations Bradycardia Sinusoidal pattern

Assessment of Extremities, Bowel and Bladder

Homan's sign: -Assess calf for redness and warmth -Adequacy of urinary elimination -Bladder distention and pain during urination -Intestinal elimination -Maternal concerns regarding bowel movements

Health promotion for future pregnancies and children

Health promotion for future pregnancies and children Rubella vaccination: For women who have not had rubella (10% to 20% of all women) or women who are serologically not immune (titer of 1:8 or enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is recommended in the postpartum period to prevent the possibility of contracting rubella in future pregnancies. Varicella vaccination: -Recommenation that varicella vaccine be administered before discharge in women who have no immunity. Tetanus-diphtheria-acellular pertussis (Tdap) vaccine: Tetanusdiphtheria acellular pertussis (Tdap) vaccine is recommended for postpartum women who have not previously received the vaccine; it is given before discharge from the hospital or as early as possible in the postpartum period to protect women from pertussis and to decrease the risk of infant exposure to pertussis Prevention of Rh isoimmunization: Rubella vaccine for women with negative serology (must have a titer of 1:8) Women should avoid becoming pregnant 28 days after vaccinated -Injection of Rh immune globulin (a solution of gamma globulin that contains Rh antibodies) within 72 hours after birth prevents sensitization in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal red blood cells (RBCs) -Rh immune globulin promotes lysis of fetal Rh positive blood cells before the mother forms her own antibodies against them. Psychosocial needs: -Meeting the psychosocial needs of new mothers involves assessing the parents' reactions to the birth experience, feelings about themselves, and interactions with the new baby and other family members. Specific interventions are planned to increase the parents' knowledge and self confidence as they assume the care and responsibility of the new baby and integrate this new member into their existing family structure in a way that meets their cultural expectations. -There is evidence that nurses and other health care providers do not adequately address maternal psychosocial needs, instead focusing their attention on postpartum physical changes and medically based care Effect of birth experience: Many women indicate a need to examine the birth process itself and look retrospectively at their own intrapartal behavior. Their partners may express similar desires. If their birth experience was different from their birth plan (e.g., induction, epidural anesthesia, cesarean birth), both partners may need to mourn the loss of their expectations before they can adjust to the reality of their actual birth experience. Maternal self-image: -An important assessment concerns the woman's self-concept, body image, and sexuality. How the new mother feels about herself and her body during the postpartum period may affect her behavior and adaptation to parenting. -Feelings related to sexual adjustment after childbirth are often a cause of concern for new parents. Women may feel reluctant to have sex. Adaptation to parenthood and parent-infantant interactions: -Psychological assessment includes adaptation to parenthood. -This task is accomplished by observing maternal and paternal reactions to the newborn and their interactions with the infant. -Examples of positive parent-infant interactions include taking pleasure in the infant and in providing care, responding appropriately to infant cues, and providing comfort -Should these indicators be missing, the nurse needs to investigate further what is hindering the normal adaptation process Family structure and functioning: Nurses can help ease the new mother's return home by identifying possible conflicts among family members and helping the woman plan strategies for dealing with these problems before discharge. Effect of cultural diversity: -To identify cultural beliefs and practices when planning and implementing care, the nurse conducts a cultural assessment. This assessment is ongoing; it is ideally begun during pregnancy and continued into the postpartum period. It can be accomplished most easily through conversation with the mother and her partner. Some hospitals have assessment tools designed to identify cultural beliefs and practices that may influence care. -Rest, seclusion, dietary restraints, and ceremonies honoring the mother are common traditional practices

Maternal Care

Early ambulation Adequate sleep, frequent rest Balanced and nutritious diet Pericare: peri-bottle, icepacks, sitzbath Analgesic for after pains Routine post-op care for C-section

Breech Presentation

Etiology: Prematurity is the main cause; others include uterine relaxation associated with parity >5 Placenta previa Polyhydraminous Hydrocephalus Complications: Prolapse of the cord, especially with footling breech, because the buttocks does not fit as snugly into the cervix as the head Dysfunctional labor results because the buttocks is too soft and makes a poor dilating wedge against the cervix Birth trauma is more likely to occur because the head does not have time to mold and it must pass through the birth canal quickly Management of Breech Presentation: External version between 36 - 38 weeks gestation If the version is unsuccessful, a skilled obstetrician will attempt a vaginal delivery (with complete or frank breech) given adequate neck flexion

Second Stage of Labor

Infant is born -Begins with full cervical dilation (10 cm) -Complete effacement (soften, shortening and thinning) -The "pushing" stage -Ends with infant's birth Median delivery time is 50 minutes in nulliparous women and 20 minutes in multiparous women. -Nulliparous women: 2 hours with no regional anesthesia use, 3 hours with use of regional anesthesia -Multiparous women: 1 hour with no regional anesthesia use 2 hours with regional anesthesia Two phases Latent: relatively calm with passive descent of baby through birth canal Active: pushing and urge to bear down Ferguson reflex: the urge to "bear down" During the phase of active pushing (descent) the woman has strong urges to bear down as the Ferguson reflex is activated when the presenting part presses on the stretch receptors of the pelvic floor. At this point, the fetal station is usually +1 and the position is anterior. This stimulation causes the release of oxytocin from the posterior pituitary gland, which provokes stronger expulsive uterine contractions. The woman becomes more focused on bearing-down efforts, which become rhythmic. She changes positions frequently to find a more comfortable pushing position. -During this early phase the fetus continues to descend passively through the birth canal and rotate to an anterior position as a result of ongoing uterine contractions. The woman is quiet and often relaxes with her eyes closed between contractions. The urge to bear down is not strong and some women do not experience it at all or only during the acme (peak) of a contraction. Allowing a woman to rest during this phase, and waiting until the urge to push intensifies, reduces maternal fatigue, conserves energy for bearing-down efforts, and provides optimal maternal and fetal outcomes -Although delayed pushing is associated with a longer second stage of labor, it results in a significantly higher incidence of spontaneous vaginal birth Care Management: -Only certain sign to the beginning of the second stage is the inability to feel the cervix during vaginal examination, indicating that the cervix is fully dilated and effaced. Other signs that suggest the onset of the second stage include the urge to push or feeling the need to have a bowel movement. These signs commonly appear at the time the cervix reaches full dilation. -The nurse continues to monitor maternal-fetal status and events of the second stage and provide comfort measures for the mother. This includes helping her change position; providing mouth care; maintaining clean, dry bedding; and keeping extraneous noise, conversation, and other distractions (e.g., laughing, talking of attending personnel in or outside the labor area) to a minimum. The woman is encouraged to indicate other support measures she would like -The use of upright and lateral positions is associated with a shorter interval to birth, less pain and perineal damage, fewer episiotomies and abnormal FHR patterns, and fewer operative vaginal births Birth in a delivery room or birthing room: The woman will need assistance if she must move from the labor bed to the delivery table. The various positions assumed for birth in a delivery room are the Sims or lateral position in which the attendant supports the upper part of the woman's leg, the dorsal position (supine position with one hip elevated), and the lithotomy position. Lithotomy position: -The lithotomy position makes dealing with complications that arise more convenient for the primary health care provider. -To place the woman in this position, bring her buttocks to the edge of the bed or table and place her legs in stirrups. Take care to pad the stirrups, to raise and place both legs simultaneously, and to adjust the shanks of the stirrups so that the calves of the legs are supported Crowning Crowning occurs when the widest part of the head (the biparietal diameter) distends the vulva just before birth. If an episiotomy (incision into the perineum to enlarge vaginal outlet) is necessary, it is done at this time to minimize soft-tissue damage. A local anesthetic may be administered if necessary before performing an episiotomy Ritgen maneuver: The physician or nurse-midwife may use a hands-on approach to control the birth of the head, believing that guarding the perineum results in a gradual birth that will prevent fetal intracranial injury, protect maternal tissues, and reduce postpartum perineal pain. This approach involves: (1) applying pressure against the rectum, drawing it downward to aid in flexing the head as the back of the neck catches under the symphysis pubis; (2) then applying upward pressure from the coccygeal region (modified Ritgen maneuver) to extend the head during the actual birth, thereby protecting the musculature of the perineum; and (3) assisting the mother with voluntary control of the bearing-down efforts by coaching her to pant while letting uterine forces expel the fetus. Nuchal cord: The umbilical cord often encircles the neck (nuchal cord) but rarely so tightly as to cause hypoxia. After the head is born, gentle palpation is used to feel for the cord. If present, the health care provider slips the cord gently over the head if possible. If the loop is tight or if there is a second loop, he or she will probably clamp the cord twice, cut between the clamps, and unwind the cord from around the neck. Use of fundal pressure: -Fundal pressure is the application of gentle, steady pressure against the fundus of the uterus to facilitate the vaginal birth -Use of fundal pressure by nurses is not advised because there is no standard technique available for this maneuver Contraindicated Immediate assessments and care of newborn

Immune System

Mildly suppressed during pregnancy Now gradually returns to its prepregnant state This rebound of the immune system can trigger "flare-ups" of autoimmune conditions.

Pain during Labor and Birth

Neurologic origins Visceral Referred Somatic Perception of pain Expression of pain

Principles of Conducting a Postpartum Assessment

Selecting a time that will provide the most accurate data Providing an explanation of the purpose of the assessment Ensuring that the woman is relaxed before starting Recording and reporting the results clearly Body fluid precautions

Discharge Teaching

Self-management: -A great deal of time during the hospital stay is usually spent in teaching about maternal self management and care of the newborn because the goal is for all women to be capable of providing basic care for themselves and their infants at the time of discharge. -In addition, every woman must be taught to recognize physical and psychologic signs and symptoms that might indicate problems and how to obtain advice and assistance quickly if these signs appear. -Before discharge, women need basic instruction regarding a variety of self-management topics such as nutrition, exercise, family planning, the resumption of sexual intercourse, prescribed medications, and routine mother-baby follow-up care -Because of the limited time available for teaching, nurses must target their teaching on expressed needs of the woman. Sexual activity and contraception: Discussing sexual activity with the woman and her partner and family planning with heterosexual couples is important before they leave the hospital because many couples resume sexual activity before the traditional postpartum checkup 6 weeks after childbirth. -The nurse needs to discuss the physical and psychologic effects that giving birth can have on sexual activity -Ovulation can occur as soon as 1 month after birth, particularly in women who bottle-feed. Breastfeeding mothers should be informed that breastfeeding is not a reliable means of contraception and that other methods should be used; nonhormonal methods are best because oral contraceptives can interfere with milk production Medications: -Women routinely continue to take their prenatal vitamins during the postpartum period. Breastfeeding mothers usually continue prenatal vitamins for the duration of breastfeeding. -Supplemental iron can be prescribed for mothers with lower than normal hemoglobin levels -Women with extensive episiotomies or perineal lacerations (third or fourth degree) are usually prescribed stool softeners to take at home. -Pain medications (analgesics or NSAIDs) may be prescribed, especially for women who had cesarean births. Follow-up after discharge: -Women who have experienced uncomplicated vaginal births are commonly scheduled for the traditional 6-week postpartum examination. -Women who have had a cesarean birth are often seen in the health care provider's office or clinic within 2 weeks after hospital discharge Home visits: -Home visits to mothers and babies within a few days of discharge can help bridge the gap between hospital care and routine visits to health care providers. Nurses can assess the mother, the infant, and the home environment; answer questions and provide education and emotional support; and make referrals to community resources if necessary. -Home visits have been shown to reduce the need for more expensive health care, such as emergency department visits and rehospitalization; they can also reduce the incidence of postpartum depression in women who are at risk. Telephone follow-up: In addition to or instead of a home visit, many providers are implementing one or more postpartum telephone follow-up calls to their clients for assessment, health teaching, and identification of complications to effect timely intervention and referrals. Warm lines: The warm line is another type of telephone link between the new family and concerned caregivers or experienced parent volunteers. A warm line is a help line or consultation service, not a crisis intervention line. Support groups: -The woman adjusting to motherhood may desire interaction and conversation with other women who are having similar experiences. -A postpartum support group enables mothers and partners/ fathers to share with and support each other as they adjust to parenting. Referral to community resources: To develop an effective referral system the nurse should have an understanding of the needs of the woman and family and of the organization and community resources available for meeting those needs.

Key Points

The rapid decrease in estrogen and progesterone levels after expulsion of the placenta is responsible for triggering many of the anatomic and physiologic changes in the puerperium. Within 6 weeks after birth, the physiologic changes induced by pregnancy have reverted to their normal state. Assessing lochia and fundal height is essential to monitor the progress of normal involution and to identify potential problems. The uterus involutes rapidly after birth and returns to the true pelvis within 2 weeks. The return of ovulation and menses is determined in part by whether the woman breastfeeds her infant. Few alterations in vital signs are seen after birth under normal circumstances. Hypercoagulability, vessel damage, and immobility predispose the woman to venous thromboembolism. Marked diuresis, decreased bladder sensitivity, and overdistention of the bladder can lead to problems with urinary elimination. Pregnancy-induced hypervolemia, combined with several postpartum physiologic changes, allows the woman to tolerate considerable blood loss at birth.

Interventions For Postpartum Hemorrhage

Uterine Atony Fundal massage with suprapubic support Medications Oxytocin; methylergonovine (Methergine); misoprostol (Cytotec); carboprost (Hemabate) PGF2α Avoid methylergonovine in hypertensive patients. Avoid carboprost in asthmatic patients. Bimanual Compression Surgical intervention (uterine artery embolization; uterine artery ligation; uterine compression sutures; hysterectomy) if bleeding persists

Fetal Oxygenation

Uteroplacental exchange Fetal circulation Regulation of fetal heart rate Autonomic nervous system Baroreceptors Chemoreceptors Adrenal glands Central nervous system

Obstetric Procedures:Version

Version: Version is the turning of the fetus from one presentation to another. It may be performed externally or internally by the physician. External cephalic version (ECV) -An attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth -Ultrasound scanning used during procedure -NST and informed consent before procedure -Contraindications to ECV -ECV is accomplished by the exertion of gentle, constant pressure on the abdomen -If ECV is not successful, the ACOG recommends that the woman undergo planned cesarean birth Internal version -Rarely used; safety questionable -Used most often in twin gestations to deliver the second fetus

Abdomen

-Returns to prepregnancy state 6 weeks after birth -Striae may persist -Return of muscle tone -Previous tone -Proper exercises -Adipose tissue -Diastasis recti abdominis -When the woman stands up during the first days after birth, her abdomen protrudes and gives her a still-pregnant appearance. During the first 2 weeks after birth the abdominal wall is relaxed. -Approximately 6 weeks are required for the abdominal wall to approximate its prepregnancy state. -Skin regains most elasticity but some striae may remain.

Planning for Discharge

From their initial contact with postpartum women, nurses prepare the mother for her return home. Length of stay (LOS) depends on many factors: -Physical condition of mother and infant -Mental and emotional status of the mother -Social support at home -Client education needs -Financial constraints Laws relating to discharge: -Newborns' and Mothers' Health Protection Act of 1996 -Advantages and disadvantages of early postpartum discharge -Criteria for early discharge -Mother recovered; able to care for self and baby -Those at low risk for complications may be discharged as early as 6 hours from a birth center and 24 to 36 hours from the hospital.

Nursing management of abnormal patterns

Nursing management of abnormal patterns -The nurse must ensure that the monitor is recording FHR and UA accurately and that the tracing is interpretable. Changing to a fetal spiral electrode or IUPC may be necessary. -NICHD Workshop 2008 proposed a three-tier system for EFM interpretation The five essential components of the fetal heart rate tracing that must be evaluated regularly are baseline rate baseline variability accelerations decelerations changes or trends over time Whenever one of these five essential components is assessed as abnormal, corrective measures must imme-diately be taken. The purpose of these actions is to improve fetal oxygenation via; -Intrauterine resuscitation. -Supplemental oxygen -Maternal position changes -Increasing intravenous fluids Other methods of assessment and interventions Fetal scalp stimulation and vibroacoustic stimulation: -Using an artificial larynx or fetal acoustic stimulation device on the maternal abdomen over the fetal head for 1 to 5 seconds. -The desired result of both methods of stimulation is an acceleration in the FHR of at least 15 beats/min for at least 15 seconds. -FHR acceleration indicates absence of acidemia. Umbilical cord acid-base determination: -In assessing the immediate condition of the newborn after birth, a sample of cord blood is a useful adjunct to the Apgar score, procedure is performed by taking blood out of the artery and vein, samples are tested for pH, carbon dioxide pressure (Pco2), oxygen pressure (Po2), and base deficit or base excess. Umbilical arterial values reflect fetal condition, whereas umbilical vein values indicate placental function. Fetal scalp blood sampling: The procedure is performed by obtaining a sample of fetal scalp blood through the dilated cervix after the membranes have ruptured. Fetal Pulse Oximetry: Fetal pulse oximetry or continuous monitoring of fetal oxygen saturation levels is a fetal assessment that indirectly measures the oxygen saturation of hemoglobin in fetal blood. Amnioinfusion: Amnioinfusion is infusion of room-temperature isotonic fluid (usually normal saline or lactated Ringer's solution) into the uterine cavity if the volume of amniotic fluid is low. Without the buffer of amniotic fluid the umbilical cord can easily become compressed during contractions or fetal movement, diminishing the flow of blood between the fetus and placenta. The purpose of amnioinfusion is to relieve intermittent umbilical cord compression that results in variable decelerations and transient fetal hypoxemia by restoring the amniotic fluid volume to a normal or near-normal level. Tocolytic therapy -Tocolysis (relaxation of the uterus) can be achieved through the administration of drugs that inhibit UCs. This therapy can be used as an adjunct to other interventions in the management of fetal stress when the fetus is exhibiting abnormal patterns associated with increased UA. Tocolysis improves blood flow through the placenta by inhibiting UCs. Electronic FHR Monitoring Equipment: Guidelines for intermittent auscultation or continuous electronic fetal monitoring for low-risk women: During latent phase, every 60 min During active phase, every 30 min During second stage, every 15 min High-Risk Women During latent phase, every 30 min During active phase, every 15 min During second stage, every 5 min

Hemorrhagic (Hypovolemic) Shock

Results from hemorrhage -Emergency situation in which perfusion of organs may become severely compromised, death may occur -If shock is prolonged, the continued reduction in cellular oxygenation results in an accumulation of lactic acid and acidosis -Acidosis (reduced serum pH) causes arteriolar vasodilation; venule vasoconstriction persists. A circular pattern is established; that is, decreased perfusion, increased tissue anoxia and acidosis, edema formation, and pooling of blood further decrease the perfusion. Cellular death occurs. Medical management -Restore circulating blood volume -Treating the cause of hemorrhage. Nursing interventions Monitor pulse and blood pressure Fluid or blood replacement therapy: Critical to successful management of the woman with a hemorrhagic complication is the establishment of venous access, preferably with a large-bore IV catheter. The establishment of two IV lines facilitates fluid resuscitation. Vigorous fluid resuscitation includes the administration of crystalloids (lactated Ringer's, normal saline solutions), colloids (albumin), blood, and blood components.

Basis for Monitoring

Fetal response -Oxygen supply must be maintained to prevent fetal compromise and promote fetal health after birth. Decrease in oxygen supply due to: -Reduction of blood flow through maternal vessels as a result of maternal hypertension (chronic hypertension, preeclampsia, or gestational hypertension), hypotension (caused by supine maternal position, hemorrhage, or epidural analgesia or anesthesia), or hypovolemia (caused by hemorrhage) -Reduction in oxygen content in maternal blood as a result of hemorrhage or severe anemia. -Alterations in fetal circulation occurring with compression of the umbilical cord (transient, during uterine contractions [UCs], or prolonged, resulting from cord prolapse), placental separation or complete abruption, or head compression (head compression causes increased intracranial pressure and vagal nerve stimulation with an accompanying decrease in the FHR) -Reduction in blood flow to intervillous space in placenta secondary to uterine hypertonus (generally caused by excessive exogenous oxytocin) or secondary to deterioration of the placental vasculature associated with maternal disorders such as hypertension or diabetes mellitus Uterine activity: -Monitoring provides information on uterine contractions. Fetal compromise: -The goals of intrapartum FHR monitoring are to identify and differentiate the normal (reassuring) patterns from the abnormal (nonreassuring) patterns, which can be indicative of fetal compromise. -Abnormal FHR patterns are those associated with fetal hypoxemia, which is a deficiency of oxygen in the arterial blood. If uncorrected, hypoxemia can deteriorate to severe fetal hypoxia, which is an inadequate supply of oxygen at the cellular level.

Postpartum Assessment

Initial assessments Chart review Need for RhoGAM Need for rubella vaccine Risk factors for hemorrhage and infection Focused Assessments Vital signs: Blood pressure is not a reliable indicator of impending shock from early postpartum hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the woman has lost 30% to 40% of her blood volume Fundus Lochia Perineum Bladder Breasts Lower extremities Homan's sign Edema and deep tendon reflexes B - Breasts U - Uterus B - Bowel B - Bladder L - Lochia E - Episiotomy/Lacerations H - Homans'/Hemorrhoids E - Emotions

Mastitis

Mastitis -Inflammation of the breast develops after milk production. -May range from inflammation of tissues around the nipples to formation of a glandular abscess. -Always results from an infection at nipple site. -Most common organism; staphylococcus aureus. -Occurs about 3rd or 4th week postpartum. -Marked breast engorgement before mastitis. Symptoms include: -Acute pain & tenderness in the breast. -Unilateral breast swelling. -Flu-like symptoms. -Increase pulse rate. -Fever, general malaise. Mastitis Treatment: Administer antibiotic therapy: Dicloxacillin, Analgesics. Promote comfort: supporting Bra. Continue breastfeeding, warm compresses. Manual expression /breast pump every 2-4 hrs. Good handwashing, breast care. Increase fluids, rest; decrease stress.

Obstetric Emergencies:

Meconium-stained amniotic fluid -Indicates fetus has passed stool prior to birth -Dark green Possible causes: -Normal physiologic function of maturity -Breech presentation -Hypoxia-induced peristalsis -Umbilical cord compression Risks: Meconium aspiration syndrome (MAS) Shoulder dystocia: -Head is born, but anterior shoulder cannot pass under pubic arch -Newborn more likely to experience birth injuries related to asphyxia, brachial plexus damage, and fracture -Mother's primary risk stems from excessive blood loss from uterine atony or rupture, lacerations, extension of episiotomy, or endometritis. Prolapsed umbilical cord -Occurs when cord lies below the presenting part of the fetus Contributing factors include: Long cord (longer than 100 cm) Malpresentation (breech) Transverse lie Unengaged presenting part Rupture of the uterus -Rupture of the uterus, in which there is complete nonsurgical disruption of all uterine layer. Rare, serious obstetric injury; occurs in 1 in 2000 births Most frequent causes of uterine rupture during: Separation of scar of a previous classic cesarean birth Uterine trauma (e.g., accidents, surgery) Congenital uterine anomaly During labor and birth: Intense spontaneous uterine contractions Labor stimulation (e.g., oxytocin, prostaglandin) Overdistended uterus (e.g., multifetal gestation) Malpresentation, external or internal version Difficult forceps-assisted birth Occurs more in multigravidas than primigravidas Amniotic fluid embolus (AFE), also called anaphylactoid syndrome of pregnancy (ASP) -Amniotic fluid containing particles of debris (e.g., vernix, hair, skin cells, or meconium) enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse

Key Points

Postpartum hemorrhage is a major cause of obstetric morbidity and mortality throughout the world and is the leading reason for obstetric intensive care unit admissions. Hemorrhagic (hypovolemic) shock is an emergency situation in which the perfusion of body organs can become severely compromised and death can ensue. The potential side effects of therapeutic interventions can further compromise the woman with a hemorrhagic disorder. Clotting disorders are associated with many obstetric complications. Postpartum infection is a major cause of maternal morbidity and mortality throughout the world. Postpartum UTIs are common because of trauma experienced during labor. Prevention is the most effective and least expensive treatment of postpartum infection.

Premature Rupture of Membranes

PROM: -Spontaneous rupture of amniotic sac and leakage of fluid prior to the onset of labor at any gestational age. -Labor will most likely be induced if it does not begin spontaneously soon after PROM occurs PPROM: Membranes rupture before 37 weeks of gestation -Responsible for 10% of all preterm births -Often preceded by infection of the urinary tract. -Chorioamnionitis PROM Risk Factors: -Infection is the major risk of PROM and PPROM for mother and fetus -Once the amniotic membranes have ruptured, micro-organisms can ascend from the vagina into the amniotic sac -PPROM is often preceded by infection -Chorioamnionitis is an infection of the amniotic membranes -The risk of infection increases if there is a lag period over the 24-hr period from when the membranes rupture to delivery Assessment / Subjective Data -Patient reports a gush or leakage of clear fluid from the vagina Assessment / Objective Data Physical Assessment Findings Temperature elevation Increased maternal or fetal heart rate Foul-smelling fluid or vaginal discharge Abdominal tenderness Assess for a prolapsed umbilical cord Abrupt FHR variable or prolonged deceleration Visible or palpable cord at the introitus Laboratory Tests A positive Nitrazine paper test (blue, pH 6.5 to 7.5) or positive ferning test is conducted on amniotic fluid to verify rupture of membranes Nursing Care: Assess vital signs every 2 hrs Notify the provider of a temperature >38º C (100º F) Assess FHR and uterine contractions Adhere to bed rest with bathroom privileges Encourage hydration Obtain a CBC Instruct the client to perform daily fetal kick counts and to notify the nurse of uterine contractions Medications: Ampicillin (Omnipen) Ampicillin is an antibiotic that is used to treat infections Obtain vaginal, urine and blood cultures prior to administration Betamethasone (Celestone) is a glucocorticoid administered IM in 2 injections, q24 hours x 2doses. The therapeutic action is to enhance fetal lung maturity and surfactant production

Endocrine System:

Placental hormones -Expulsion of the placenta results in dramatic decreases of the hormones produced by that organ particularly estrogen and progesterone. -Estrogen and progesterone levels decrease -Human chorionic gonadotropin (hCG) disappears fairly quickly from maternal circulation. -Metabolic changes Pituitary hormones and ovarian function: -Lactating and nonlactating women differ considerably in the time when the first ovulation occurs and when menstruation resumes. -Prolactin remains elevated in women who breastfeed -Duration of an ovulation is influenced by the frequency of breastfeeding, the duration of each feeding, and the degree to which supplementary feedings are used. -In women who breastfeed, the mean length of time to initial ovulation is approximately 6 months -In nonlactating women, prolactin levels decline after birth and reach the prepregnant range by the third postpartum week -Ovulation in 27 days after birth for nonlactating women -Ovulation in 70 to 75 days for lactating women

Abdominal Assessment

Position of fundus related to umbilicus Position of fundus to midline Firmness Assess incision for bleeding, approximation, and signs of infection Measuring descent of the fundus for a woman having a vaginal birth. Always support the bottom of uterus during any assessment of fundus.

Care Management

Preparing for birth Maternal position: Supine, semirecumbent, or lithotomy positions are still widely used in Western societies despite evidence that an upright position shortens labor. Bearing-down efforts Valsalva maneuver Fetal heart rate and pattern Support of father or partner Supplies, instruments, and equipment

Preterm Labor Risk Factors

Risk Factors -Infection is the only factor definitely shown to cause preterm labor. When bacterial cervical or urinary tract infections are present, the risk of preterm birth increases. -Thus early, continuous, and comprehensive prenatal care, which can detect and treat infections, is essential in dealing with this aspect of preterm birth prevention -Another proposed cause of preterm labor and birth is bleeding at the site of placental implantation in the uterus in the first or second trimester of pregnancy. -Chorioamnionitis (infection of the amniotic sac) Previous preterm birth Multifetal pregnancy Hydramnios (excessive amniotic fluid) Low socioeconomic status Smoking Substance use Signs and Symptoms are the Following: Cramps, pelvic pressure. Low backache. Vaginal discharge or spotting/bleeding. Change in cervical dilation. Regular uterine contractions with a frequency of 6 or more contraction in one hour. Premature rupture of membranes. The diagnosis of preterm labor is based on three major diagnostic criteria: • Gestational age between 20 and 37 weeks • Uterine activity (e.g., contractions) • Progressive cervical change (e.g., effacement of 80%, or cervical dilation of 2 cm or greater) Laboratory Tests Fetal fibronectin: If the presence of fetal fibronectin is used as another diagnostic criterion, a sample of cervical and vaginal secretions for testing should be obtained before an examination for cervical changes because the lubricant used to examine the cervix can reduce the accuracy of the test for fetal fibronectin Cervical cultures CBC Urinalysis

Psycho-Social Considerations

Taking In Phase 1: -There is a need for therapeutic sleep. -It is a period of dependency. -She wants to talk about labor and birth. -During 1-2 days after delivery, she needs 'mothering', nurturing and protective care. -She relies on others to respond to her need for comfort. Taking Hold Phase 2: -The second or third day after birth -Mother becomes independent -Assumes a mothering role -Resumes control of her body -Responds enthusiastically to opportunities to learn and practice the mothering role -Becoming a care giver -Asserting her independence and autonomy -She may suffer mood swings in this stage -Lack of sleep, fatigue and hormonal shifts may precipitate the blues Postpartum Blues -Transient periods of depression; sometimes occurs during the first few days postpartum -Mood swings -Anger -Weepiness -Anorexia -Difficulty sleeping -Feeling let down Causes of postpartum blues: -Changing hormones -Lack of supportive environment Letting Go Phase 3 (at home 6-8 wks after delivery) -Plateau is reached -Lifelong effects of the parent's new responsibilities come into focus -Some parents experience a feeling of being trapped and wonder what life is all about Letting Go Phase 3: -New maternal roles -Separate self from baby

Third Stage of Labor

Third Stage of Labor: -Birth of the baby until the placenta is expelled -The goal in the management of the third stage of labor is the prompt separation and expulsion of the placenta. -The third stage is generally by far the shortest stage of labor -Usually expelled within 10 to 15 minutes after the birth. -If the third stage has not been completed within 30 minutes, the placenta is considered to be retained and interventions to hasten its separation and expulsion are usually instituted. -Sudden gush of dark blood from the introitus -Apparent lengthening of the umbilical cord -Vaginal fullness -Depending on preference, the primary health care provider may use either a passive or an active approach to manage the third stage of labor. Passive management involves patiently watching for signs that the placenta has spontaneously separated from the uterine wall -Active management of third stage labor involves administering oxytocic medication (e.g., oxytocin [Pitocin]) to hasten placental separation in order to decrease the incidence of postpartum hemorrhage and reduce total blood loss. -Placental examination to make sure it was all released and no parts are within the uterus and disposal -Cultural preferences

Postpartum Infections

Also called puerperal infection Any clinical infection of the genital tract that occurs within 28 days after miscarriage, induced abortion, or birth Defined as presence of a fever of 38 C (100.4 F) or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth) Endometritis Infection of the lining of the uterus Most common postpartum infection Wound infections Often develop after mothers are discharged home Typically cesarean incision, repaired laceration, or episiotomy site Urinary tract infections Risk Factor for Endometritis: -C-Section delivery. -Hemorrhage or trauma during delivery, use of instruments -Retention of placental fragments. -Chorioamnionitis. -Operative procedures; forceps, vacuum extraction. -Multiple cervical examinations. -Prolonged labor (more than 24 hours). -Prolonged rupture of membranes. -Manual extraction of the placenta. Signs and Symptoms of Endometritis: -Elevated fever up to 100.4oF, Chills. -Tachycardia, uterine tenderness, pelvic pain, subinvolution. -Lochia: Scanty to profuse. -Elevated WBC. Treatment/Management: Broad spectrum antibiotics; such as Gentamycin and Clindamycin. Consult with MD if worsening or no response. Hospitalization if severe.

Fourth Stage of Labor

Care management Fourth Stage of Labor: -First 1 to 2 hours after birth -Both mother and newborn are not only recovering from the physical process of birth but are also becoming acquainted with each other and additional family members. During this time maternal organs undergo their initial readjustment to the nonpregnant state, and the functions of body systems begin to stabilize. Assessment of maternal physical status: -For healthy women, hemorrhage is the most dangerous potential complication during the fourth stage of labor, the mother is monitored and assessed for hemorrhage. -During the first hour following birth, the mother is assessed frequently -Physiologic changes to prepregnancy status -Signs of potential problems -Excessive blood loss -Alterations in vital signs and consciousness Care of the new mother: -In the absence of complications, a woman who has given birth vaginally; has recovered from the effects of the anesthetic; and has stable vital signs, a firm uterus, and small to moderate lochial flow may have fluids and a regular diet as desired. Care of the family -Family may gather together to hold or keep the baby warm. -Many women wish to begin breastfeeding their newborns at this time to take advantage of the infant's alert state (first period of reactivity) and to stimulate the production of oxytocin that promotes contraction of the uterus and prevents hemorrhage. Family-newborn relationships -Parents usually respond to praise of their newborn. Many need to be reassured that the dusky appearance of their baby's extremities immediately after birth is normal until circulation is well established. If appropriate, explain the reason for the molding of the newborn's head -Different responses from laughing, smiling, to angry and disappointed, assess responses and make notes.

Factors That Retard Uterine Involution

Factor:Prolonged labor Rationale: Muscles relax because of the prolonged time of contraction during labor Factor:Anesthesia Rationale: Muscles relax Factor:Difficult birth Rationale: The uterus is manipulated excessively Factor: Grand multiparity Rationale: Repeated distention of uterus during pregnancy and labor leads to diminished tone, muscle stretching and muscle relaxation Factor: Full bladder Rationale: As the uterus is pushed up and usually to the right, pressure on it interferes with the uterus remaining fully contracted Factor: Incomplete expulsion of placenta or membranes Rationale: The presence of even small amounts of tissue interferes with ability of the uterus to remain firmly contracted Factor: Infection Rationale: Inflammation interferes with the uterus' ability to contract effectively Factor: Over distension of uterus Rationale: Overstretching of uterine muscles with multiple gestations, hydramnios or a very large baby may lead to slower uterine involution

Fetal Heartrate Categories:

Fetal Heartrate Categories: Normal FHR patterns described as reassuring Category I Baseline FHR in the normal range of 110-160 beats/min Baseline fetal heart rate variability: moderate Late or variable decelerations: absent Early decelerations: may be present or absent Accelerations: either present or absent Evaluating Intermittent Auscultation and Palpation Data Contractions are evaluated for: Frequency Duration Intensity Resting interval Resting tone Characteristics of Uterine Anxiety: Baseline resting tone: done by palpation and internal monitor Frequency: number of contractions in a given time, measured from the beginning of last contraction to the beginning of the next one Duration: the length of time a contraction lasts Intensity: determined by palpation and internal monitor; described as mild, moderate and strong Strong contraction: described as the contraction that cannot be indented by the thumb Pathologic Influences on Fetal Oxygenation Maternal cardiopulmonary alterations Uterine activity Placental disruptions Interruptions in umbilical flow Fetal alterations Risk factors

Physiologic Adaptation to Labor

Fetal adaptation Fetal heart rate (FHR) provides reliable and predictive information about the condition of the fetus related to oxygenation. The average FHR at term is 140 beats/min. The normal range is 110 to 160 beats/min. Earlier in gestation the FHR is higher with an average of approximately 160 beats/min at 20 weeks of gestation. The rate decreases progressively as the maturing fetus reaches term. However, temporary accelerations and slight early decelerations of the FHR can be expected in response to spontaneous fetal movement, vaginal examination, fundal pressure, uterine contractions, abdominal palpation, and fetal head compression. Stresses to the uterofetoplacental unit result in characteristic FHR patterns. Fetal circulation: Fetal circulation can be affected by many factors, including maternal position, uterine contractions, blood pressure, and umbilical cord blood flow. Uterine contractions during labor tend to decrease circulation through the spiral arterioles and subsequent perfusion through the intervillous space. Most healthy fetuses are well able to compensate for this stress and exposure to increased pressure while moving passively through the birth canal during labor. Usually umbilical cord blood flow is undisturbed by uterine contractions or fetal position. Fetal respiration: Certain changes stimulate chemoreceptors in the aorta and carotid bodies to prepare the fetus for initiating respirations immediately after birth These changes occur during labor and include the following: • Fetal lung fluid is cleared from the air passages during labor and (vaginal) birth. • Fetal oxygen pressure (Po2) decreases. • Fetal arterial carbon dioxide pressure (Pco2) increases. • Fetal arterial pH decreases. • Fetal bicarbonate level decreases. • Fetal respiratory movements decrease during labor.

Key Points:

Fetal well-being during labor is gauged by the response of the FHR to UCs. Standardized definitions for many common FHR patterns have been adopted for use in clinical practice by the ACNM, ACOG, and AWHONN. The five essential components of the FHR tracing are baseline rate, baseline variability, accelerations, decelerations, and changes or trends over time. The monitoring of fetal well-being includes FHR and UA assessment and assessment of maternal vital signs. The FHR can be monitored by either IA or EFM. The FHR and UA can be assessed by EFM using either the external or internal monitoring mode. Assessing FHR and UA patterns, implementing independent nursing interventions, and reporting abnormal patterns to the physician or nurse-midwife are the nurse's responsibilities. The AWHONN and ACOG have established and published health care provider standards and guidelines for FHR monitoring. The emotional, informational, and comfort needs of the woman and her family must be addressed when the mother and her fetus are being monitored. Documentation of fetal assessment is initiated and updated according to institutional protocol.

Care Management for Pharmacological Interventions:

General informed consent Informed consent for anesthesia: Pregnant women have the right to be active participants in determining the best pain care approach to use during labor and birth. The primary health care provider and anesthesia care provider are responsible for fully informing women of the alternative methods of pharmacologic pain relief available in the hospital Timing of administration: -It is often the nurse who notifies the primary health care provider that the woman is in need of pharmacologic measures to relieve her discomfort. Orders are often written for the administration of pain medication as needed by the woman and based on the nurse's clinical judgment. -It is still recommended that the administration of systemic opioid analgesics be delayed until labor is well established -Non pharmacologic measures can be used to relieve pain and stress at any time. Preparation for procedures: -The methods of pain relief available to the woman are reviewed and information is clarified as necessary. The procedure and what will be asked of the woman (e.g., to maintain flexed position during insertion of epidural needle) must be explained. Administration of medication: Accurate monitoring of the progress of labor forms the basis for the nurse's judgment that a woman needs pharmacologic control of discomfort. Knowledge of the medications used during childbirth is essential. The most effective route of administration is selected for each woman; then the medication is prepared and administered correctly. Intravenous Route. The preferred route of administration of medications such as hydromorphone, butorphanol, fentanyl, or nalbuphine is through IV tubing, administered into the port nearest the point of insertion of the infusion (proximal port). The medication is given slowly, in small doses, during a contraction. It may be given over a period of three to five consecutive contractions if needed to complete the dose. It is given during contractions to decrease fetal exposure to the medication because uterine blood vessels are constricted during contractions and the medication stays within the maternal vascular system for several seconds before the uterine blood vessels reopen. Intramuscular Route. The maternal plasma level of the medication necessary to bring pain relief usually is reached 45 minutes after IM injection, followed by a decline in plasma levels. The maternal medication levels (after IM injections) also are unequal because of uneven distribution (maternal uptake) and metabolism. The advantage of using the IM route is quick administration by the health care provider. IM injections given in the upper arm (deltoid muscle) seem to result in more rapid absorption and higher blood levels of the medication. If regional anesthesia is planned later in labor, the autonomic blockade from the regional (e.g., epidural) anesthesia increases blood flow to the gluteal region and accelerates absorption of medication that may be sequestered there. Administration of opioids, including nalbuphine, subcutaneously in the upper arm avoids this risk and as a result is often used as an alternative to IM injection. Regional (Epidural or Spinal) Anesthesia. An IV infusion is established before the induction of regional anesthesia (epidural, subarachnoid). Anesthesia protocols will likely include the prophylactic administration of IV fluid before epidural and spinal anesthesia for blood volume expansion to prevent maternal hypotension. Hypotension is one of the most common complications of regional anesthesia. Safety and general care The nurse monitors and records the woman's response to nonpharmacologic pain relief methods and to medication(s). This includes the degree of pain relief, the level of apprehension, the return of sensations and perception of pain, and allergic or adverse reactions (e.g., hypotension, respiratory depression, fever, pruritus, and nausea and vomiting). The nurse continues to monitor maternal vital signs and fetal heart rate and pattern at frequent intervals, the strength and frequency of uterine contractions, changes in the cervix and station of the presenting part, the presence and quality of the bearing-down reflex, bladder filling, and state of hydration. Determining the fetal response after administration of analgesia or anesthesia is vital.

Uterine Involution

Involution Process: -The return of the uterus to a nonpregnant state after birth is known as involution, begins immediately after expulsion of the placenta. -Within 12 hours the fundus rises to approximately the level of the umbilicus. The fundus descends 1 to 2 cm every 24 hours. By 1 week after birth the fundus is normally located halfway between the umbilicus and the symphysis pubis. The uterus should not be palpable abdominally after 2 weeks and should have returned to its nonpregnant location by 6 weeks after birth. -Subinvolution is the failure of the uterus toreturn to a nonpregnant state Uterine Contractions: -The hormone oxytocin strengthens and coordinates uterine contractions. -Exogenous oxytocin (pitocin) is usually administered after expulsion of the placenta, for the uterus to remain firm and well contracted. -Mothers who breastfeed may be encouraged to put the baby to the breast because suckling releases oxytocin. After Pains -Periodic relaxation and vigorous contraction are more common in subsequent pregnancies and may cause uncomfortable cramping called afterpains (afterbirth pains) that persist throughout the early puerperium. -The uncomfortable cramping that persists throughout early postpartum. -Breastfeeding and exogenous oxytocin intensify afterpains. -More noticeable in a distended uterus e.g. large baby, multiple gestation.

Key Points

Labor and birth are affected by the five Ps: passenger, passageway, powers, position of the woman, and psychologic response. Because of its size and relative rigidity, the fetal head is a major factor in determining the course of birth. The diameters at the plane of the pelvic inlet, the midpelvis, and the outlet plus the axis of the birth canal determine whether vaginal birth is possible and the manner in which the fetus passes down the birth canal. Involuntary uterine contractions act to expel the fetus and placenta during the first stage of labor; these are augmented by voluntary bearing-down efforts during the second stage. The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. The third stage of labor lasts from the infant's birth to the expulsion of the placenta. The fourth stage of labor begins with the delivery of the placenta and includes at least the first 2 hours after birth. The cardinal movements of the mechanism of labor are engagement, descent, flexion, internal rotation, extension, restitution and external rotation, and expulsion of the infant. Although the events precipitating the onset of labor are unknown, many factors, including changes in the maternal uterus, cervix, and pituitary gland, are thought to be involved. A healthy fetus with an adequate uterofetoplacental circulation is able to compensate for the stress of uterine contractions. As the woman progresses through labor, various body systems adapt to the birth process.

Preterm Labor Medication

Nifedipine (Procardia, Adalat) -A calcium channel blocker used to suppress contractions by inhibiting calcium from entering smooth muscles Nursing Considerations: -Monitor for headache, flushing, dizziness and nausea; usually related to orthostatic hypotension from administration of it -Should not be given concurrent with magnesium sulfate Medications: Magnesium Sulfate -Magnesium sulfate is a commonly used tocolytic that relaxes the smooth muscle of the uterus -It inhibits uterine activity by suppressing contractions Nursing Considerations - Tocolytic Therapy -Monitor the patient receiving tocolytic therapy closely Discontinue it immediately if the patient exhibits symptoms such as the following: -pulmonary edema -chest pain -shortness of breath -respiratory distress, audible wheezing and crackles a productive cough containing blood-tinged sputum Classification/ Therapeutic Intent: Betamethasone (Celestone) -Betamethasone; a glucocorticoid that is administered IM in two injections, 24 hrs apart and requires a 24-hr period to be effective It is used to enhance fetal lung maturity and surfactant production

Key Points:

Nonpharmacologic pain and stress management strategies are valuable for managing labor discomfort alone or in combination with pharmacologic methods. The gate-control theory of pain and the stress response are the bases for many of the nonpharmacologic methods of pain relief. The type of analgesic or anesthetic to be used is determined by maternal and health care provider preference, the stage of labor, and the method of birth. Sedatives may be appropriate for women in prolonged early labor when there is a need to decrease anxiety or promote sleep or therapeutic rest. Naloxone (Narcan) is an opioid (narcotic) antagonist that can reverse narcotic effects, especially respiratory depression. Pharmacologic control of pain during labor requires collaboration among the health care providers and the laboring woman. The nurse must understand medications, their expected effects, potential side effects, and methods of administration. Maintenance of maternal fluid balance is essential during spinal and epidural nerve blocks. Maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response. The use of opioid agonist-antagonist analgesics in women with preexisting opioid dependence may cause symptoms of abstinence syndrome (opioid withdrawal). Epidural anesthesia and analgesia are the most effective available pharmacologic pain relief methods for labor. They are used by the majority of women in the United States. General anesthesia is rarely used for vaginal birth but may be used for cesarean birth or whenever rapid anesthesia is needed in an emergency childbirth situation.

Passageway, Bony Pelvis, Soft Tissues

Passageway: -The passageway, or birth canal, is composed of the mother's rigid bony pelvis and the soft tissues of the cervix, the pelvic floor, the vagina, and the introitus (the external opening to the vagina). -Soft tissues, particularly the muscular layers of the pelvic floor, contribute to vaginal birth of the fetus however the maternal pelvis plays the most important role because the fetus must accommodate itself to pass through. -The determination of the size and shape of the pelvis can be done at the initial prenatal visit or on admission in labor. Bony Pelvis: -Gynecoid -Android -Anthropoid -Platypelloid -Soft tissues -The bony pelvis is formed by the fusion of the ilium, the ischium, the pubis, and the sacral bones. Soft Tissues: -The soft tissues of the passageway include the distensible lower uterine segment, the cervix, the pelvic floor muscles, the vagina, and the introitus. -The cervix effaces (thins) and dilates (opens) sufficiently to allow the first fetal portion to descend into the vagina. -The pelvic floor is a muscular layer that separates the pelvic cavity above from the perineal space below

Perineal Trauma Related to Childbirth

Perineal Trauma Related to Childbirth Perineal lacerations: First degree: laceration that extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle Second degree: laceration that extends through the fascia and muscles of the perineal body, but not the anal sphincter Third degree: laceration that involves the external anal sphincter Fourth degree: laceration that extends completely through the rectal mucosa, disrupting both the external and internal anal sphincters Third- and fourth-degree lacerations must be carefully repaired so that the woman retains fecal continence Vaginal and Urethral Lacerations. Vaginal lacerations often occur in conjunction with perineal lacerations. Vaginal lacerations tend to extend up the lateral walls (sulci) and, if deep enough, involve the levator ani muscle. Additional injury may occur high in the vaginal vault near the level of the ischial spines. Vaginal vault lacerations are often circular and may result from use of forceps to rotate the fetal head, rapid fetal descent, or precipitous birth. Cervical Injuries: Cervical injuries occur when the cervix retracts over the advancing fetal head. These cervical lacerations occur at the lateral angles of the external os. Most lacerations are shallow and bleeding is minimal. Larger lacerations may extend to the vaginal vault or beyond it into the lower uterine segment; serious bleeding may occur. Extensive lacerations may follow hasty attempts to enlarge the cervical opening artificially or to deliver the fetus before full cervical dilation is achieved. Injuries to the cervix can have adverse effects on future pregnancies and childbirths. Episiotomy: An episiotomy is an incision made in the perineum to enlarge the vaginal outlet Median (Midline) Episiotomy -Extends from the vaginal outlet toward the rectum and is the most commonly used. -Easier to repair. -Less blood loss. -Associated with a higher incidence of third and fourth degree lacerations. Mediolateral Episiotomy -Mediolateral episiotomy is used in operative births when the need for posterior extension is likely. -Extends from the vaginal outlet posterolateral, to the left or right of the midline. -Third-degree laceration may occur. -Blood loss is greater and the repair is more difficult. -A local anesthetic is administered to the perineum prior to the incision. Care Management Vaginal and urethral lacerations Cervical injuries Episiotomy An incision in the perineum used to enlarge the vaginal outlet Has steadily declined in recent years due to a lack of sound, rigorous research to support its benefits

Postanesthesia Recovery

Postanesthesia Recovery -The woman who has given birth by cesarean or has received regional anesthesia for a vaginal birth requires special attention during the recovery period -The length of time required to recover from regional anesthesia varies greatly. Often it takes several hours for these anesthetic effects to disappear completely. -Feeling in the legs and tingling should dissipate. -Postanesthesia recovery (PAR) unit

Transfer from the Recovery Area

Postanesthesia recovery -Regardless of obstetric status, no woman should be discharged from the recovery area until completely recovered from anesthesia. -Women who have received general or regional anesthesia should be cleared by a member of the anesthesia team. -Transfer from recovery area In LDRP settings, nurse provides the same level of care without moving the client.

Key Points

Postpartum care is family centered and modeled on the concept of health. Cultural beliefs and practices affect the maternal and family response to the postpartum period. The nursing care plan includes assessments to detect deviations from normal, comfort measures to relieve discomfort or pain, and safety measures to prevent injury or infection. Common nursing interventions in the postpartum period focus on preventing excessive bleeding, bladder distention, and infection; providing nonpharmacologic and pharmacologic relief of discomfort associated with the episiotomy, lacerations, or breastfeeding; and instituting measures to promote or suppress lactation. Teaching and counseling measures are designed to promote the woman's feelings of competence in self-management and infant care. Meeting the psychosocial needs of new mothers involves taking into consideration the composition and functioning of the entire family. Early discharge classes, telephone follow-up, home visits, warm lines, and support groups are effective means of facilitating physiologic and psychologic adjustments in the postpartum period.

Postterm Pregnancy, Labor, and Birth

Postterm pregnancy (postdates) pregnancy -Extends beyond the end of week 42 of gestation Maternal risks: -Dysfunctional labor and birth canal trauma -Labor and birth interventions more likely -Woman may experience fatigue and psychologic reactions as estimated date of birth passes. -Risk for hemorrhage and infection is higher. Fetal risks -Abnormal fetal growth (macrosomia) -Prolonged labor -Shoulder dystocia -Birth trauma -Compromising effects on fetus of "aging" placenta, enlarging areas of infarction and increased deposition of calcium and fibrin in its tissue decrease the placenta's reserve and may affect its ability to oxygenate the fetus. -Decrease of amniotic fluid, there is a potential for cord compression and resulting hypoxemia. -Other potential complications include meconium stained amniotic fluid, increased chance of meconium aspiration, and low Apgar scores. -Postmaturity syndrome, postmaturity syndrome is characterized by dry, cracked, peeling skin; long nails; meconium staining of skin, nails, and umbilical cord; and perhaps loss of subcutaneous fat and muscle mass. -Macrosomic infants have an increased risk for birth injuries caused by difficult forceps-assisted births and shoulder dystocia Care management: -Most physicians induce labor at 41 weeks. -Alternative method is testing which generally consists of either a BPP or NST along with an assessment of amniotic fluid volume -Perinatal morbidity and mortality increase greatly after 42 weeks of gestation. More frequent fetal assessment, testing

Chapter 32 Labor and Birth Complications

Preterm labor and birth Preterm labor (PTL): Cervical changes and uterine contractions occurring at 20 to 37 weeks of pregnancy Preterm birth: Birth that occurs before the completion of 37 weeks (<37 0/7 weeks of gestation) Preterm birth versus low birth weight Preterm birth or prematurity: length of gestation regardless of birth weight More dangerous than birth weight alone because less time in the uterus correlates with immaturity of body systems Low birth weight: ≤2500 grams at birth Many potential causes, including preterm Intrauterine growth restriction (IUGR) Spontaneous versus indicated preterm birth Spontaneous: 75% of preterm births Indicated: 25% of preterm births Preeclampsia Fetal distress Intrauterine growth restriction Placental abruption Intrauterine fetal demise Pregestational and gestational diabetes Renal disease Rh sensitization Congenital malformations Causes of spontaneous preterm labor and birth Multifactorial Infection is the only definitive factor Placental causes Predicting spontaneous preterm labor and birth Risk factors: Major risk factors associated with preterm labor and birth are a history of preterm birth, current multifetal pregnancy, cervical or uterine abnormalities, bleeding after the first trimester of pregnancy, and a low or a high maternal body mass index Non-white race (especially non-Hispanic black), low socioeconomic and educational status, living with chronic stress, intimate partner violence lack of social support, smoking, substance abuse, and physically demanding working conditions also have been identified as risk factors Cervical length: -Another possible predictor of preterm labor is endocervical length. Changes in cervical length occur before uterine activity, so cervical measurement can identify women in whom the labor process has begun. -Not predictive of PTL or birth -Women whose cervical length is greater than 30 mm are unlikely to give birth prematurely even if they have symptoms of preterm labor. Fetal Fibronectin (fFN)Test: -Fetal fibronectin has been studied extensively and is marketed in the United States as a diagnostic test for preterm labor. Fetal fibronectin is a glycoprotein "glue" found in plasma and produced during fetal life. The test is performed by collecting fluid from the woman's vagina using a swab during a speculum examination. Fetal fibronectin normally appears in cervical and vaginal secretions early in pregnancy, and then again in late pregnancy. -fFN is a glycoprotein "glue" found in plasma and produced during fetal life.

Pain Management

Sources of Pain During the Stages of Labor First Stage: Internal Visceral Pain: -May be felt as back and leg pain, it is caused by: Dilation, effacement and stretching of the cervix Distention of the lower segment of the uterus Contractions of the uterus with resultant uterine ischemia. Located over the lower portion of the abdomen. Referred pain: Occurs when pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, gluteal area, thighs, and lower back Second Stage -Pain that is somatic and often described as intense, sharp, burning, and well localized and occurs with fetal descent and expulsion -This pain results from stretching and distention of perineal tissues and the pelvic floor to allow passage of the fetus, from distention and traction on the peritoneum and uterocervical supports during contractions, from pressure against the bladder and rectum, and from lacerations of soft tissue -Pain is caused by pressure and distention of the perineum and; described by patients as "burning, splitting and tearing" Pressure and pulling on the pelvic structures; including ligaments, fallopian tubes, ovaries, bladder and peritoneum Lacerations of soft tissues; the cervix, vagina and perineum Third Stage: -Pain with the expulsion of the placenta is similar to the pain experienced during the first stage -Pain is caused by uterine contractions, pressure and pulling of pelvic structures -Pain experienced during the third stage of labor and the afterpains of the early postpartum period are uterine, similar to the pain experienced early in the first stage of labor. Fourth Stage: -Pain is caused by distention and stretching of the vagina and perineum incurred during the second stage with a splitting, burning and tearing sensation

Giving Birth: Five P's

The five factors that affect and define the labor and birth process: Passenger (fetus), Passageway (birth canal), Powers(contractions), Position (of the mother) and Psychological response Factors that affect the birthing process: Passenger: Fetus -Passenger - consists of the fetus and placenta -The fetal head size, fetal presentation, position, lie, attitude, and station affect fetus' navigation of the birth canal -The placenta can be considered a passenger because it also must pass through the canal Size of the fetal head: -Major affect on the birthing process. Bones in the fetal skull: -The fetal skull is composed of two parietal bones, two temporal bones, the frontal bone, and the occipital bone. -These bones are united by membranous sutures: sagittal, lambdoidal, coronal, and frontal. Fontanels: -Membrane-filled spaces called fontanels are located where the sutures intersect -Palpation of fontanels and sutures during vaginal examination reveals fetal presentation, position, and attitude. -The anterior and posterior fontanels are the two most important. The larger of these, the anterior fontanel, is diamond shaped, is about 3 cm by 2 cm, and lies at the junction of the sagittal, coronal, and frontal sutures. It closes by 18 months after birth. -The posterior fontanel lies at the junction of the sutures of the two parietal bones and the occipital bone, is triangular, and is about 1 cm by 2 cm. It closes 6 to 8 weeks after birth. Molding: -Sutures and fontanels make the skull flexible to accommodate the infant brain, which continues to grow for some time after birth. -Because the bones are not firmly united, slight overlapping of the bones, or molding of the shape of the head, occurs during labor, capacity of the bones to slide against one another allows the fetal skull to adapt to the different diameters of the maternal pelvis. -Head of most newborns assumes its normal shape within 3 days after birth. -Shoulders can comply and change positions for birth as well. Presentation of the fetus: the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor Cephalic Most common, head first Breech Feet or buttocks first Shoulder: -Shoulder presentation first. Types of Presentations: -It is the part of the fetal body first felt by the examining finger during a vaginal examination. Cephalic, Breech, and Shoulder -In Cephalic presentation, the following are the presenting parts: Vertex Brow Face

Postpartum Hemorrhage (PPH) Causes

Uterine atony: -Uterine atony is marked hypotonia (low muscle tone) of the uterus. Normally, placental separation and expulsion are facilitated by contraction of the uterus, which also prevents hemorrhage from the placental site. -Marked hypotonia of uterus -Leading cause of PPH Associated with: -High parity -Hydramnios -Macrosomic fetus -Multifetal gestation Retained placenta Nonadherent retained placenta: -Nonadherent retained placenta may result from partial separation of a normal placenta, entrapment of the partially or completely separated placenta by an hourglass constriction ring of the uterus or mismanagement of the third stage of labor -Management of nonadherent retained placenta is by manual separation and removal by the primary health care provider Adherent retained placenta: -Abnormal adherence of the placenta occurs for reasons unknown, but it is thought to result from zygotic implantation in an area of defective endometrium such that no zone of separation is present between the placenta and the decidua. -Attempts to remove the placenta in the usual manner are unsuccessful, and laceration or perforation of the uterine wall may result. -Placenta accreta—slight penetration of myometrium by placental trophoblast -Placenta increta—deep penetration of myometrium by placenta -Placenta percreta—perforation of uterus by placenta Lacerations of genital tract: Lacerations of the cervix, the vagina, and the perineum also are causes of PPH. Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, an oozing, or frank hemorrhage. Factors that influence the causes and incidence of obstetric lacerations of the lower genital tract include operative birth, precipitate birth, congenital abnormalities of the maternal soft parts, and contracted pelvis. Hematomas Inversion of the uterus: Uterine inversion may be partial or complete. Complete inversion of the uterus is obvious; a large, red, rounded mass (perhaps with the placenta attached) protrudes 20 to 30 cm outside the introitus. Incomplete inversion cannot be seen but must be felt; a smooth mass will be palpated through the dilated cervix. -Inversion of the uterus turning it inside out when the placenta doesn't detach. Potentially life threatening Occurs in 1 in 2500 births Subinvolution of the uterus: -Late postpartum bleeding may occur as a result of subinvolution of the uterus. Recognized causes of subinvolution include retained placental fragments and pelvic infection. Signs and symptoms include prolonged lochial discharge, irregular or excessive bleeding, and sometimes hemorrhage. A pelvic examination usually reveals a uterus that is larger than normal and that may be boggy. -Failure of the uterus to return to pre pregnancy state. Late postpartum bleeding