Labor & Delivery

What are the components of child birth?

*THE 4 P's - powers - passage - passenger - psyche* Other factors: - preparation - professional help - place - procedures - people

A sign of fetal hypoxia from uteroplacental insufficiency - REQUIRE IMMEDIATE INTERVENTION - placenta separating - mom has HTN - uterus isn't being supplied enough - AFTER contraction What to do: - turn the pt - turn pitocin off - give oxygen

LATE decelerations

What do contractions create?

- effacement - dilation - *early effacement & dilation to 3 cm may be a result of braxton - hicks contractions* - bloody show (caused by true uterine contractions)

Stages of labor: - from onset of regular contractions to complete cervical dilation

1st stage of labor

Stages of labor: - from complete dilation to the birth of the baby

2nd stage of labor

Completely dilated - increase in bloody show - involuntary urge to push w/contractions - FHT just above pubic bone - perineum bulges, anus dilates - baby crowning, may see caput or fetal scalp - prepare for delivery

2nd stage or labor

- placenta is delivered - fundal massage is started after delivery of placenta - assess for bleeding, should be moderate amount, but should progressively slow down Fundal checks done every 15 minutes for the first 2 hours - weigh the pads

3rd stage of labor

Stages of labor: - from the birth of the infant to the expulsion of the placenta

3rd stage of labor

- recovery stage 1-4 hours after birth - perineal repair is done - document lacerations: 1st, 2nd, 3rd (towards rectal area) or 4th degree (hits the rectum) - clean perineum, apply peri pads, ice - remove Epidural - VS, fundus, lochia assessment(bleeding) q 15 minutes for 2 hrs - emotional status - pain - fluid status, I&O, need to void

4th stage of labor

Stages of labor: - 1 - 4 hours after the birth, stabilization

4th stage of labor

Usually associated w/ fetal movements and contractions - increases above the baseline - may resemble the shape of the uterine contractions Anything over 32 weeks should be 15 bpm times 15 seconds

Accelerations

- mom more introverted, less outgoing, concentrating on breathing - encourage slow deep breaths - contractions may be lasting 40-60 seconds - patient may request pain med at this stage - vag exams may be more frequent depending on status of mom - water may be broke at this time either artificially or spontaneously

Active phase of 1st stage (4-8 cm)

- amnioinfusion - induction of labor - episiotomy & lacerations - forceps & vacuum extraction - cesarean Birth - precipitous Delivery

Additional OB procedures

- Check prenatal record (When is the due date, labs, how she delivered prior kids, any complications) - Initial fetal assessment - Assess status of contractions - Assess BOW (water breaking) - Assess vaginal discharge - Check cervix - Pain status - Lab work (H&H, WBC, Platelets - BIG ONE!) - IV

Admission for labor

To detemine the frequency of uterine contractions, the nurse should note the time from the: A. beginning to end of the same contraction B. End of on contraction to the beginning of the next contraction C. Beginning of contraction to the beginning of the next contraction D. Contraction's peak until the contraction begins to relax.

Beginning of contraction to the beginning of the next contraction

- descent - engagement - flexion - internal Rotation - extension - external Rotation - expulsion *LOOK AT PAGE 127 & KNOW IT!!!*

Cardinal movements of labor

A primigravida at term is admitted to the birthing room in active labor. Later, when the client is dilated 8 cm, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time because pushing can cause which of the following?

Cervical edema

prep and recovery the same as other surgical and postpartum pt reasons: - breech, transverse positions - placenta previa (placenta blocking opening), abruption (placenta pulls away from uterus) - fetal, pelvic disproportion - prolapsed cord - previous c/s - arrest of labor

Cesarean section

A woman who is pregnant with her first child phones an intrapartum facility and says her "water broke". The nurse should tell her to: A. wait until she has contractions every 5 minutes for an hour B. take her temp every 4 hrs and come facility for temp greater then 100.4 C. come to the facility promptly, but safely. D. call an ambulance to bring her to the facility.

Come to the facility promptly, but safely

- decreased ability to push - maternal hypotension w/ resultant decreased placental perfusion and fetal oxygenation - spinal headache (blood patch)

Complications

- mom should push w/ contractions - usually 3X with each contraction - don't let mom hold breath for very long M.D. should be on way if not there already - delivery table should be set up and ready- sterile do not touch - episiotomy (only if necessary) - controlled by manually supporting the perineum during the birth of the head - assess for nuchal cord - slip over head

Delivery

- allow blood to continue going to baby, after pulsation stops, cord is clamped - baby's airway is further aspirated, and respirations are encouraged - may need to lower head, stimulate or bag to get baby to breathe - *dry baby off and keep warm!!!* - assure stabilization of infant

Delivery - baby's airway

- nares and mouth are cleared out with a bulb syringe - head is guided to sided during restitution and external rotation - pressure down delivers anterior shoulder - pressure up delivers posterior shoulder Down = anterior Up = posterior

Delivery - delivering shoulders

- begins generally 2 wks prior to birth - referred to as *lightening* - results in engagement of present part

Descent

Opening of cervix - measured in cm - closed to 10 cm

Dilation

A client in labor is receiving an oxytocin (Pitocin) infusion. What should the nurse do first when repetitive late decelerations of the fetal heart rate are observed?

Discontinue the oxytocin

A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take?

Discontinuing the test because the pattern is reassuring

Caused by pressure on the fetal skull possibly *r/t contractions* or descent into the pelvis and impending delivery - head is moving down! - heart rate gradually goes down then goes back up

EARLY decelerations

Shortening & thinning of the cervix (thinning and opening) - measured in %

Effacement

A multigravida of Asian descent weighs 104 lb, having gained 14 pounds during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do?

Encourage family to bring in special foods

Station: - relation of presenting part to the ishial spines When the widest part of the head has passed the pelvic inlet and is at the level of the ishial spines it is *ENGAGED* and at "0" station - Engaged head the baby's head will stay and not float back up Each cm *ABOVE* this landmark is -1, -2, and etc Each cm *BELOW* is +1, +2, and etc - baby is coming down

Engagement & station

At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations?

Enlarging area of caput with each contraction

Anterior shoulder is delivered after firm pressure is applied then after the head is raised slightly the posterior shoulder is delivered

Expulsion

Head is delivered by *extension* - once the occiput rotated and the head has moved under the pubic arch, no futher progress can be made unless the head extends Episiotomy is done at this time if needed prior to birth of head

Extension

After the birth of the head, it remains in the anterior/posterior position for a very short time then turns to one side to facilitate delivery of the shoulders

External rotation

- FHR monitoring -- intermittent -- continuous electronic fetal monitoring (EFM) Can be done externally or internally - start off with externally - US ultrasound (baby's heart rate) - Toko Internally: - used when having trouble with externally - Intrauterine pressure catheter (monitors contractions - SFC - fetal scalp electrode *Evaluates fetal well being through: - baseline rate of HR - variability - presence of accelerations & decelerations*

Fetal assessment during labor

A nurse is observing the electronic fetal monitor as a client in labor enters the second stage. The nurse identifies early decelerations of the fetal heart rate with a return to the baseline at the end of each contraction. What does this usually indicate?

Fetal head compression

Should be 110 - 160 bpm - "baseline" is found in the non-laboring pregnant mom between contractions - line should look squiggly and irregular, should have *"VARIABILITY"* - should not be flat - should not have "dips" or *"DECELERATIONS"*

Fetal heart rate

In the second stage of labor the nurse should plan to discourage a client from holding her breath longer than 6 seconds while pushing with each contraction. What complication does this prevent?

Fetal hypoxia

The normal attitude of the baby's head into pelvis and head is generally forced into flexion

Flexion

- used usually for emergency situations - time is issue when general anesthesia is used b/c it affects fetus - must deliver baby quickly after general is administered - usual postop complications must be assessed for

General anesthesia

A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored?

Hypotensive episode

Stadol Demerol Fentanyl - used in small doses to prevent infant respiratory depression - avoided if birth is expected w/ in 1 hr *must have narcan on hand to reverse effects if needed*

IV meds

- depends on position of fetus and the way the head rotates to accommodate itself - most common is occiput anterior -- occiput bone is on anterior bone of mom - fetus may rotate minimally or quite a bit - *position changes in mother may help rotate baby to preferred position*

Internal rotation

Happy go lucky phase - mom is alert, talkative, nervous - contractions are uncomfortable, but tolerable - mom responds to suggestions - maybe up walking around in BOW is intact - HOB up 30 degrees - TPR per policy - FHT/contractions per EFM - may be NPO or ice chips, ice pops

Latent phase of the 1st stage (0-4 cm)

- direct injection of medication into perineal tissues - usually used prior to episiotomy or immediately after delivery to repair episiotomy or laceration - no effect on maternal or fetal vital signs

Local anesthesia

After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time?

Massage the fundus

- VS - I&O - contractions - progress through stages of labor - response to labor

Maternal assessment during labor

Combined powers of contractions and pushing propel fetus downward (push with contractions only)

Maternal pushing

- Gate Control Theory (distractions - prevents pain sensations) - bradley method- father led coaching - lamaze - relaxation techniques

Non-pharm methods

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the next nursing action?

Notify HCP

- assess for allergies to medications - presence of diseases contraindicated to anesthesia - when was last meal - point in labor - lab tests - medications pt is on

Nursing responsibilities

- prepare instruments and equipment - perineal scrub - administering meds - provide initial care to infant - apgar scores -- appearance, pulse, grimace, activity, respiration - Pt identification - promoting bonding

Nursing responsibilities with delivery

Decel that lasts longer than 2 minutes - CALL MD!!!

PROLONGED decelerations

Can be non-pharmacologic or pharmacologic Mothers perception of pain influences by: - pain threshold - psychosocial factors Informed consent must be obtained for most pain methods Most common types are: - IV meds - epidurals - spinals

Pain control in labor

- pelvis and muscles of the pelvic floor and perineum *false* pelvis helps guide the guide the fetus into the true pelvis inlet - true pelvis is the bony limits of the passageway

Passage

*- fetus, amniotic fluid, and placenta* Many characteristics determine how and if the baby will move through the passageway: - fetal head - fetal lie - fetal attitude - fetal presentation - fetal position Transverse position: sideways

Passenger

- different routes available - most cross placental barrier and cause hypnotic effects in both mom and baby - drug, Dose, and Timing of medication must be considered in relation to delivery time and whether baby is preterm or not - *also must consider what med may do to stage of labor*

Pharmacological methods

Uterine contractions - during 1st stage contractions are powers that cause the cervix to thin and open - starts at the fundus Maternal voluntary pushing efforts - during the 2nd stage of labor contractions continue but the maternal pushing moves the baby down

Powers

Little as 3 hours and less than 5 hours - quick, unexpected delivery - may occur in multiparas - mom may have strong, forceful contractions - mom may have decreased pain sensation, inadequate warning - usually have precip packs in ambulances, ER, etc

Precipitous delivery

*Reaction to labor* - patterns of coping, preparation for labor, culture, attitude, expectations play part in determining how a woman will react - prenatal class preparation, presence of support, care by experienced nurse reduce anxiety

Psyche

- *bolus of fluids is given initially!!* - sitting or side-lying position - may feel burning or stinging when local is injected - relief occurs gradually over 10-15 minutes

Pt prep of epidural

A fetal monitor is applied to a client in labor. The nurse should take action in response to a fetal heart rate that:

Repeatedly drops abruptly to 90 beats/min unrelated to contractions

May spontaneously happen when cervix dilates - nitrazine test - fern test May be done by practitioner when cervix is effaced & dilated - amniotomy (dr breaks the water) - BABY'S HEAD SHOULD BE ENGAGED After ROM, good peri-care must be given frequently Note color, odor, amount *FHR assessment is priority after ROM*

Rupture of membranes

Sometimes first indication - report to hospital immediately - *1st thing you check: obtain FHT immediately* (To make sure the baby is okay - cord could collapse) - will be induced in labor does not occur - consider emergency situations

Ruptured membranes

- GI upset - burst of energy - increased vaginal discharge - bloody show - lightening (baby moving down) - braxton hicks - ruptured membranes

Signs of impending labor

- difference in the two is the space where the medication is administered *-- spinal is administered into the subarachnoid space -- epidural into the epidural space* - level of administration depends on type of birth - little effect on the baby - continuous infusion of medication is administered w/ epidural's Numbness Hypotension Headache

Spinal or epidural anesthesia

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse do to confirm that the membranes have ruptured?

Test the leaking fluid with nitrazine paper

- contractions are more forceful, occurring every 2-3 minutes, 60-80 seconds in duration - blood show increases - mom may be fatigued and discouraged, possibly very irritable - may have n/v - encourage pt to void frequently to avoid distention

Transitional phase of 1st stage (8-10 cm)

- contractions are regular - gradually increasing interval - pressure in lower back and lower abd - walking intensifies contractions - bloody show - cervix effaces or dilates False: - movement ceases contraction pain

True labor vs false labor

During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction?

Turning client on her side

A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client?

Urine retention

- assess frequency, duration, intensity -- start on one contraction to the start on the other - palpation - continuous EFM -- external: Toco -- internal: intra uterine pressure catheter

Uterine contractions

- hormonal triggers - cause the cervix to efface & dilate - *start at the fundus and radiate downward* - gradually increase in strength, then peak and gradually decrease in strength - frequency, intensity, and duration should be assessed

Uterine contractions

A nurse places fetal and uterine monitors on the abdomen of a client in labor. While observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. What condition is most frequently associated with late decelerations?

Uteroplacental insufficiency

NO relation to contraction pattern - usually from cord compression or nuchal cord - fast and abrupt What to do: - turn on their side - amnioinfusion - push fluids

VARIABLE decelerations

- done to check dilation, effacement, station, position - should be sterile if ruptured - need to use lubricating jelly - should be supine w/ knees flexed and relaxed Best time: - after epidural

Vaginal exams

- normal irregularity of fetal cardiac rhythm - indicates normal neurological control of FHR and a measure of fetal reserve - flat baseline indicates CNS depression Baby's heart beat is "bumping up and down" Min - <6bpm Moderate - 6-25bpm Marked - > 25bpm Absent - doesn't change - sick baby *want it to be moderate - normal fetal acid base*

Variability

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

Warming the newborn

A laboring woman suddenly begins making grunting sounds and bearing down during a strong contraction. The nurse should initially: a) leave the room to find an experienced nurse to assess the woman b) look at her perineum for increased bloody show or perineal bulging c) ask if she needs pain meds d) tell her that these are common sensations in late labor

look at her perineum for increased bloody show or perineal bulging