NURS 434: Intrapartum PP

COAT:

(when water breaks) C: clear, green, brown, chunks in it O: odor is in infection, earthy smell A: amount is it trickle, continuously running out T: time, want baby born within 24 hours

Intrapartum Procedures : Episiotomy

*An episiotomy is a surgical incision of the posterior aspect of the vulva made during the second stage of labor. *An episiotomy is used if the patient is at high risk for a third- or fourth-degree perineal tear or if an expedited delivery is needed because of fetal compromise. *Risks include infection, bleeding, and pain.

true labor:

-regular contractions -interval shortens -increasing intensity -back to abdomen -walking increases pain -no effect from milk sed -bloody show -dilation of the cervix

Vaginal Birth: Assisted Deliveries

-vacuum extractor or episiotomies Forceps or vacuum - head has to be crowning Less use of forceps. See more vacuums. However, see less of either as C-section rates increase. Vacuum-Indications: Need to shorten second stage of labor—Maternal indications = exhaustion, cardiac/pulmonary disease, inability to push effectively. Fetal indications = non-reassuring FHR, failure of presenting part to rotate or descend. Risks: trauma to tissue either maternal (lacerations, hematoma) or fetal (chigmon—scalp edema where cap applied), bruising, abrasions, facial nerve damage, cephlohematoma, intrercranial hemorrhage No more than 3 pop offs. Do not go outside green zone on suction indicator. Episiotomy—Indications: shoulder dystocia, reduce pressure on fetal head, control direction of vag. opening Risks—infection, perineal pain Daily massage during pregnancy may help stretch perineum and prevent episiotomy, perineal massage second stage of labor 2 different methods: median or midline mediolateral

FYI

-when amniotic fluid is gone its easier for umbilical cord to be compressed by shoulder or something -variable is normally with hydration issues

predictive signs of labor

-lightening: fundus lowers 1.—"dropping" Fetus descends toward the pelvic inlet. Breathing becomes easier (pressure on diaphragm released), increase pressure on bladder, pressure of fetal head I pelvis may cause leg cramps and edema. "Lightening" more noticeable in nulips about 2-3 weeks before natural onset of labor. -contractions (Braxton hicks contractions): 1.contractions throughout pregnancy are irregular and mild. Near term, become more noticeable and painful. See more uterine activity with preceding labor with parous than nulips. May make sleep difficult. May become regular, but than decrease spontaneously. Can cause confusion if labor has really started. BH Contractions (false) decrease with walking and hydration. -cervix and vaginal changes a. ripening b. bloody show, more secretions c. loss of mucus plug 1.Increase vaginal mucous secretions—As fetal pressure causes congestion of the vaginal mucosa, see increase in clear, nonirritating vaginal secretions. 2.Cervical Ripening and Bloody Show—Cervix softens because of the effects of the hormone relaxin and increased water content. These changes (ripening/soften) allow cervix to yield more easily to the forces of labor contractions. As fetal head descends, puts pressure on cervix starting effacement and dilation. Effacement and dilation cause expulsion of mucus plug that sealed cervix and rupturing small cervical capillaries in the process. Bloody show-mixture of cervical mucus and pink or brown blood from ruptured capillaries in the cervix; often precedes labor and increases with cervical dilation—may begin several days to a few weeks before onset of labor, especially nulliparous women. Recent vaginal exam or intercourse may result in bloody show. -energy spurt: "nesting": 1.Some women have sudden increase in energy, "nesting" (normally around 37 weeks and after they are tired, large) -weight loss: 1.may occur d/t altered estrogen to progesterone ratio and causes excretion of extra fluid that accumulates during pregnancy. 2.Might develop some diarrhea

Critical Factors Affecting Labor and Birth (4 P's)

1: Powers (contraction) 2: Passageway (maternal pelvis & soft tissue) 3: Passenger (fetus and placenta) 4: Psyche response -4 major factors interact during normal childbirth -nurses don't determine if mom's pelvis is adequate for delivery: provider does -Psyche: if mom is stressed, evidence if mom's face is scrunched and tight her cervix is too (help her relax and educate her importance)

fourth stage of labor

Stage of physical recovery for the mother and infant physical recovery for mother and baby Assess for firmly contracted uterus; Discomfort due to birth trauma and after pains (lacerations, episiotomy, edema, hematoma); Initiate Skin to Skin Contact; Breastfeeding Delivery of placenta to the first 1 - 4 hours after birth. Care of Infant Maintain cardiopulmonary function 1.Apgar score at 1 and 5 minutes. Position, bulb suction mouth and nose as needed. If infant in distress, interventions to correct problems must be instituted immediately. Baby with vigorous cry and minimal secretions is usually sufficiently warmed by skin to skin contact with parents. Prewarmed warmer should be available. Support thermoregulation 1Place infant on prewarmed warmer and quickly dry with warm towels to reduce evaporative heat loss. The head should be dried well. Stimulus with drying will promote crying and lung expansion. Use skin to skin contact to maintain temp and promote bonding. Delay first bath to allow for temp to stabilize. Remove wet linen replace with warm dry linen, A stockinette cap may be placed on baby's dry head to further reduce heat loss. Identify the infant 1.Bands with imprinted matching numbers and identifying information are the primary means to ensure the right baby and right mom. 2 bands on baby—arm, ankle. Band may be given to support person. Care of the mother 1.Observe for haemorrhage 2.Relieve discomfort Uterine firmness, height and position checked every 15 minutes x 1 hour, plus temp, BP and pulse and respirations Fundus should be firm, midline and below umbilicus. If boggy (soft) should be massaged until firm. Inspect perineum for lacerations/repair—ice (hematoma) Check lochia Rubra (blood, tissue) Serosa (blood, serum, leukocytes and tissue debris) Alba (leukocytes, cells, mucosa, bacteria) Assist with breast feeding and family bonding Check bladder—suspect full bladder if fundus above the umbilicus of displaced to one side. First 2 voidings may be measured(usually 300-400 mls) until it is evident mom voids without difficulty and completely empties bladder Encourage breast feeding for oxytocin release and uterine contractions Promote comfort 1.Ice packs 2.Analgesics-take on regular schedule 3.Warmth—warm blanket , warm drinks (common to have chill after birth) Promote family attachment 1.First hour important d/t healthy neonate is alert and responsive. 2.Provide privacy 3.Infant can be held while assessing mom 4.Allow other family members, siblings to visit Firmly contracted uterus can be palpated through the abd. Wall as a firm, rounded mass about 10 - 15 cm in diameter at or below the umbilicus. Uterine size varies with size of infant and parity of the mother. Full bladder or blood clot in the uterus interferes with uterine contractions, increasing blood loss. Soft (boggy) uterus and increasing uterine size is associated with postpartum hemorrhage because to vessels at the placenta site are not compressed. Vaginal discharge is lochia—rubra, serosa, alba. Woman may be chilled--?d/t sudden decrease in effort, loss of heat produced by fetus, decrease in intraabdominal pressure, and loss of fetal blood entering maternal circulation. Offer warm blanket or hot drink. Discomfort due to birth trauma and after pains. (lacerations, episiotomy, edema, hematoma—ice packs Mom may be too excited to rest, may be exhausted Ideal time for bonding, eye contact, kangaroo care Initiate breastfeeding

coro amniotic infection:

amniotic fluid gets infected -once water breaks there is a straight route for infection to baby

nursing responsibilities

◦Start an IV line (18 gauge). Midwife might not require it ◦Draw blood and collect urine for laboratory assessment. (CBC, blood type and Rh, UA for protein) ◦Monitor vital signs. ◦Fetal monitoring ◦Provide continuous or intermittent fetal monitoring. Encourage the laboring woman to void at least every two hours. ◦Assess progress of labor. (contraction pattern; cervical dilation; pain; membranes) ◦Provide labor support. ◦Provide patient education as needed. ◦ Administer pain medications. ◦Notify provider (they decide if IV is needed and if they need to be admitted) ◦Consents. (if giving narcotics and teens: CANNOT sign, next relative, significant other. Anything alerting consciousness cannot sign) 1.Reason for coming to the birth center (ROM, contractions, etc.) 2.Prenatal Care—when it began, her most recent visit, name of physician and midwife—in records 3.Estimated Date of Delivery (EDD) 4.Number of pregnancies, births, spontaneous and elective ABs (gravida, parity, ABs, term and preterm births.) 5.Allergies—in records, but reassess if it is correct—Rh, GBS status 6.Medical, surgical and pregnancy histories—in records 7.Recent illness, including treatment—in records 8.Medications—prescription, OTC, herbal, alternative therapy 9.Use of tobacco, alcohol, illicit substances 10.Her subjective evaluation of her labor 11.Birth plans, including planned pain management methods 12.Support persons—who they are and the role of each 13.Prior abuse—domestic, sexual, physical, etc. ONLY ASK WOMAN WHEN ALONE. Fetal assessment—presentation, position Labor status—assessing contraction pattern, vaginal examination, and determining if ROM: Nitrazine paper: blue alkolotic (+), yellow acidic (-) urine Contractions are assesses by palpation, electronic monitor or both. Vaginal exam assesses for dilation, effacement, fetal station, presentation, position, may also reveal ROM if no leaking of fluid. DO NOT PERFORM A VAGINAL EXAM IF THERE IS ACTIVE BLEEDING (OTHER THAN BLOODY SHOW)—it may increase bleeding. Physical exam may include presence and location of edema, abdominal scars and fundal height., observe skin color, nutritional state, fatigue, deep tendon reflexes (brisk jerk without spasm, hypoactive with slight twitch, report hypo- hyper—seizure, hypertension, heart and lung sounds, pain level Notify physician, midwife and obtain orders Consent forms for care during L&D, anaesthesia, vaginal birth, C-section, transfusions, lab testing, separate consent for sterilization Labs—May not need any if had prenatal care, may be need more extensive tests if no prenatal care (complete CBC, Blood type and Rh, syphilis, HIV, GC, CT, GBS, drug screen—tests often include—haematocrit by finger stick, midstream UA to assess protein and glucose levels. IV—may or may not be ordered—saline lock or continuous infusions Light meals-OK. Contraindicated due to aspiration—very rare (1 case in 2005-2013). Better d/t increase epidural, spinal. Beneficial d/t calories, energy needed during labor—individual decision.

nurses need to know

◦What is Dystocia? (Dysfunctional Labor) -Dystocia is defined as long, difficult or abnormal labor and is associated with the "Five P's". Describe how each of the "Five P's" is involved in dystocia -dystocia can be because of OP ◦The Five P's? -passageway: Birth canal - Bony pelvis, Size of pelvis a. Cephalo-pelvic disproportion related to inadequate pelvis. (Pelvis and canal, bone and tissue (pelvic bone dystocia, tumors, fibroids, cervical edema, etc.) -passenger: size of fetal head, fetal lie, fetal presentation, fetal position, engagement a. BABY. Cephalo-pelvic disproportion related to excessive fetal size. Head, fetus/pelvis relationships. Malposition, Malpresentation, fetal anomalies, multiple gestations (Movement through the canal into the pelvis) -powers: ctx effectiveness, bearing down a. Dysfunctional labor.....pain/ctxs. Effacement and dilation -position of laboring patient a. (Maternal): Restriction of maternal movement and position may contribute to dystocia (side lying, back, up/walking, knee chest recommended) -psychologic response: emotional a. Mother's emotions, anxiety, increased pain perception. Lack of support ◦What is dysfunctional labor? -long/difficult or abnormal labor; or anything that prevents the dilation and effacement of the cervix ◦Dysfunctional labor patterns associated with the "Five P's? ◦Cephalopelvic Disproportion -A narrowed diameter in the maternal bony pelvis, beginning at the pelvic inlet and ending at the pelvic outlet or the maternal soft tissues within these anatomic areas. The fetus is larger than the pelvic diameters and unable to fit through. ◦ Hypotonic (contractions aren't lasting long and wide-spread, less than 60 seconds) - Usually develops in the active phase of labor, after labor has been well established. Characterized by fewer than two to three contractions in a 10 minute period. May occur when the uterus is overstretched. -Hypertonic (too long and too close together, lasting 2 minutes or more) -ineffectual uterine contractions of poor quality occur in the latent phase of labor, and the resting tone of the myometrium increases. Contractions more frequent but their intensity may decrease. The contractions are painful but ineffective in dilating and effacing the cervix, and a prolonged latent phase may result Contractions ◦Prolonged Labor -Labor is said to be prolonged when the combined duration of both the first stage and second stages of labor is more than 18 hours. It is more common in a first pregnancy and in women over the age of 35 years. -Precipitous Labor: a. Lasts less than 3 hours and results in rapid birth. Impact of psychological disorders on labor and birth - May require increased support from family and nursing staff, difficulty managing pain in labor ◦Malposition (breech- biggest concern is cervix clamping down around neck) -The normal position of the fetus is longitudinal with the fetal spine parallel to the mother's spine. The fetus lies in a completely flexed position with the chin touching the chest and the arms and legs flexed in front. The fetus normally faces the mother's back for a smooth delivery. Any change in this position can cause prolongation in the duration in labor. ◦Anomalies -Fetal anomalies such as hydrocephaly, encephalocele, and soft tissue tumors may obstruct labor. -Multiple gestation a. May require C/S for birth and difficulties related to malpresentation of fetuses, overstretched uterus. ◦Gastrotesis (where babies intestines are on outside of body) ◦OP: occiput posterior ◦OA: occiput anterior ◦R and L: mom's side

Five Ps of labor: position

*Contractions are generally more effective when a woman is in an upright position. *Gravity can assist successful labor and delivery. *The angle of the pelvis is most conducive to birth when a woman's hips are sharply flexed, like when squatting. *Encouraging movement into positions of comfort is associated with improved outcomes. *Lithotomy position for birth may have evolved for the ease of the provider. *Providers are becoming more open to different positions

Cesarean Birth—Types of Incisions

-Know from medical records -NOT tested on preterm labor

baby coming out of vagina (picture on slide)

-Look for bulging perineum; visualization of head -Role of nurse is to monitor perineum for crowning -Reassure that passage of stool very common -Ring of fire (if no epidural): burning, crying, screaming -after baby's head is delivered burning is gone -if umbilical cord is too tight around baby's neck: clamp for both mom and baby so they don't bleed out

Nursing Considerations of Induction/Augmentation

-Maternal response—dose related. -Risk of hyperstimulation with hypertonic contractions -Placental insufficiency: fetal hypoxia/fetal distress—assess FHR -Emergency Cesarean -Assess uterine activity for hypertonia—Stop Pitocin for contractions lasting > 90 seconds, contractions , 2 minutes apart with fetal pattern of late decelerations. -Assess BP and pulse every 30 minutes -Be aware that pain management may be needed sooner -Record I & O—Fluid retention may precede water intoxication—risk for fluid volume excess -Observe for water intoxication—HA, blurred vision, behavioral changes, increased BP and RR, wheezing, coughing -Assess for uterine atony in postpartum period—received pit. For a long time, uterine muscles fatigued—do not contract to compress vessels at placental site.

fourth stage of labor - care of mother

-Observe for hemorrhage (assess fundus, lochia) -Assess discomfort due to birth (lacerations, episiotomy, edema) -Comfort a. Warm blankets, ice packs, analgesics b. Cleanse perineum -Provide Skin to Skin time -Initiate Breastfeeding

#4 Psychological Response - Psyche

-Woman's psychological response influenced by anxiety, culture, life experiences and support Anxiety: 1.Anxiety and fear decreases a woman's ability to cope with the pain of labor 2.Catecholamines secreted in responses to anxiety and fear can inhibit contractions and placental blood flow. 3.Preparation for childbirth can enhance a woman's efforts to work with her body during labor instead of resisting them 4.Nurse promotes relaxation thus decreasing anxiety and fear 5.Nurse provides information and a positive sense of control and mastery over the birth, increases the woman's sense of satisfaction with her birth experience. Culture: 1.A woman's culture affects her values, expectations for and responses to birth and the practices surrounding it. 2.Modesty—gender of HCP 3.Expression of pain—quiet, non-vocal, vocal 4.Self control 5.Presence of support persons—father's participation 6.Activities/foods that represent hot or cold state 7.Non English speaking 7. Nurse needs to be familiar with group's cultural value, customs and practices in order to care for the woman and her family, Integration of cultural beliefs. Birth as an Experience: 1.Childbirth is a physical and emotional experience. 2.It is a pivotal event 3.A woman with more realistic expectations about the birth is likely to have a positive experience. 4.Nurse needs to help woman perceive birth experience as a positive event 5.Woman's past experiences with childbirth, pain, success, failure will influence her expectations for this birth 6.Childbirth as trauma -PTSD—out of control, uncontrollable events, shock, overwhelming pain, loss of self esteem, feelings of failure, loss of the "perfect full experience" being failed by others. Symptoms: depression, anxiety, self punitive, dissociation, confusion Support: can cut 2 hours off a woman's labor; and decrease medical interventions 1.Positive effects of continuous labor support are well documented. 2.Support includes physical comfort measures, providing information, advocacy, praise, reassurance, presence and the maintenance of a calm and comfortable environment. Technology: 1.Equipment may make maternity care seem less personal 2.Nurse must be careful against "nursing the machines" 3.Nurse must maintain a focus on the woman, fetus and support person rather than technology. Attitude and expectations will determine how mother copes: State of mind Self confidence Patterns of coping with stress Expectations about labor and birth Support Responses to pain Current experience Previous birth experiences Preparation of birth Transition to new role

characteristics of contractions

-coordinated (relaxes and contracts in coordinated way), involuntary (no conscious control, can't stop or start, anxiety, stress may impact), intermittent (allow for relaxation, rest period, resumption of blood flow to and from placenta) -peak: acme, nadir -count from beginning of one contraction to beginning of the next -goal every 2-3 minutes lasting 60-90 seconds, need rebound, longer than 30 seconds hypertonic contraction

cervical changes:

-effacement (thinning and shortening): Cervix becomes shorter and thinner as it is drawn over the fetus and amniotic sac. The cervix merges with the thinning lower uterus. Effacement is estimated as a percentage of the original cervical length. (before labor about 2 cm long). Fully thinned cervix is 100% effaced. -dilation (open): As the cervix is pulled upward and the fetus is pushed downward, the cervix dilates. Dilation is expressed in centimeters. Full dilation = 10 cm, then can start pushing -1st pregnancy effacement before dilation -Next pregnancies occurs together -when women come in saying they're in labor they go into triage: NST, VS -if cervix isn't dilated and effaced she probably wont stay unless she has complications -we want face to be facing the back* -want to feel hard head, not fingers or have to go for C-section

false labor:

-irregular contractions -interval same -intensity same or less -felt in abdomen -walking decreases pain -sedation relieves pain -no show -0 ft dilation False labor = prodromal labor = common because exact timing of labor onset is unknown Contractions inconsistent Discomfort is more annoying than truly painful Cervix does not change -cervix is key: HAS to dilate for true labor -if water breaks: generally want at facility right away, want baby born within 24 hours (infection) The best distinction between true and false labor is a progressive change in the cervix. If ROM—go to hospital. Infection and compression of umbilical cord are possible complications. Greatest risk is prolapsed cord...requires immediate c/section ROM-Check fetal heart tones, check if baby engaged, increase chance of infection. (Document: Color Odor Amount Time (COAT) FHR may drop if cord compression/prolapse-reposition mom-hips above head, knee chest

Critical to Remember: Nursing Responses to Non-reassuring (Abnormal) FHR patterns:

1. Identify the cause of the nonreassuring pattern to plan the best interventions: • Evaluate the pattern to determine its probable cause (late or variable decelerations, bradycardia or tachycardia, absent variability). • Evaluate maternal vital signs to identify hypotension, hypertension, or fever. • Perform vaginal examination to identify a prolapsed umbilical cord. 2. Stop oxytocin infusion if the drug is being administered. 3. Reposition the woman, avoiding the supine position, for FHR patterns associated with cord compression; repositioning may improve other nonreassuring patterns as well. 4. Increase the rate of a nonadditive intravenous fluid to expand the mother's blood volume and improve placental perfusion. 5. Administer oxygen by face mask at 8 to 10 liters per minute (L/min) to increase her blood oxygen saturation, making more oxygen available to the fetus. 6. Initiate electronic fetal monitoring if intermittent auscultation data are questionable. 7. Initiate continuous electronic fetal monitoring with internal devices if no contraindication exists. 8. Notify the physician or nurse-midwife as soon as possible. Report and document: • The pattern that was identified • Nursing interventions taken in response to the pattern • The fetal response after nursing interventions • The response of the physician or nurse-midwife (e.g., orders, other response) 9. If the nonreassuring pattern is severe, other staff members should begin preparing for immediate delivery (usually cesarean birth unless vaginal birth is imminent). Preparation for birth should include staff members for neonatal resuscitation.

FHR monitoring - the display

Baseline fetal heart rate Transient and recurrent changes from the baseline rate associated with uterine contractions. Accelerations—see with fetal movement. Non-periodic—having no relation to the contraction-- or periodic May occur with vaginal examination, uterine contraction, mild cord compression. Reassuring sign reflecting responsive, non acidotic fetus. Decelerations are classified into 3 types based on their shape and relationship to uterine contractions - Can be because of medications, benzo, stadol, hypoxia (placental insufficiency), chronic HTN, sleep cycle usually doesn't last longer than 30 minutes Early = fetal head compression. Benign. Require no intervention. "Mirror the contraction" Occur during contraction as fetal head is pressed against woman's pelvis or soft tissues (cervix) Rarely decreases more than 30 - 40 bpm from the baseline Variable = cord compression. Do not have uniform appearance. They fall and rise abruptly. Shape, duration and degree of fall varies. Periodic and non-periodic. Decrease in FHR is at least 15 bpm and lasts at least 15 seconds, but less than 2 minutes. Late = indicate uteroplacental insufficiency. Non-reassuring. Fetus has reduced reserve to tolerate the recurrent reduction in O2 supply that occurs with contractions. Begin after the peak of the contraction and returns to baseline after the contraction ends. Consistent appearance. Usually no lower than 30 - 40 bpm below baseline -hypoperfusion, maternal diabetes, preeclampsia, post-date baby -if Oxytocin is running and have late deceleration: shut it off, putting her on L, R, hands and knees (change position to improve perfusion), oxygen, increase fluids (increase volume), may elevate legs, notify provider, may prepare for C-section (only 3-4 cm dilated and not resolved with interventions most likely c-section) -starts at peak of contraction and doesn't recover back to baseline until after contraction ends = late (not good)* -late are the worst Variability denotes fluctuations in the baseline FHR within a ten minute window that cause the printed line to have an irregular rather than a smooth appearance. -cord compression, V's (garden hose), once compression lessen it comes right back up, can see with or without contraction -if water broke, dehydrated: going to see more variables -if lining up with contraction: lie on side Absent = undetectable Minimal = undetectable to < 5 bpm (baby could be sleeping, narcotics, give OJ, snack) Moderate = 6 to 25 bpm Marked = > 25 bpm -Lost variability: c-section -Average-moderate variability: positive sign -Jaggy points: stomach muscles automatically feeling like she needs to push

theories of labor onset

Begins between 38 - 40 weeks gestation (not tested on)

#2 passageway

Boney pelvis and sort tissue 4 types: -Gynaecoid: diameters favorable for vaginal delivery, true female pelvic inlet (50%) -Anthropoid: "ape like" narrow side to side (24%) -Android: typical male inlet "heart" shaped (23%) -Platypeloid: flat and narrow, front to back (3%) Mixed types most common Android and playpeloid "most inadequate" for vaginal delivery

A patient's cervix was dilated 6 cm and 100% effaced 2 hours ago. She is now agitated, irritable, and her contractions have increased in intensity. What should the nurse do next?

Check the patient's cervix to determine if the patient is in the transition phase of labor. -1 cm an hour that cervix is dilating in active phase -more we progress in labor more pain -2 hours ago was active, so now she is 8 cm -notice change in behavior, notice change in fetal strip: only when to check cervix (if GBS+ try not to check cervix if possible) -need to check if anything has changed in cervix dilation, has she felt urge to push and now swelling cervix -best time for pain medications is 5-6 cm (discussed during early/latent phase) -multive for epidural before 7 cm -primip not contacting provider, but multive contact provider -8 cm: notify provider

second stage of labor

Complete dilation to delivery of baby -Duration varies; contractions may diminish slightly or even pause briefly; Voluntary efforts plus involuntary uterine contractions -Labor down; Correct breathing -Rest between contractions; privacy -Instructions on how to "bear down"-No Valsalva

fetal assessment during labor

Fetal assessments are preformed to identify signs of well being and those that suggest compromise. Due to labor stage 1 and 2 periods of physiologic stress for baby , frequent monitoring may be needed. Goal is to promote placental functioning during normal labor. -toco is the circle part on top of fundus -bottom circle is ultrasound (use Leopold's maneuver) Uterine activity on lower grid. Intensity and resting tone (uterine muscle tone before labor or during contraction interval) from 0 to 100mmHg Vertical lines on both grids are time divisions. Dark vertical lines = 1 minute, lighter lines = 10 second segments. Ch. 14 ATI: category I- good, baseline 110-160, 6-25 beat difference -late and variables are not category I -absent or minimal variability: NOT good sign -variable: cord compression

non-pharmacologic techniques

Relaxation—quiet environment, reduces tension, promotes uterine blood flow, promotes efficient contractions, increase self control and focus on normality of birth Cutaneous stimulation-self massage (effleurage—touch stimulates path to brain) Thermal stimulation—hot, cold therapy, warm pack to back, cool cloth to forehead Massage by others— counter pressure —with tennis balls or other firm objects, low back labor Touch—acupressure points Hydrotherapy—warm water, use of shower, whirlpool, increase coping Women who ambulate & reposition report increased satisfaction with birthing process. Mental stimulation—imagery, focal point Breathing—cleansing breath, slow paced, modified paced breathing, patterned paced breathing, breathing to prevent pushing Intradermal injections of sterile water for severe back pain. (for OP moms) 0.1 ml fluid in 4 areas, will feel stinging with injection, most women relief for 60-90 minutes, use time to reposition mother to optimize rotation of fetus to anterior position, gives mother chance to rest from intense pain

contraction cycle

Increment, Acme, Decrement: 1.Frequency (how often contractions are occurring-start of one contraction to the beginning of the next contraction-minutes; 2.Duration (length of contraction from beginning to end-seconds: 3.Intensity (strength of contraction-mild (nose), moderate (chin), strong forehead). True measurement only with IUPC. Resting tone dangerous if less than 30 secs. Upper 2/3 contracts actively to push fetus down Lower 1/3 remains less active promoting downward passage of the fetus. Cervix is also passive The downward push from the upper uterus is accompanied by reduced resistance to fetal descent in the lower uterus.

Management of cord prolapse

Monitor FHR after AROM Trendelenburg or knee chest position Manual elevation of presenting part May need c-section—O2, tocolytic, explain to mom what is happening, remain calm, work quickly.

Amniotic fluid embolism:

NOT on exam *An amniotic fluid embolism, referred to as anaphylactoid syndrome of pregnancy, may occur in pregnancy, labor, delivery, and the immediate postpartum period. *An amniotic fluid embolism is caused when amniotic fluid enters maternal circulation and is associated with a maternal mortality rate of 32%. *Initial symptoms include respiratory failure and cardiac arrest. *If the patient survives an amniotic fluid embolism, she is at risk for hemorrhagic shock with disseminated intravascular coagulation.

Complication of Intrapartum: Cord Prolapse

Prolapsed umbilical cord slips downward after the membranes rupture, subjecting it to compression between the fetus and the pelvis. May slip down immediately with fluid gush or long after membranes have ruptured. Interruption in blood flow through the cord interferes with fetal O2 and is potentially fatal. -goal is get cord off head and go for c-section Signs: May or may not be visible. May be able to feel pulsations with vaginal exam. Occult—may see changes on FHR—variable decelerations or prolonged bradycardia.

pain management during labor:

Unique pain in childbirth Pain is a universal experience, but difficult to define Involves 2 components: 1.Physiologic - reception by sensory nerves and transmission to the central nervous system 2.Psychological- recognizing sensation, interpreting it as painful and reacting to the interpretation Pain is subjective and personal. Childbirth pain differs in that it: 1.Part of a normal process—as opposed to other pain due to trauma, injury 2.Prep time exists—Pregnant woman has time to prepare, acquire skills to help manage pain, learn about birth process 3.It is self-limiting—It has a foreseeable end. Although intense, it will end in hours rather than days, weeks, months 4.Labor pain is not constant, but intermittent—even during labor woman can be reasonably comfortable between contractions 5.Labor ends with the birth of a baby—Care about fetus often motivates woman to tolerate more pain during labor. Emotional significance of birth.

Renee is a 22-year-old G2 P0 at 42 weeks of gestation in active spontaneous labor. Her pregnancy has been complicated by mild hypertension, but no medications were needed. She is 4 cm/100/0 station, vertex position. Her membranes have just ruptured, and there is thick meconium staining. She is comfortable and using epidural anesthesia.

What risk factors are present that may impact the way this fetus tolerates labor? ◦Mild hypertension, meconium staining, ROM (changes to make sure temp is checked every 2 hours, everything else is 15-30 minutes depending on phase of labor) ◦Meconium: respiratory distress- can suck it into their lungs when they take first breath on their own ◦Have to suction before takes first big breath, nose and mouth, appropriate team there ◦Have to look at vocal cords and suction ◦Just because meconium doesn't mean baby will aspirate but greater risk ◦42 weeks is post-date -Want to monitor her BP closer, checking reflexes, asking about headache -Mild hypertension can turn into preeclampsia really fast -Vertex: head down -transverse: sideways, arm first (can be horrible) -4cm is active labor (contractions about every 3 minutes, lasting around 60 seconds, breathing through contractions) -zero station: engaged -epidural: BP, catheter, manage pain (1-2 L of fluid prior to epidural to prevent hypotension), relaxes mom right away and have drop BP and have fetal distress but fluid can try to help. Hypotension is very likely immediately after, want to prevent

a labor patient has:

been admitted to the hospital for a total of 18 hours. Her membranes are intact, and her last vaginal exam was reported as 6/80%/0 station. 1. What stage of labor is the patient in? Active phase of 1st stage of labor, head is engaged, cervix is getting thin2. What priority nursing interventions are required at this time? Fetal heart tones (NST), VS every 15 minutes can do doppler for full minute and need to hear for any decelerations in fetal heart tones internal: only used if needed external toco: top of fundus, show contractions (Does NOT show how strong*) need to palpate, mom's mood -6-8 cm (fetal monitor on entire time) -magnesium sulfate: continuous monitored -fetal heart tones in relation to contraction, VS, is water broke, is she continuing to leak clear fluid? -how is she doing with relaxation and breathing, is it time for epidural or narcotic -position change

gas exchange:

can be as simple as positioning

intrapartum:

client during labor phase

family support impacts

her progression into labor (how does she feel, what resources does she need?)

uterine contractions

primary uterine contractions a. Involuntary muscle activity b. mom cannot stop, but medically we can stop or slow them down secondary uterine contractions a. maternal expulsive efforts b. Voluntary muscle activity

if mom is hypotension:

she is hypoperfusion*

nitrous oxide

—"laughing gas" see with dental procedures 1.Colorless, almost odorless, tasteless gas 2.Mechanism not well understood—stimulate endorphins and give euphoric effect 3.Rapid onset—30-60 seconds 4.Quick clearance—prevent accumulation in tissues 5.Remain awake, alert, have sensory and mother functioning, remain ambulatory 6.Does not alter uterine activity 7.50% oxygen 50% nitrous 8.Can change to another form of pain management if not satisfied with nitrous—used in early labor 9.N/V (5- 36%); vertigo (39%) 10.Crosses placenta—quickly eliminated-no CNS or resp. depression 11.Less costly, self administered, others can't hold the mask, is pain free -patient controls it, reversal is oxygen

positioning

•Change positions often A specific maternal position may help reduce discomfort and assist the labor process. Encourage woman to assume any position she finds comfortable other than supine and change positions frequently. Movement and frequent position changes decrease pain, improve maternal-fetal circulation, improve strength and effectiveness of contractions, decrease the length of labor, facilitate fetal descent, and decrease perineal trauma and episiotomies. "Back labor"—is common when the back of the fetal head puts pressure on the woman's sacral promontory (OP position)—hands and knees, leaning over birthing ball—encourages fetus to move away from sacral promontory. SHOW COUNTERPRESSURE Change positions often

electronic monitoring - internal

•Fetal scalp electrode (FSE), an internal fetal heart monitor •Intrauterine pressure catheter (IUPC), an internal contraction monitor More precise measurement, heart tones and contraction intensity After ROM Clip attaches to fetal head, may be applied to buttocks in breech position, avoid face, genitals, fontanels Spiral electrode in scalp—detects electrical signals from fetal heart (placed 1 mm). Can get displaced Cervical dilation needed Increase risk of infection-try to avoid in GBS+ Protrudes from vagina and attaches to a leg plate on mom's thigh -if HR range is 140-150, HR = 145 on NST

Induction and Augmentation of Labor

•Induction: Measures used to begin labor •Augmentation: Measures used to increase the strength of labor

Oxytocin (Pitocin)

◦2 channel pump ◦Isotonic IV solution as primary mainline fluid ◦Start slowing, increase gradually 0.5 mU /min ◦Increase 1-2 mU/min every 30-60 min ◦Constant monitoring of mom and baby ◦Sometimes oxytocin, once 3-4 cm, break water Augmentation of labor is stimulation of contractions to promote progression in labor that started in some normal manner. Ch. 15 p. 406-410 Pitocin given as secondary infusion Insertion of oxytocin line close to venipuncture Start slowly and increase infusion rate gradually Monitor uterine activity and FHR frequently Low dose = 0.5 millunits/min, increase 1-2 millunits every 30-60 minutes High dose—increase dose up to 6 milliunits/min Reduce or stop infusion with non reassuring FHR Position woman on side Give O2 by snug facial mask

induction readiness

◦BISHOP SCORE ◦Assess cervical readiness ◦Confirm 39 weeks gestation ◦Informed consent ◦Favorable cervix—most important to predict for success FYI- NOT exam* Used to determine how easily a woman's labor can be induced. Higher scores have greater likelihood of success because cervix has undergone "ripening" pre-labor changes to cervix Multi = score > 5 Primip = score > 7

Amniotomy (Artificial Rupture of Membranes)

◦Baseline FHR ◦Monitor following procedure ◦Characteristics of fluid ◦Monitor temp every 2-4 hours ◦RISK—CORD PROLAPSE ◦Presenting part not engaged ◦Breech ◦Polyhydramnios Prolapse—Do not try to replace cord—trauma, decrease blood flow thru cord, can cause umbilical artery spasm. May see sudden onset of persistent variable decelerations or prolonged bradycardia. Elevate presenting part off of cord. Ch. 15 p. 388-389

third stage of labor

◦Birth of baby to expulsion of placenta ◦Contractions continue ◦Signs of placental separation ◦Cord lengthens ◦Uterus has globular shape—rises up in abdomen ◦Sudden gush of blood ◦Administer meds as ordered ◦10-40 units of Pitocin in 1000ml of LR or 10 units IM with delivery of anterior shoulder ◦Vastus lateralis IM -Third stage begins with the birth of the baby and ends with the expulsion of the placenta. -Shortest stage 5 - 30 minutes (if not delivered in 10 minutes- pulling on cord, massaging fundus) Placenta can detach and have another medical emergency -Signs of placental separation -Lengthening of cord; Gush of blood (trapped behind placenta); Uterus rises upward in abdomen as placenta descends into the vagina and pushes the fundus upward. -After separation, placenta can be delivered having mother bear down. -Prevent fluid loss -Maintain safety and prevent trauma Delayed cord clamping help prevent iron deficiency in childhood; improved fine motor and social skills in children at age 4, especially boys. (JAMA Pediatrics) -with tub: have equipment ready in case she delivers

Pharmacologic Pain Management

◦Effects on: ◦Fetus ◦Woman ◦Labor ◦Timing is key - active phase, 5-6 cm (epidural or narcotics)** 1.Effects on fetus may be indirect or secondary to maternal effects = maternal hypotension = decreased blood flow to placenta. May be direct = decrease FHR 2.Maternal—physiologic alterations 1.Cardiovascular- supine = compression of aorta and inferior vena cava = need to displace uterus 2.Respiratory - reduced respiratory capacity, breathes more rapidly, deeply, more vulnerable to reduced arterial oxygenation during induction of general anesthesia and inhalation anesthesia. 3.GI—vulnerable to regurgitation and aspiration due to displacement of stomach, progesterone also slow peristalsis 4.Nervous system—endorphins and enkephalins (natural substances with analgesic properties) are high These modify pain perception and reduce requirements for analgesia and anesthesia. 3.Effects on course of labor—given when labor is well established to avoid slowing. Consider adverse effects of excessive pain on labor progress regardless of cervical dilation 4.Complications—Complications may limit options for pain management. Heart disease and large volumes of fluid could be detrimental. 5.Interactions with other substances—recent ingestion of illicit drugs, alcohol, herbs may have fewer pain management options due to interactions (alcohol and opioids = respiratory depression Antagonist/agonist substance that blocks another substance=withdrawal Nubain mixed opioid

#3 passenger - fetus, membranes, and placenta

◦Fetal skull—overlapping at sutures ◦Fetal accommodation to passageway ◦Lie-longitudinal or transverse ◦Attitude-flexion -B when face is presenting first: NO vaginal, c-section Anterior fontanel has a diamond shape formed by the intersection of 4 sutures—2 coronal, 1 frontal, 1 sagittal. Connects the 2 frontal and 2 parietal bones. (closes 18 months) Posterior fontanel is very small and looks like a slight indentation in the skull. (closes 2 months) The sutures and fontanels allow the bones to move slightly, changing the shape of the fetal head so that it can adapt to the size and shape of the pelvis by molding (shaping the fetal head during movement through the birth canal) Sutures and fontanels provide important landmarks to determine fetal position (relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis) and head flexion. Fetal head diameters Most fetuses enter the pelvis in the cephalic (head) presentation. Fetal lie the orientation of the long axis of the fetus to the long axis of the woman. Relationship of the spine of the fetus to the spine of the mother.

Psychosocial Concerns

◦General health ◦Physical function ◦Family dynamics ◦Financial considerations ◦Postpartum recovery -Entire family affected. Often unexpected. -Identify their greatest concerns and needs. What concerns you the most? -Help them cope—How have they coped with stressful situations in past? -Financial concerns—off work, any leave time, cost of care during pregnancy -Household concerns—chores at home, other children—they may be aware of parent's stress, anxiety, depending on age may not understand mom can't play, School age children may understand and be helpful. Adolescent may resent intrusion. -Provide information—knowledge can help decrease fear and anxiety of unknown. -Promote expression of feelings—concerns and constructive ways to deal with these—finances, effect on family—social worker, church. Teach what may occur—NICU, or transferred to one -Identifying appropriate activities—Help her understand her restrictions and why she cannot do certain things. Identify activities that will keep them occupied and busy. May be able to do some work at home -Change physical surroundings-identify 2 areas where she can maintain rest. Helps woman be more willing to reduce activities and feel a part of the family. -Access to phone, computer, play board games with kids, watch movies, knitting, hobbies, etc.

Induction of Labor - indications

◦Hostile environment (preeclampsia) ◦SROM/chorioamnionitis ◦Hypertension ◦Worsening conditions ◦Post term ◦Fetal death (best for vaginal vs. c-section)

Risks of Induction/Augmentation

◦Hypertonic uterine contractions (overstimulated) ◦Uterine rupture ◦Water intoxication (IV fluids; SE of Pitocin) ◦Increased risk of requiring cesarean ◦Increased risk chorioamnionitis (invasive) Hypertonic uterine contractions reduce uterine blood flow > 5 contractions per 10 min Uterine rupture—tear in uterine wall; complete, incomplete, dehiscence—cause previous surgery, high parity, trauma, CPD cephalo pelvic disproportion May see: abdominal pain and tenderness, "something ripped", chest pain between scapulae or on inspiration d/t pain below the diaphragm, hypovolemia, shock, impaired fetal O2, cessation of contractions, absent fetal heart activity, palpation of fetus outside the uterus—fetal demise Water intoxication r/t prolonged administration—HA, blurred vision, behavioral changes, increased BP, RR, wheezing, coughing. I & O Nullips 3 times more likely to have CS

Regional Pain management Epidural Nursing care

◦IV fluids—preload bolus ◦Assist during initiation of epidural ◦Assess maternal vital signs and fetal heart rate frequently ◦Observe for bladder distension ◦Observe for and report side effects -can have struggle pushing and respiratory distress for mom at first possibly Epidural block 1.Pain relief for labor and birth 2.Start after labor is established—1st stage (active phase) 4 - 5 cms 3.Allows for continuous or intermittent administration of medications 4.Puncture of dura may cause leakage of CSF and result in "spinal" headache 5.Blocks pain of uterine contractions 6.Used for vaginal and C-section births 7.Medication injected between the 4th and 5th lumbar vertebrae into epidural space 8.Epidural opioid include—fentanyl (sublimaze), sufentanil (Sufenta), ropivacaine (Naropin) and morphine (duramorph, astramorph) Nursing Care 1.Start IV, and give prescribed preload of fluids 2.Obtain baseline maternal vital signs and FHR patterns for comparison after block is started 3.Support the woman in the correct positon and inform anesthesia if woman is having a contraction. Assist her in remaining still. 4.Woman may feel brief "shock like" sensation as catheter is being passed 5.After injection, observe for signs of subarachnoid puncture or intravascular injections. 6.Monitor VS, FHR frequently--AWONN—BP and FHR every 5 minutes during first 15 minutes after epidural initiated. Repeat at 30 minutes and I hour after procedure. 7.Assess bladder frequently r/t large fluid dose and reduced sensation to void. My need catheter. 8.Observe for migration of catheter, nausea, vomiting, pruritus. Maternal hypotension Bladder distention Prolonged second stage Catheter migration Cesarean birth Maternal fever Epidural opioids Spinal Simpler procedure than epidural Injected into subarachnoid space where the medication mixes with CSF. Single dose of medication. Use smallest needle possible to reduce chance of headache Preformed just before birth providing no pain relief during labor Loss of both sensory and motor function below the level of the subarachnoid block Hypotension more likely—treated with larger volume of preload IV fluid "spinal headache" Postural puncture headache—worse when upright, may disappear when flat Bed rest and fluids, caffeine, blood patch—injection of 10 -20 mL of woman's blood (obtained with sterile technique) into the epidural space. Blood forms a gelatinous seal over the hoe in the dura stopping leakage of CSF. Can be repeated General—used when needed for emergency situations Maternal aspiration of gastric content—airway obstruction, infections, respiratory depression—see with infant r/t if interval between delivery and cord clamping prolonged, uterine relaxation-post partum hemorrhage (3 minutes to deliver baby)

Cesarean Birth

◦Indications: shoulder dystocia, hypertension, active herpes, maternal diseases, previous c-section, non-reassuring FHTs, prolapsed cord, fetal mal-presentation, hemorrhagic conditions ◦Risks: Infection, hemorrhage, thromboembolism, anesthesia complications, injuries to baby or mother ◦Nursing Considerations: ◦Emotional support ◦Teaching ◦Safety ◦Post operative care ◦Vaginal Birth After Cesarean (VBAC) -With general: no support people, baby out in 2 minutes top

nursing care during labor

◦Keep team informed of progress Comfort measures ◦Lighting -bright lights irritating ◦Temperature—hot/perspiring with effort of labor ◦Cleanliness—bloody show and leaking amniotic fluid ◦Mouth care-ice chips, lip balm ◦Bladder-full bladder delays fetal descent ◦Assess for dehydration ◦Support person's response ◦Positioning ◦Assessment of cervix, station, contraction pattern, FHT's, membranes, vital signs Encouragement—Tell the woman her labor is progressing. Praise the woman and her support person when they use breathing and other coping mechanisms effectively. This reinforces their actions, gives a sense of control and conveys respect and support of the nurse. Giving of self—importance of the presence of the nurse. Become dependent and need human contact. Woman needs reassurance that all is going well and the nurse is there for her. Gives sense of safety, acceptance, support, comfort. Often welcome suggestions from the nurse. Skilled , empathetic and intuitive bedside nurse. Being there for them. Provide comfort measures 1.Soft indirect lighting is soothing. Bright lights irritating. 2.Labor is hard work. The woman is often hot and perspiring. Cool, damp clothes on woman's face and neck. Fan may help 3.Bloody show and AF leak from vagina during labor. Change sheet and gown as needed to keep dry and comfortable. Be aware of where she is in labor, may not want to be touched or bothered. Change under pad regularly to reduce microorganisms that may ascend into vagina. Folded towel may help absorb fluid better. 4.Dry mouth can be common during labor. Offer ice chips, frozen bars, hard candy. Brush or rinse mouth, Lip balm for moisture 5.A full bladder intensifies pain during labor and can delay fetal descent. Empty bladder every 2 hours or check suprapubic area if epidural. 6.Assess hydration 7.Support person's response—accept whatever pattern of support the partner is able and willing to provide and is comfortable to the couple. Do not take over partner's role. Encourage partner to conserve strength, eat and drink. May need a break Use of pharmacologic measures—may have plans to use or not use. Nurse must be informative and neutral as to what is available. Careful review of the woman's birth plan, discussion of options and let her know she can change her mind. Elimination of pain is not a realistic goal. The goal is for a positive birth experience.

fourth stage of labor - care of infant

◦Maintain cardiopulmonary function ◦APGAR scoring ◦Thermoregulation ◦Identification of infant ◦Provide Skin to Skin time ◦Initiate Breastfeeding

Danger signs during labor (noticing, interpreting):

◦Maternal BP > 140/90 or < 90/50 ◦Elevated maternal temperature > 100.4 F ◦Amniotic fluid that is green, cloudy, or foul-smelling ◦Non-reassuring FHR patterns ◦Prolonged uterine contractions > 100 seconds ◦Failure of uterus to relax between contractions ◦Heavy or bright red bleeding ◦Unrelenting pain, RUQ pain, visual changes ◦How would the nurse respond? What would these indicate? What would you do? Impending seizure—N/V, HA, pain, RUQ, visual changes

Cervical Ripening Balloon

◦Mechanical pressure directly on cervix as balloon is filled ◦Foley catheter or specifically designed balloon device ◦Removed after 6 hours, when membranes rupture, or spontaneous expulsion of balloon ◦Done with fetal demise, might to hemabate, keep them very sedated and drugged up because we don't have to worry about baby (as comfortable as can be) Remove after 6 hours, ROM or spontaneous expulsion of balloon. Uterine balloon side first, vaginal balloon side second—dilates cervix by gentle constant pressure at the level of cervix from both internal/external os. Sterile water, 30-50 ml saline balloons, 1 liter IV fluids end of bed.

induction

◦Medical Methods—Prostaglandins (ripen/soft cervix, sometimes encourage moms to have sex because sperm does this as well) ◦Cervidil (Dinoprostone)- vaginal insert ◦Cytotec (Misoprostol)- Orally or vaginally ◦25-50 mcg orally ◦25 mcg vaginally (put in capsule and right up into cervix) - can't remove it -fetal monitoring Cervical Ripening Prostaglandins—enable cervical ripening, relax smooth cervical muscles, increase intracellular calcium levels causing contraction of myometrial muscle. Medical methods--Prostaglandin E2 (PGE2)—intravainal gel, intracervical gel, timed released vaginal insert Cervidil (dinoprostone) —10 mg cervical vault for 12 hours, pull cord Prepidil (dinoprostone gel)—0.5 mg every 6-12 hours, max 1.5/24 hrs; 25 vag Cytotec (Misoprostol) prostaglandin E1 (PGE1)-usually given for gastric ulcers, can be used for cervical ripening and induction of labor. Off label use 100 -200 mcg tablets. Usual dose is 25 mcg and placed high in the vaginal. Low cost and effective. An oral dose of 100 mcg has also been reported to be effective. Major side effect is hyperstimulation of uterine contractions. Given where there is availability of EFM and emergency care—C-section—monitor FHR for at least 30 minutes after given. In bed recumbent x 30 min—continuous EFM at least 3 hours before ambulation. Another method cervical ripening balloon

Vaginal Birth: Local Anesthesia for Repair

◦Not for labor pain ◦Used locally for episiotomy or tearing repair Anesthesia for episiotomy Adverse effects are rare Used to numb the perineum just before birth to allow for episiotomy and repair 10 - 20 mL of 1% lidocaine or 2 % chloroprocaine into the skin Epinephrine often added to solution to localize and intensify the effect of anesthesia

first stage of labor

◦Onset of regular contractions and ends with complete dilation (10 cm) and effacement (100%) Three phases: latent (0-3 cm), active (4-7 cm), transition (8-10 cm) Early/Latent: 0-3 cm (0-4) Nulliparous: 7.3 - 8.6 hours Multipara: 4.1 - 5.3 hours Frequency: 30 to 5 minutes apart Duration: 30 - 40 seconds Intensity: mild to moderate Low backache, may sweep to lower abdomen, discomfort increases as labor progresses Sociable, excited, somewhat anxious Active: 4- 7 cm (5-7) Nulliparous: 8 -10 hours (range 6 -18) dilates 1.2 cm/hr Multiparas: 6-7 hours (range 2-10) dilates 1.5 cm/hr May vary with epidural anesthesia. May help shorten labor. Frequency: 2-5 min apart Duration: 40 - 60 seconds Intensity: moderate to strong Discomfort increases More anxious, may feel helpless, serious inward focus, unlikely to initiate interactions Transition: 8 - 10 cm Nulliparous: 3.6 hours Multiparas: 0 - 30 minutes Frequency: 1 ½ - 2 minutes Duration: 60 - 90 seconds Intensity: strong Short, but intense. Urge to push, leg tremors, nausea, vomiting may occur. Help woman blow if bearing down is a problem. Irritable, lose control, partner may be confused because actions are no longer helpful

Systemic analgesia

◦Opioid analgesics ◦Sublimaze (Fentanyl) ◦Butorphanol (Stadol) - does go to babies ◦Nalbuphine (Nubain) ◦Epidural: goes to CNS, generally not to baby ◦Narcotics go to baby and make it sleepy, born within 2 hours going to have respiratory distress, need Narcan ready Parenteral analgesia— 1.opioid analgesics are most common. Reduce pain without loss of consciousness. Demerol (meperidine) fentanyl (sublimaze), stadol (butorphanol), nubain (nalbuphine). Fentanyl is a pure opioid agonists (substances which cause a physiologic effect), nubain and stadol have mixed opioid agonist and antagonist ( substance that blocks another substance or body secretion). Risk of respiratory depression in newborn. Given in small, frequent amounts May be delivered by PCA (patient controlled analgesia pump) 2.Opioid antagonists—Narcan (naloxone) reverse opioid induced respiratory depression. Seldom used. May be given to neonate for respiratory depression, but airway management takes precedence over use of naloxone. 3.Adjunctive drugs—Phenergan (nausea and vomiting) , Atarax or Vistaril (antihistamine and antiemetic)—only given IM large deep muscle with Z track technique 4.Sedatives—Not usually given because they have prolonged depressant effects on the neonate. Small, short acting dose may promote rest if fatigue from false labor or prolonged latent phase. Advantages: 1.Increased ability for the woman to cope with labor 2.Medications can be nurse administered 3.Given to promote analgesia during labor Disadvantages 1.Frequent occurrence of uncomfortable side effects such as nausea, vomiting, pruritus, drowsiness and neonatal depression 2.Pain is not completely eliminated

induction of labor - contraindications

◦Placenta previa (c-section) ◦Abnormal presentation ◦High station (not safe, running risk of prolapsed cord) ◦Classical uterine incision (vertical, can never vbac, cutting against the muscles and not with them) Any contraindication to vaginal birth Hostile uterine environment SROM with chorioamnionitis Hypertension, preeclampsia Worsening medical condition Post term—aging placenta Contraindications: Previa-result in hemorrhage High station—cord prolapse Previous surgery in upper uterus. Classical uterine incision

#3 passenger - fetus, membranes, and placenta (continued)

◦Presentation -Part of fetus that enters pelvis FIRST ◦Station-descent past ischial spines ◦Position- LOA ROP... ◦Is it engaged or ballotable ◦Bouncing up and down is not engaged The fetal part that first enters the pelvis is termed presenting part. Falls into 3 categories—cephalic, breech, transverse (shoulder) Cephalic most common, other presentations may prolong labor or cause other problems and more likely to have C-section Usual head flexed into chest (smallest diameter) ovoid occiput presents vertex presentation Vertex or an occiput presentation most favorable for vaginal delivery Military = head is in a neutral position, neither flexed nor extended Brow = head partially extended. Largest diameter Face = head hyper-extended (largest diameter) Fetal position describes the location of a fixed reference on the presenting part in relation to the four quadrants of the maternal pelvis The 4 quadrants are the right and left anterior and the right and left posterior. Abbreviations are used to describe the relationship (LOA-occiput in left anterior quadrant of mom's pelvis) First letter: R or L mother's pelvic side. If neither to R or L, the letter is omitted Middle letter: refers to the fixed fetal reference point which varies with the presentation O (occiput) is used in the vertex presentation M (mentum or chin) is the reference point in a face presentation S (sacrum) is used for breech presentations F (fronto or brow) presentation SC (scapula or shoulder) presentation Final letter: location of presenting point in relation to maternal pelvis A= anterior P = posterior T = transverse (neither A or P) Engagement—widest diameter of fetal presenting part (usually the head) has passed through the pelvic inlet and entered the pelvic cavity. Presumed to have happened when the presenting part reaches maternal ischial spines (0 station) Level of ischial spines is zero station. Other stations are described with numbers representing the approximate number of centimeters above (negative) or below (positive) the ischial spines. As fetus descends statin changes from higher negative numbers (-3, -2, -1)to zero to higher positive numbers (+1, +2, +3) POSITIVE= PUSH Engagement often takes place before onset of labor in nulliparous. In parous and some nullips does not occur until labor begins.

electronic monitoring - external

◦Ultrasound transducer belt ◦Reposition as fetus moves (explain to parents) ◦Mom can ambulate Not a replacement for nursing assessment Needs intermittent assessment Devises are secured on abdomen by ultrasound transducer belt, elastic straps a tube of wide stockinette, or adhesive ring. Less accurate than internal, noninvasive Do not require dilation or ROM Doppler ultrasound detects movements Tocodynamometer or toco with a pressure sensitive area detects changes to abd. Contour to measure uterine activity Movement other than uterine activity also registers, e.g. respirations, fetal hiccups