Unit 5 Birth Experience

cephalic presentation

birth position in which any part of the head emerges first. It is the most common presentation

placental stage (3rd stage)

birthing stage in which the placenta and umbilical cord are expelled from the mother's body

FHR accelerations

reassuring; abrupt increase of 15 bpm of at least 15 beats lasting at least 15 sec (15X15) (10X10 in preterm); usually caused by fetal movement,often accompany contrxn

measuring progress in labor

recorded on a partogram, type/amount of anesthesia, dilation effacement and fetal station, and norms

vacuum extraction

with fetal head at perineum, a disk shaped cup is pressed against the fetal scalp over the posterior fontanelle and traction is applied to guide the fetal head out when the mother pushes.

Fetal factors (labor triggers)

1. Placenta reaches set age and begins deteriorating 2. Rising fetal cortisol levels, which reduces progesterone formation and increases prostaglandin formation 3. Fetal membrane production of prostaglandin, which stimulates contractions

hypotonic contraction

# of contractions unusually infrequent (less than 2-3 in 10 minutes); resting tone less than 10 mm Hg and strength of contrxn does not rise above 25 mmHg; active phase of labor*tends to occur after the admin. of analgesia, esp. if not dilated past 3-4cm or full bowel/bladder preventing fetal descent or engagement *multiple gestation, LGA fetus, hydramnios, grand multiparity *not especially painful (but pain is subjective....)*increased risk of PP hemorrhage (increased length of labor and also ineffective PP contraction of uterus)

anesthesia

causes partial or complete loss of pain sensation

Intrauterine Pressure Catheter (IUPC)

A catheter that can be placed through the cervix into the uterus to measure uterine pressure during labor.

Tocometer

Monitors contractions

Passenger

fetus and placenta

discharge planning s/p c-section

redness or drainage at incision line lochia heavier than a normal menstrual period Abdominal pain other than suture line or after pains Temp greater than 100.4F Frequency or burning on urination Sexual activity can be resumed when allowed by provider

complete breech

fetal buttocks in contact with cervix; similar to frank breech BUT the legs are flexed (folded) against fetal body (like vertex presentation but upside down)

physiological causes of labor pains

fetal size in relation to maternal pelvis history of dysmenorrhea (higher levels of prostaglandins) labor position presence of endorphins helps with maternal sense of well-being and response to labor

face presentation

fetus has extended the head to make the face the presenting part (extreme bruising, edema and distortion of the face may occur)

Augmentation of labor

refers to assisting labor that has started spontaneously but is not effective. Can be done by giving pitocin IV or artificial rupture of membranes (amniotomy).

INDUCTION of labor by oxytocin...(after a cervix is 'ripe')

*Administration of oxytocin initiates contractions in a uterus at pregnancy term. *Oxytocin is ALWAYS administered IV PIGGYBACK so that it can be quickly discontinued. Connect at the port closest to the patient. *FHR is monitored continuously and maternal VS are monitored q15-30min

diagnostics and procedures prior to c-sect

*VS, UA, CBC, PT/PTT, Electrolytes, pH, Type&Cross, US *hygeine (hair back, clean gown, jewelry off), GI prep (emptying), Baseline I & O (place f/c), hyrdation (large g IV patent), pre-op meds

Occipitoposterior position

- (ROP or LOP Position)- woman may experience back pain, forceps may need to be used

Intrathecal Narcotics during labor

- (injection into the spinal cord) analgesia/anesthesia (during labor and cesarean birth)

Preliminary signs of labor

- Lightening - Increase in level of activity (full of energy, nesting) - Braxton Hicks contractions - Ripening of cervix - Bloody show (mucus plug expelled) -Membrane rupture (2 risks: infection and prolapsed cord) -Weight loss -GI disturbances (N/V/D) -Uterine contrxns(regular interval and strong)**sign of TRUE labor**

Periodic changes in FHR

- acceleration and deceleration IN ASSOCIATION WITH contractions; early, late and variable

disadvantages pf breech presentation

-increased risk for cord prolapse (presenting part doesn't completely cover the cervix to "seal" it) -presenting part not smooth (like fetal head) to ensure adequate pressure on cervix for dilation/effacement -dangerous during delivery - largest part of fetus (head) delivers last and can get stuck (this is an EMERGENCY) or cord can become compressed after delivery of fetal body with head entrapped

advantages to cephalic presentation

-largest part of fetus- if it can pass, so can the rest of fetus (usually...) capable of molding to fit canal as labor progresses -smooth and round - puts even pressure on cervix for dilation and effacement

Responses to labor

-response to pain (strongly influenced by cultural factors) -response to fatigue (sleep hunger make it diff for a woman to perceive clearly or adjust to rapidly changing or new situations), -response to fear (women who have a sense of control and knowledge have a decreased fear and that is better for mom, baby and nurse.)

ethnicity and c-section

AA 34%, white 32%, Asian 31%, Hispanic 30%, Native American 28%

"P"'s of Labor

1. Powers (uterine contractions PLUS maternal pushing effort) 2. Passageway (maternal pelvis-adequate size and contour) 3.Passenger (fetus and placenta) 4. Passenger/Passageway relationship (advantageous position and presentation, appropriate size) 5. Psychosocial Influences (previous experiences, emotional status) 6. Position (not yet established as 6th "P")

4 Maternal Factors That May Trigger Labor

1. Stretching of uterine muscles; release of prostaglandins 2. Estrogen/progesterone changes; "progesterone withdrawal" 3. Oxytocin release; initiate contrxns 4. Fetal pressure on the cervix

inversion of uterus prevention

1.) not putting pressure on an uncontracted fundus immediately after birth 2.) not exerting pressure on the umbilical cord to achieve placental delivery

anomalies of the cord

2 vessel cord, unusual cord length

When can the mother begin to push?

AFTER complete dilation and effacement of the cervix, the mother may feel the urge to "bear down" or push due to the pressure of the fetus on the pelvic floor nerves. The cervix MUST be completely dilated for pushing to begin or swelling/trauma of the cervix can occur. (10cm/100%)

dilation stage of labor

3 phases: Latent , Active and Transition

breech presentation facts

3% of births present breech increased in preterm births (haven't had time to turn) or with certain fetal abnormalities (i.e. hydrocephalus) possibly D/T abnormalities of the maternal uterus or pelvis usually delivered via C-SECTION

pretreat for epidural

500 to 1000 cc of IV fluid (fluid bolus) is given prior to the epidural to help hydrate her prior to the epidural to help prevent the side effect of hypotension....usually LR

fetal heart monitor

A machine that detects and records fetal heart rate and activity during labor.

Prolonged deceleration

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, rebound tachy indicative of hypoxia; Sometimes seen after epidural block, prolapsed cord, profound ureteroplacental insufficiency, hypertonic uterine contractions, insertions of fetal scalp electrode, rapid descent of fetus, maternal valsalva

Spinal anesthesia during labor

Anesthetic agent injected into subarachnoid space with lumbar puncture technique; produces heavy anesthetic effect and anesthetizes both legs and abdomen to level of umbilicus; used for scheduled cesarean sections and sometimes in an emergency....not used if woman will be pushing. Medication injected, needle removed.

APGAR

Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) done at 1 minute and 5 min after birth

Induction & Augmentation of Labor

Artificial methods to stimulate uterine contractions; Fetus is in longitudinal lie,Cervix is ripe or ready for birth, Presenting part is engaged, There is not CPD, Fetus is estimated to be mature by date (over 39 weeks), demonstrated by lecithin-sphingomyelin ratio or ultrasound biparietal diameter to rule out preterm birth.

Nursing process for woman in labor

Assessment, Nursing Dx, Outcome ID, Planning, Implementation

When minimal or absent variability is detected

Assist pt into a position that promotes oxygenation, assess fetal response to fetal scalp stimulation, assess maternal hyrdation; d/c oxytocin, admin O2 8-10L, more invasive monitoring, offer support and notify provider

baseline fetal heart rate

Average FHR during a 10-minute period that excludes periodic and episodic changes and periods of marked variability; normal FHR baseline is 110-160 beats/min, tachy: >160bpm, brady: <110bpm

admission assessment of woman in labor

EDD FHM over last few days other labor symptoms experienced GTPAL & anesthesia plans time frame of previous labors cultural considerations psychosocial concerns Characteristics of contrxns (when started, duration and freq) Bloody show(amount and character) and membrane status(ruptured? color and amount and odor?)

Maternal responses to labor

CARDIOVASCULAR: CO increases,HR increases,BP increases Fluid and Electrolyte-Water loss occurs with increased respiration and diaphoresis RESPIRATORY RR increases and O2 consumption increases,Metabolic acidosis can occur from muscle activity causing muscle aches/cramps RENAL Increased GFR and polyuria (reduced bladder tone so need to be reminded to pee), SpGrav increases G.I. Gastric emptying slowed IMMUNE WBC increase 25-30000, glucose levels drop

Assessment of contractions

DIF; Duration(how long), Intensity(how strong), Frequency(how often)

Describe how baby presents

Diameters of fetal skull - fetus must present the smallest diameter of head (the transverse or BPD) to the maternal pelvis Molding- change in shape of fetal skull due to overlapping of skull bones along the suture lines produced by the force of uterine contractions pressing the vertex of the head against a not yet dilated cervix.

sinusoidal pattern of FHR:

Don't really fit any classification of variability mooth, undulating wave form Can be indicative of severe fetal anemia or of use of certain types of medications (Stadol)

nursing care after epidural

During regional or general anesthesia administration, if a woman must lie supine, she should have a wedge positioned under her right buttock to help prevent supine hypotension syndrome - "left tilt"; BP/P/R and FHT's monitored closely for 30 minutes following administration of regional- usually q5min. x 30 min

use of general anesthesia during labor

Emergency cesarean birth or woman with contraindication to use of regional anesthesia (refusal, clotting issues) •Ensure patent IV in place (this is why ALL patients should have at minimum a saline lock!) •Oral antacid if there is time (gas) •May give IV Zantac or Tagamet •ELeft tilt insure patent IV in place (this is why ALL patients should have at minimum a saline lock!) •E100% O2nsure patent IV in place (this is why ALL patients should have at minimum a saline lock!) •Commonly, first thiopental IV to produce unconsciousness; always intubated, volatile halogenated agent also possible to produce amnesia, *Aspiration of vomitus can be a fatal complication of general anesthesia

Fetal response to labor

FHR changes d/t pressure on head, decrease in circ and perf during contrxn, labor aids in fetal lung maturation by clearing lung fluid d/t squeezing

placenta circumvallata

Fetal side of the placenta is covered to some extent with chorion.

Dysfunctional Labor and Associated Stages of Labor

First stage •Prolonged latent•Protracted active•Prolonged deceleration•Secondary arrest of dilation Second stage •Prolonged descent•Arrest of descent

recognizing and responding to uterine tachystole

Hyperstimulation; contractions lasting longer than 90 seconds and/or more than 5 contractions in 10 min; caused by cervical ripening agents, induction and augmentation of labor.

Hemorrhage signs and symptoms

Hypotension Weak and rapid pulse Cool and clammy skin Rapid breathing Restlessness Reduced urine output

Unusual cord length

Length rarely varies. *Short cord can result in premature separation from the placenta or an abnormal fetal lie. *A long cord may be easily compromised because of its tendency to twist or knot.

Landmarks of the fetal skull

Mentum (chin), Sinciput (anterior area known as brow), Bregma (lg diamond-shaped anterior fontanelle), Vertex (area b/w anterior and posterior fontanelles), Posterior fontanelle (intersection b/w posterior cranial sutures), Occiput (area of fetal skull occupied by the occipital bone beneath posterior fontanelle)

Anaphylactoid Syndrome of Pregnancy (previously called Amniotic fluid embolism)

Occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after membrane rupture or partial, premature, separation of the placenta. Clinical picture is dramatic- woman in labor sits up and grasps her chest in pain, turns pale, blue-gray, immediate management Oxygen and CPR, if she survives the initial insult the risk for DIC is high. **80% maternal mortality rate

Pitocin (oxytocin) admin info

Pitocin is usually mixed 30 IU in 1000ml of LR. Ten international units of oxytocin is the same as 10,000 (mU) so each ml of this solution contains 10 mU of oxytocin. Doctors orders usually designate the number to millinunits to be administered per minute. Always "piggyback" the oxytocin solution, so if it needs to be turned off, the main line is open. Also, always use an infusion pump!

4th stage of labor

Placental delivery--> maternal stabilization (up to 48hrs for both), VS Q15 x 1 hour, fundus, perineal area, comfort level, lochia and bladder status.

scheduled c-section

Planned - enough time for preparation and teaching of the patient. **previous C-section,breech presentation,transverse position,herpes simplex virus,cephalopelvic disproportion

precipitate labor

Precipitate dilation- cervical dilation that occurs faster than 5 cm or more per hour in a primipara or 10 cm in one hour in a multipara. Precipitate birth -occurs when uterine contractions are so strong that a woman gives birth with only a few rapidly occurring contractions. It is often defined as labor that is completed in fewer than 3 hours. The labor room should be prepared on arrival for a laboring woman who is a grand multipara or a woman with a history of precipitous delivery

Nursing care while promoting comfort during labor

Reducing anxiety with explanations Coping strategies Comfort measures Positioning Childbirth method Pharmacologic pain relief

Passageway

Refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum; Consists of maternal bony pelvis and soft tissues (pelvic floor)

position of fetus

Relationship of a fixed point of fetal presenting part to specific quadrant of woman's pelvis.

umb cord prolapse and tx

a loop of the umbilical cord slips down in front of the presenting fetal part...Prolapse of the umbilical cord is an emergency situation that requires prompt action. TX: relieving pressure on the cord!!! Position a woman quickly either into a Trendelenburg or a knee-chest position to relieve cord compression, or apply manual pressure vaginally to lift the fetal head away from the cord--, O2at 10L by facemask, notify the doctor

effacement

Shortening and thinning of the cervix, measured in percentage

Pitocin (oxytocin) side effects

Side effects: vessel dilation can cause extreme hypotension, take VS every 15 minutes, and monitor uterine contractions and FHR. *Contractions should not occur more often than every 2 minutes or stronger than 50 mm Hg pressure and last no longer than 70 seconds. *Also, pitocin has an antidiuretic side effect that can result in decreased urine flow and lead to water intoxication

Oxytocin (Pitocin)

Stimulates smooth muscle to contract. Helps in birthing process/ expel placenta/fully contracting uterus s/p delivery

opioid analgesics during labor

butorphanol (Stadol),nalbuphine (Nubain), fentanyl (Sublimaze), and meperidine (Demerol), morphine sulfate (NOT to be confused with Magnesium sulfate!!)- advantageous as an analgesic in labor because it has additional sedative and antispasmodic actions- helpful for pain AND relaxing the cervix should be given less than 1 hour or more than 3 hours out from delivery to decrease negative effects to fetus. **May cause nausea/vomiting/respiratory depression

fetal presentation

The fetal body part that enters the maternal pelvis first. The three possible presentations are cephalic, shoulder, and breech.

breech position

by week 38 a fetus usually turns cephalic -meconium staining is not abnormal like in a vertex position.

hypertonic contractions

Uterine contractions that are too long or too frequent, have too short a resting interval, or have an inadequate relaxation period to allow optimal uteroplacental exchange; intensity of contrxn may not be greater than that of hypotonic ctx *occur frequently *most common in latent phase*more than one 'pacemaker' starting contrxn*more painful (tender muscle from no relaxation and anoxia)*dangerous because it leads to fetal anoxia (uterine muscle must relax to allow for filling of uterine arteries)*sometimes a sedative is given to relax the mother and this will also 'relax' uterus; may need C-section if fetal distress is occurring and not resolving

VEAL CHOP

V- Variable <=========C- Cord Compression E- Early Decels <=====H- Head Compression A- Accelerations <====O - OK L-Late Decels <=======P - Placenta

Two vessel cord

absence of one of the umbilical arteries. associated with congenital heart and kidney defects

classifications of FHR variability and possible causes

absent:undetectable:may represent fetal cerebral asphyxia minimal:>2-<5bpm:may be r/t narcs, tranqs, MgSO4, barbituates, anesthetic agents, supine hypotension, cord compression, uterine tachystole, prematurity or fetal sleep moderate:6-25bpm:indicative of fetal well-being marked:>25bpm:believed to be a less common response to fetal hypoxia

uterine rupture

accounts for 5% of all maternal deaths- occurs most commonly with VBAC's with vertical scars. S/S- woman c/o sudden sharp pain during a labor contraction or a tearing sensation Immediate emergency situation-- anticipate use of pitocin to contract uterus and minimize bleeding- emergency laparotomy may be performed. Viability of the fetus depends on extent of the rupture and the time elapsed between rupture and extraction. A woman's prognosis depends on the extent of the rupture and blood loss.

education for c-sect

aimed to prevent complications. **deep breathing exercises post-op (5-10 deep breaths per hour),IS, repositioning, early ambulation **always obtain informed consent (Surgeon does, you make sure it is done)

Scalp stimulation

an acid/base assessment in fetus. The fetal scalp is gently rubbed or pressed on to illicit a response (FHR acceleration) in the fetus.

oblique fetal lie

an angle other than longitudinal or transverse; think diagonal

Intraoperative Care of C-section

anesthesia, skin prep (clipping of hair and cleansing area), incision, birth (begin admin of Oxytocin as placenta is being delivered), introduction of newborn

amniotomy

artificial rupturing of the membranes. The woman's cervix must be dilated at least 3 cm and an amnio hook is used. Always watch the FHR after ROM because the fetus is at risk for cord prolapse - this is an EMERGENCY

amniotomy

artificial tearing of the amniotic sac to induce or expedite labor

3. asssessment

assess placental separation, placental and fetal membranes, vaginal/vervix/perineum

Fetal Scalp Electrode (FSE)

attached to the baby's scalp to record the electrical conduction of fetal heart

Women with cultural concerns

be considerate of her beliefs, female circumcision may have been performed and may affect delivery

Measuring frequency of contractions

beginning of one contrxn to the beginning of the next contrxn; can be seen with tocodynameter "toco"

narcotic analgesics during labor

cause maternal respiratory depression and fetal CNS depression.......use with caution....know approximately how long you have until delivery so the baby will have minimal effects at birth. Preterm fetuses have immature livers and may not metabolize drugs as quickly.

Variable decelerations

caused by umb cord compression, nuchal cord, short cord, or prolapsed cord; vary in onset and occurrence and waveform; abrupt drop remains low then abrupt RTB; classified as: mild, moderate, severe. (V, U, W shaped)

Active phase of labor:

cervical dilation occurs more rapidly, increasing from 4-7cm, longer contrxns; duration: 1cm/hr for primipara, 1.5cm/hr for multipara; Fetal malposition or CPD *may be ineffective myometrial activity--If fetal malpresentation or CPD, c-section may be necessary *oxytocin augmentation if safe

cervical dilation

cervix opens from 0-10cm; occurs for 2 reasons: -increase the diameter of the cervical canal lumen by pulling the cervix up over the presenting part of the fetus. -the fluid filled membranes press against the cervix (if intact); otherwise the fetal presenting part puts pressure on it

Cervical ripening

change in cervical consistency from firm to soft; Bishop score of at least 8 is ready for birth; methods used is 'stripping of the membranes', use of hygroscopic suppositories (laminaria), prostaglandin gel - dinoprostone (Cervidil, Prepidil); Oxytocin should not be started for 12 hours after the last dose--- Also fetal heart rate should be monitored for at least 30 minutes after each dose. Misoprosil (Cytotec) is also used off-label for cervical ripening and induction of labor.

birth

child is considered born when the entire body is expelled-record time, skin-to-skin (promotes fetal temp reg, initation of BF, bonding and release of oxytocin for uterine involution), cut/clamp cord, introduce infant

C-section incision

classic (vertical, no VBAC) low segment/transverse (horizontal, can VBAC)

implementation of care of c-sect

collaboration: CRNA, Surgeon, pediatrician, neonatologist, Recovery room nurses or NICU nurses

Physical exam of woman in labor

complete health and pregancy hx VS between contrxn Leopold's maneuvers Status of membranes Vaginal exam (dilation, effecement, presenting part, fetal station) FHR, position and station pain lab studies(T&S, Rh, CBC, H&H, BGluc, HbsAg screening, HIV-with consent, drig screen if indicated, and UA) IV-large gauge Uterine activity (contrxn timing)

epidural

continuous infusion via pump or intermittent injection through epidural catheter left in back; usually started when dilation >3-5 cm; Chief Concern: Hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space; this is an emergency....blood will be shunted away from uterus and baby resulting in fetal hypoxia!

Powers

contractions and pushing; increment, the acme, and decrement

the acme

contrxn is at its strongest point

Transition phase of labor

contrxns reach their peak of intensity, occurring Q 2-3min with 60-90s duration and cervical dilation 8-10cm, membranes rupture

Where are fetal heart tones best heard?

convex portion of fetus-most often this is the fetal back; FHR can vary greatly during labor

battledore placenta

cord insertion into the margin of the placenta

Cardinal movements of labor

descent, flexion, internal rotation, extension, restitution, external rotation, expulsion

Cervical Assessment

dilation and effacement; Cervical exam stated as dilation/effacement/station (example: 10/100/+1 means: 10cm dilated/100% effaced/+1 station)

stages of labor

dilation, expulsion, placental

Duncan presentation

dull maternal surface of placenta emerges first

complications of labor POWERS

dystocia (dysfunctional labor patterns and prolonged labor, ineffective uterine force (hyper/hypotonic and uncoordinated contrxns)

s/p labor interventions

episiotomy repair, support and inform, FUNDAL CHECKS (r/f hemorrhage), perineal care, bladder status (full bladder=uterus cant contract=continued bleeding=hemorrhage), comfort measures, attachment, teaching, documenting in birth book

fetal position is determined by 3 things:

first letter: where landmark (occiput) is pointing to R/L second letter: denotes fetal landmark (Occiput, Mentum, Sacrum or Acromion process) third letter: defines whether the landmarks most anteriorly (A), posteriorly (P), or transversely (T)

forcep birth

forcep outlet procedure in which the forceps are applied after the fetal head reaches the perineum; before: cervix must be dilated, bladder empty, presenting part engaged, membranes ruptured and without any cephalopelvic disproportion

measuring duration of contraction

from the beginning of a contrxn to the end of the same contrxn; can be seen with tocodynameter

contraction rings

hard band that forms across the uterus at the junction of the upper and lower uterine segments and interferes with fetal descent, usually appears in the second stage of labor. It is a warning sign that severe dysfunctional labor is occurring- may be treated with Morphine sulfate or amyl nitrate may be administered. If not relieved a C-Section may need to be performed to prevent uterine rupture.

vertex presentation

head is FULLY flexed, most common and optimal presentation; smallest diameter presents

military presentation

head is in neutral position..."at attention"...not flexed or extended; top of head presents

brow presentation

head is moderately flexed, the brow or occiput becomes the presenting part

Maternal Danger Signs

high or low BP(>140/90 or rise of 30/15), abn HR (tachy=hemorrhage), inadequate or prolonged contrxns)fetal compromise d/t no rest period), abn lower abd contour(full bladder), increasing apprehension(O2 deprivation or hemorrhage)

Fetal Danger Signs

high or low FHR (>160 or <110), meconium staining (fetal distress), hyperactivity (hypoxia), low O2sat (40-70% is norm for fetus during labor), loss of variability

shoulder presentation most often occurs in:

high parity (uterus stretched) prematurity preterm birth or preterm ROM hydramnios placenta previa

alternative pain relief during labor

hot/cold tx, intradermal water block, relaxation, focus or guided imagery, support person (nurse, doula, spouse), prayer, breathing, holistic tx, , hypnosis, hydrotherapy, effleurage

Woman who is morbidly obese

increased BP, edema, difficulty auscultating FHR and UC's, easily fatigued, respect modesty, baby may be LGA

bony pelvis sections

inlet, midpelvis, outlet

Velamentous insertion of the cord

instead of entering the placenta directly it separates into small vessels

decrement

intensity decreases

increment

intensity of the contrxn increases

Procedures for High-Risk Pregnancies

internal electric monitoring, scalp stim, , fetal O2 sat, fetal blood sampling

physical causes of labor pains

length of labor (short labors more intense...long labors cause maternal exhaustion and fatigue) fetal position (OP can cause back pain, even between contrxn, unrelenting) maternal fatigue (coping mechanisms diminished, can't concentrate) certain interventions (invasive monitoring, IVs, EFM and toco, augmentation, amniotomy, vaginal exams)

regional blocks during labor

local perineal infiltration, pudendal nerve block(perineum/lower vagina affected), spinal anesthesia block(uterus, cervix, vagina and perineum affected), combined spinal-epidural(uterus, cervix, vagina and perineum affected)

transverse fetal lie

long axis of fetus at 90 degree angle to mom; think plus sign

longitudinal fetal lie

long axis of fetus is same as long axis of mom; think parallel

Women who will be placing baby for adoption

may change mind, has a time frame in which woman can decide, offer support

breech presentation

means that either the buttocks or the feet are the first body part that enter the pelvis

Fetal O2 Saturation Monitoring

measured with sensor placed alongside fetal cheek in utero after membranes ruptured.

labor pain relief goal

meds must relax woman and relieve her discomfort yet have minimal systemic effects on uterine contractions, pushing efforts, or her fetus

Electronic Fetal Monitoring (EFM)

method that tracks the fetus's heartbeat, either externally through the mother's abdomen or directly by running a wire through the cervix and placing a sensor on the fetus's scalp

Barbiturates during labor

mild sedation;(secobarbital sodium, pentobarbital

laboring women with unique needs:

morbidly obese woman, women with cultural concerns, drug addiction and tobacco use

frank breech

most common; fetal legs extended straight up against fetal body; buttocks contact cervix

Late decelerations

most ominous if accompanied by decreased variability and/or tachy; smooth uniform shape, begins at the acme of contrxn RTB at end of contrx, repetitive: UNCOIL Un C-change position (left side) O-O2 on, Oxytocin off I-IV fluid L-lower HOB

Internal electronic fetal monitoring

most precise method for assessing FHR and UC's. Fetal scalp electrode (FSE) for the fetus and Intrauterine Pressure Catheter (IUPC) for sensing UC's. These are invasive techniques and carry risks as such.

inlet contraction

narrowing of the anteroposterior diameter to less than 11 cm or of the transverse diameter to 12 cm or less-- usually caused by rickets early in life or a small inherited pelvis.

outlet contraction

narrowing of the transverse at the outlet to less than 11 cm (distance between the ischial tuberosities--and can be done at a prenatal visit or by sonogram)

women w/o support person

needs supportive nurse to remain with her, nurse IS support person

Early decelerations

no associated with fetal distress; caused by pressure on head-vagal response, mirrors contrxns, uniform, smooth waveform; begins at onset and ends with contrxn

Uncoordinated contractions

normally, all ctx are initiated at one pacemaker high in the uterus-> ctx 'sweeps' down over the uterus-> repolarization-> relaxation->another ctx begins (at same point) *can occur so closely (or 'on top' of each other) that they interfere with the blood supply of the placenta *difficult for woman to 'cope' with them, pace breathing, rest, etc.....mentally and physically exhausting *oxytocin administration might help regulate

operative risks for women

nutritional status (obese or poor protein intake=poor healing and dehiscense), age (>40), general health (diseases incresae risks, htn, dm, etc), fluid/electrolyte imbalance (npo x 2 hours), fear

psychological causes to pain

previous personal experiences with pain and/or childbirth presence of fear, anxiety, worry, body image, and self-efficacy (anxiety->tension->pain cycle diminishes progress of labor D/T release of catecholamines) expectations of and preparations for labor unrealistic expectations of labor pain (both positive and negative) - it WILL hurt, BUT it ends with a baby :) culturally influenced labor environment (those present as well as physical space...)should be conducive to relaxation and privacy and provide a sense of security (THINK: where do pets go when they give birth? Somewhere quiet, private, and safe...) availability of meaningful support people

2. placental expulsion

occurs from bearing down effort of mother or from GENTLE pressure on the CONTRACTED uterine fundus by the provider. NEVER APPLY PRESSURE TO A NONCONTRACTED UTERUS as this could cause uterine eversion and massive hemorrhage, an obstertric emergency!!! If the placenta does not deliver spontaneously, it may need to be removed manually. Once delivered, the placenta must be inspected to make sure all was delivered and intact. If the placenta has not delivered in 30 minutes, it is considered RETAINED.

vasa previa

occurs when the umbilical cord vessels cross the internal os of the cervix

footling breech (single or double)

one ("single") or both ("double") feet enter the maternal pelvis first

Variability

one of the most reliable indicators of fetal well-being; he variation or differing rhythmicity in heart rate over time; the difference between the highest and lowest heart rates shown on a strip

placenta succenturiata

one or more accessory lobes connected to the main placenta by blood vessels

Latent phase of labor:

onset of regularly perceived contrxns, ends when dilation begins 0-3cm, cervical effacement occrus;duration: nullipara-6-12hrs, multipara-4-5hrs; may occur if the cervix is not ripe*excessive use of analgesic early in labor--Help uterus to rest, providing adequate hydration, and pain relief, darkening room, changing linen, and decreasing stimulation C-section or amniotomy with oxytocin may have to be done

Postpartal Care

pain control (PCA), fluid volume (VS and fundus to assess for fluid loss; s/s hemorrhage= falling BP {SBP <80} and change in HR, increased RR and sense of thirst), circulation (Homans sign, cap refill), infection (incision)

measuring intensity of contraction

palpating the fundus during a contrxn: mild {nose}, moderate {chin} or strong {forehead} or by internal uterine pressure catheter- IUPC

Birth Second Stage Labor

period of full dilation and cervical effacement to the birth of infant; takes around an hour, up to 3 hours; unbearable urge to bear down or have BM, N/V may be present.

Factors influencing pain response

physical, physiological, psychological

1. placental separation

placenta separates from wall, uterus in spherical shape and rises up into abd, umb cord lengthens, gush of blood as placenta fully detaches. Schultze and Duncan presentation

Care during second stage of labor

prepare place for birth, position ofr birth, promote effective second stage pushing, perineal cleaning, laceration, episiotomy

contraindications to the use of oxytocin in labor

previa, transvers fetal lie, umb cord prolapse, previous c-sect, active genital herpes, previous myomectomy; special precautions: breech, multifetal, presenting above pelvic inlet, severe htn, maternal heart dz, polyhydramnios, previous low-transverse c-sect, abn FHR patterns

emergency c-section

reasons that arise suddenly in labor; less time for preparation and teaching that still must be done. **placenta previa/abpruptio (premature separation of the placenta),fetal distress,failure to progress

analgesia

reduces or decreases awareness of pain

Station

refers to the relationship of the presenting part of a fetus to the level of the ischial spines- when the presenting part is at the level of the ischial spines, it is a station 0. If above, the distance is - 1 to -4 cm and if below +1 to +4 cm.

engagement of fetus

refers to the settling of the widest diameter of the presenting part of fetus into the pelvis past the pelvic inlet

contraindications for spinal/epidural block

refusal, infxn, coagulation disorder, hemorrhage, allergy or lack of trained staff

fetal attitude

relationship of fetal body parts to one another

fetal lie

relationship of the long axis of the fetus to the long axis of the mother

cesarean section nursing diagnoses

risk for infxn r/t surgical incision, risk for hemorrhage r/t surgical procedure, fear r/t impending surgery, pain r/t surgical incision, def fluid vol r/t blood loss from surgery, Powerlessness r/t medical need for C-section birth or episiotomy, Risk for anxiety r/t unanticipated circmstances surrounding birth, Risk for impaired parent-infant attachment r/t unplanned method of birth

fetal blood sampling

sample taken from fetal scalp during labor to monitor for hypoxia.

Schultze presentation

shiny fetal surface of placenta emerges first

Oversized Fetus (macrosomia)

size may become a problem is the baby weighs more than 4000 to 4500 g or 9 to 10 lbs. Usually born to gestation diabetics or women with diabetes. Also, it is more common in multiparity since each infant born to a woman tends to be slightly heavier and larger than the one just before.

Complications: Force of Labor

soft tissue dystocia, contrxn rings, precipitate labor

effects of surgery on woman

stress, body defenses (skin is opened), circulatory fxn (blood loss), body organ fxn (affected by uterine manipulation), self-esteem (scar and loss of self-worth)

cesarean section

surgical incision of the abdominal wall and uterus to deliver a fetus, may be performed electively or if complications arise.

episiotomy

surgical incision of the perineum to enlarge the vagina and so facilitate delivery during childbirth

2 main measurements of the pelvis

the diagonal conjugate (AP-front to back diameter of the inlet) and transverse (side to side-diameter of the outlet)

lightening

the sensation of the fetus moving from high in the abdomen to low in the birth canal

passageway and passenger

the way in which the pelvis and fetus MEET as well as the size of both pelvis and fetus and the shape of pelvis will determine if vaginal "passageway" is possible

Psychosocial influences on labor

the woman's psychological outlook/feelings that a woman brings into labor; good self-esteem usually manage best, women without adequate support may have a stressful & frightful experience

Why is it important to have complete relaxation in between contrxns?

to allow for fetal oxygenation and maternal rest to prevent maternal fatigue

shoulder presentation

transverse lie; rare; fetus lies horizontally, presenting part is usually the shoulder, but may be arm, back, abdomen or side, iliac crest, a hand, or elbow. C-Section! Fundal height not as expected (wide side-to-side)

True labor vs False labor

true- pain in lower back; regular rhythmic contractions; increased intensity with ambulation false-little discomfort to none at abdomen; no lower back pain; contraction stop with ambulation or position change

External Cephalic Version (ECV)

turning of the fetus from a breech to a cephalic position before birth; the FHR and UC are typically monitored after the procedure for 30min-2 hrs. Rh negative women should receive Rhogam afterwards. There is a risk of placental or cord injury involved.

labor pains

unique to labor because the contraction of involuntary muscles of the uterus cause pain

Placenta accreta

unusually deep attachment of placenta to the uterine myometrium so deeply that the placenta will not loosen and deliver. Hysterectomy is the only treatment

What happens between contractions?

uterus relaxes, Intervals between ctx decrease from 10 min to 2-3 minutes, duration changes increasing from 20 to 30 seconds to a range of 60 to 90 seconds; abdominal contour changes d/t uterus elongating

Inversion of the uterus

uterus turns inside out-the woman can bleed out in as little as 10 minutes! Large bore IV, oxygen, be prepared for CPR, woman will be given general anesthesia or a tocolytic to relax the uterus so that it can be placed back in the abdomen by the provider and then pitocin given to help it contract.

Types of cephalic presentation

vertex, military, brow, face

local anesthesia

•Injection of local anesthesia to block specific nerve pathways •Local infiltration (usually for episiotomy or laceration repair of the perineum) •Pudendal block ("Saddle block")- (usually for 2ndstage, episiotomy, or operative vaginal birth)

Anomalies of the Placenta

•Placenta Succenturiata, Placenta Circumvallata, Batteldore Placenta, Velamentous Insertion of cord, Vasa Previa, Placenta Accreta

H-1 Antagonists during labor

•sedative and anti-emetic effects; •hydroxyzine (Vistaril),promethazine (Phenergan), diphenhydramine (Benadryl)

Benzodiazepines during labor

•used to treat anxiety; •diazepam,midazolam (Versed)