Intrapartum care

Pain in Labor It is very important to realize that pain management decisions belong only to the patient (and not to her care providers).

"Providers must realize that labor pain belongs to the woman experiencing it and the management of the pain also belongs to her" (Lowe, 1996)

Skin to skin contact immediately after birth

- Skin to skin contact immediately after birth promotes bonding, breastfeeding, temperature and glucose regulation - Separation of mothers and infants is standard practice - despite evidence of possible harm. Just a few years ago, less than 30% of women report that babies were in their arms after birth in the USA. ACOG, AWHONN, WHO, ABM all recommend that all healthy newborns be routinely placed on their mothers chest. Skin to skin contact can even be done in the OR after a C-section as shown in this photo. This is very, very important to mothers and babies. Teach it, promote it, support it, do it. Hospital protocols are finally following the recommendations and promoting a minimum of one hour of skin to skin contact with mom or another supportive adult if she isn't able. - Partners can participate too!

Modes of Delivery Women may also have VBAC - Vaginal delivery after Cesarean section Indicated when mothers has had only 1-2 previous C sections - no other uterine scars or history of a rupture Clinically adequate pelvis Providers immediately available for C/S No others contraindications - LGA, malpresentations, Cephalopelvic disproportion (CDP), previous classical uterine incision

- Spontaneous Vaginal Delivery (SVD) - Forceps - Vacuum Extraction

Fetal presentation - Breech

A baby can also be born breech - this means that the buttocks/foot/feet/ of the baby are coming first. Breech births only account for 5% or less of births. There are different types of breech positions in this photo - "frank" where the entire butt is coming first and the baby's legs are flat against him and "footling" where the baby's foot is coming out first. A footling breech must be delivered by a C-section - a frank breech can sometimes be born vaginally, but is commonly born by Csection in the USA. A complete breech has presenting part of sacrum and legs crossed.

Uterine Contractions Latent first stage - irregular, mild to moderate lasting a duration of 30 - 45 seconds, and frequency of 5-30 minutes Active first stage - more regular, moderate to strong lasting a duration of 40 - 70 seconds and frequency of 3-5 minutes Transition first stage - strong to very strong regular contractions expulsive in nature, frequency of every 2-3 minutes and lasting a duration of 45 - 90 seconds

•Nature of contractions •Duration •Frequency - from onset to complete relaxation •Strength

1st Stage: Active Labor This slide has all the pieces that describe active labor: contraction pattern, dilation, and emotions.

Cervical Dilation in Active Labor: 6-8 cm Emotions:Serious, Focused

1st Stage: Early Labor

Cervical Dilation: 0-6 cm Emotions:Happy, Excited, Some anxiety

1st Stage: Transition This slide has all the pieces that describe transition: contraction pattern, dilation, and emotions.

Cervical Dilation: 8-10 cm Emotions: Frustrated, Dependent

2nd Stage This slide has all the pieces that describe 2nd stage labor: contraction pattern and emotions.

Contractions: 60 - 90 seconds; 3 - 5 minutes apart Emotions:Happy, Relieved, Exhausted

Perineal trauma

Here are graphics of what a 1st and 2nd degree tear look like - these are less damaging than episiotomy. The two types of episiotomy are midline (straight cut down the center) and mediolateral) diagonal cut off to the side. Many providers use the midline approach as the mediolateral approach has been known to be more painful and more difficult to heal. The decision about the type of episiotomy (if needed ) is a physician (or midwife) decision.

Descent

Descent - head enters the inlet in the occiput transverse or oblique position

Flexion

Flexion - as fetus descends it meets resistance of pelvic floor muscles and more flexion occurs, helps with presenting smaller diameters

Fetal position

Here is a graphic about the fetal position. Another way of looking at the presentation: The baby will also have his head tilted a certain way - either toward the maternal back or the maternal abdomen. The head can also be further turned toward the right or left side of the mother. We label these positions as R or L (right or left) and O, M, A, S (Occiput, Mentum, Acromion process, Sacrum) and then A, T, OR P (anterior, transverse, or posterior). So a fetal head position might be recorded on a maternal chart as "ROA" - Right occiput anterior (photo on top left). Babies in an anterior position are facing the maternal back - their spines face up toward the maternal abdomen. Babies in a posterior position are facing the maternal abdomen - their spines are against the maternal spine. The posterior head position is also called "persistent occiput posterior". The posterior position is more uncommon - but when present , it can contribute to what we call "back labor" or posterior labor - which can cause significant back pain in the mother. Mother's with a baby in a posterior position often complain more about back pain than contraction pain! 1st letter- R or L (location of presenting part on R or L of maternal pelvis) 2nd letter- O, M, A, or S (specific presenting part - occiput, mentum, shoulder or sacrum) 3rd letter- A or P (location of presenting part in anterior or posterior pelvis)

Promoting and Supporting Normal Birth

In the United States, six evidence based practices have been proposed by organizations that promote normal labor and birth. Lamaze International is a group that certifies childbirth educators and advances the science of normal birth. Lamaze has published a document and created a short film that lists ways to promote normal birth - the six primary ways are noted above and explained in the next slides. #1 - Allow labor to begin on its own 35% of all labors in the USA are induced (2006) Induction "sets the stage" for more interventions - IV's, epidurals, continuous monitoring, supine positions Induction for "soft" indications ("impending macrosomia", 40+ weeks): Associated with increased risk of instrumental birth and C/S Evidence suggests that any elective induction Increases the risk for analgesia, epidural anesthesia, instrumental birth, C/S, neonatal resuscitation and NICU admission #2 - Allow Freedom of Movement in Labor and Birth Evidence shows that nonsupine positions Result in shorter labors, better contractions, more maternal comfort and reduced need for medication No study has ever shown evidence of harm from ambulation in labor and upright positioning for birth Standing, walking, leaning forward and hands and knees positions should be encouraged during labor High epidural rates make this difficult Some positions may be feasible even for women with epidurals #3 - Provide Continuous Labor Support in Labor and Birth 85% of women labor with a partner present Although partners provide a very important presence, labor support provided by trained doulas is beneficial Evidence shows the benefits of labor support Decreased maternal anxiety and decreased stress hormones Higher incidence of vaginal birth, decreased rate of C/S Less medication use, fewer instrumental births Less dissatisfaction with birth experience Nurses are present at 99% of all births in the world Excellent source of labor support - but often do not see it as their role due to competing demands (charting, staffing, demands of unit, use of increased medication and technology) #4 - Avoid Routine Interventions Routine interventions are the norm 80% have an IV, 60% have amniotomies, 50-60% have oxytocin, 95% have EFM, 75-80% have epidurals, 32% have C/S (2012) Eating and drinking in labor should not be discouraged (dated rationale is a fear of aspiration) Provides nutrition and energy - women will self regulate RCT found no differences in complications with nutrition IV fluids do not decrease poor outcomes Limit freedom of movement and can cause fluid overload Dated rationale is to provide quick access - rarely a problem Continuous electronic fetal monitoring Many studies reveal no clear benefit Augmentation of labor - Research shows minimal benefit Epidural anesthesia - Alters normal birth and can increase C/S #5 - Encourage Spontaneous Pushing In Nonsupine Positions 57% of women reported giving birth in supine positions; 35% in semi-sitting positions (2006) Kneeling, squatting and standing help move baby down into the pelvis, widen the pelvis and use gravity to shorten labor Squatting increases the pelvic diameter Directed pushing at 10 cm can be harmful - women should be allowed to wait to push until they feel the urge to push "Directed" closed glottis pushing can be harmful Causes fetal heart rate abnormalities and pelvic floor trauma Pushing in an upright position (Cochrane) Shortens the second stage of labor Decreases maternal pain and abnormal fetal heart rates Decreases episiotomies and instrumental births #6 - No Separation of Mother and Baby After Birth Separation of mothers and infants is standard practice - despite evidence of possible harm Less than 30% of women report that babies were in their arms after birth ACOG, AWHONN, WHO, ABM all recommend that all healthy newborns be routinely placed on their mothers chest Infants placed skin to skin on their mothers chest immediately after birth and beyond (Cochrane) Cry less, have warmer body temperatures and more stable blood glucose than infants placed in warmers Have more stable breathing and better breastfeeding Can "self-attach" to the breast

Internal Rotation Another graphic of internal rotation and molding of the fetal head.

Internal rotation - the fetal head meets resistance of the pelvic floor then rotates 1/8 (45 degrees)anteriorly in anterior positions to lie under the symphysis pubis

Birth

Let parents know that they will be seeing an actual birth now. Remind them that reactions to birth vary, and there is no right way to feel or act as they receive their baby.

Nursing Admission Assessment

Once it is determined that the patient is in active labor, the patient is admitted and the above history information is obtained. Maternal age Young maternal age (i.e < 16) and and old maternal age (≥35) Marital Status Is father or mother or partner in the picture - are they supportive Assessing for safety: History of domestic or sexual abuse, etc. (safety questions asked when patient alone) Race Some complications are more prevalent in people of some racial backgrounds compared to others. Other socio-demographics - occupation, health insurance, geographical location, culture/ethnicity Past and Present Medical history Hypertensive disorder, diabetes mellitus, blood group type and Rh, immunizations, medications (prescription and over the counter meds - anticoagulants use), STIs (including HIV, Group B Strep syphyllis, gonorrhea, chlamydia, e.t.c), obesity, renal disease, and other conditions, smoking/alcohol/substance abuse Past Obstetric History Gravidity, parity (0 or >5 and spacing of pregnancy), type of birth (SVD or CS or vacuum extraction or forceps), pregnancy and labor complications (including bleeding disorders, preeclampsia/eclampsia, gestational diabetes e.t.c), Present Obstetric history LMNP, gestational age, attendance of prenatal care (review any concerns or recommendations that need to be considered intrapartum), pregnancy related complications, medications, birth plan (whether she wants to breastfeed, pain management options, birth positions, plans for doula or birth companion and others preferences), pediatrician who will care for infant, e.t.c. Patient complaints What symptoms are you feeling? - assess mothers pain/comfort level When did they start? What did you take for the symptoms or what makes you feel better? Last solid and liquid intake Pay attention to danger signs - bleeding, severe headache, blurred vision, severe abdominal or epigastric pain, seizures, fever Laboratory Investigations Blood and Rh type (from prenatal records or obtain) CBC (Hgb, Hct, WBC, platelets) Urinalysis - clean catch urine sample to assess Hydration status - specific gravity Nutritional status - ketones Protenuria Glycosuria Infections Group B Strep - done at 35-37 weeks, check and if positive intravenous prophylactic antibiotic is prescribed Assessing safety- needs to be done upon admission, patient must be alone in order to promote accurate responses, eg: do you feel safe at home? Has anyone ever hit you or threatened to hit you? Do you have thoughts of harming yourself? If patient answers yes to any of these questions this would prompt a social work referral and the nurse would need to notify the physician. Exceptions for prophylaxis in GBS are planned C section with membranes intact

1st Stage of Labor: Active phase (4 to 7 cm dilation of cervix) Labor and birth are divided up into stages. The first stage is labor - it is divided into three phases. (dilation of the cervix to 10cm) The second stage is birth.

Physiological Adaptations •Cervical dilatation from 4 to 7 cm •Cervix dilates at 1.2cm per hour in nullipara and 1.5cm in multipara •Uterine contractions increase in frequency and intensity Psychological Adaptations •She begins to fear a loss of control •Anxiety levels heighten •Some may show signs of helplessness

1st Stage of Labor: Transition phase (8 to 10 cm dilation of cervix)

Physiological Adaptations •Cervical dilatation from 8 to 10 •Contractions are more intense, more frequent •With fetal descent and full dilatation mother exhibit - •Hyperventilation; increased bloody show; generalized discomfort; hiccups, belching, nausea, and vomiting; beads of perspiration on the upper lip or brow; increasing rectal pressure and the urge to bear down Psychological adaptations •Increased need for physical presence of a support person •Increased apprehension and irritability •Difficulty understanding directions •Restlessness, •A sense of bewilderment, frustration and anger at contractions, •Request for medications,

Fetal Presentation and Lie Fetal Presentation Determined by: •fetal lie (relation fetal/maternal spine) •presenting part of fetus Cephalic (head down) is most common Breech Shoulder The most common way for a baby to "present" is to be head (cephalic) down. In this photo the fetus presents in either Left Occipital Anterior (LOA) cephalic presentation or could also be considered Left Occipital Transverse (LOT) cephalic presentation. More than 95% of babies are born head down - physics favors this position as the head is the heaviest part of the baby. The head is also "moldable" as the cranial bones can actually "mold" or move to accommodate the trip through the maternal pelvis. Remember from A&P class that the occipital bone is on the back of the head, the mentum is the chin (on the mandible bone), acromion process is the shoulder, and the sacrum is the buttock. Anterior is towards the front or the front side, posterior is towards the back or facing back, transverse is sideways. The left and the right refer to where that presenting bone is nearest or facing to the side of the women's body.

Presentations •Cephalic •Vertex •Face •Brow •Breech •Shoulder or hand Lie •Longitudinal •Transverse

External Rotation Here is external rotation as the baby is being born. Once the baby is born providers may allow for delayed cord clamping (1-2 min until cord stops pulsating) if mother and infant are stable.

Restitution and external rotation - the head rotates briefly to the position it started with aligning with the shoulders. Shoulders enter the pelvic floor and rotates to midline to lie under se symphysis pubic. The head follows in external rotation

Cervical Effacement & Dilatation

The cervix (or bottom on the uterus) must efface (thin out) and dilate (open) in order for the baby to come out. This is a nice graphic of how effacement and dilation increase throughout labor.

Caput and Molding of the fetal head

The fetal head has areas called "sutures" which allow the head to mold. The bones in the head can actually "crossover or override" these membranous suture lines so that the head can mold and accommodate the maternal pelvis and vaginal canal. Nurses and doctors can actually fell these sutures with a sterile glove to assess the position of the fetal head. The larger triangular shaped opening in the lower part of the picture is the anterior fontanel - this is a larger, non-skull covered part of the cranium that again allows the head to mold in labor and birth. It is approximately 2-3 cm wide and it usually closes by 18 months of age. The open fontanels also allow for the enormous brain growth that occurs in the first two years of life. The smaller posterior fontanel is at the top of the photo - it is much smaller (2x2 cm) and usually closes 6 to 8 weeks after birth.

Fetal Monitoring Strip

This is a photo of how an electronic fetal monitor (EFM) strip looks. The fetal heart rate is shown on the top and recorded from the ultrasound transducer placed on the mothers abdomen (or the internal lead placed on the baby). The contractions are shown on the bottom of the photo and show us the relative strength of the contraction as measured by the tocotransducer. I wanted you just to see this photo today - we are going to do a module on EFM in our next session.

Palpation of Contractions (ctx)

When the uterus contracts, it tightens up and "balls up" or rises a bit in the abdomen. The nurse can then palpate it with her fingers/hand.

Active Phase Supportive Nursing Care Patients in this active phase of labor need a lot of support- from nurses and their labor support team (family members).

•Partner or nurse is VITAL now - do not leave alone! •Encourage, praise, focus on one contraction at a time •Keep aware of her progress - education and support •Use comfort techniques - back massage, massage, position changes, cool washcloth to forehead •Maintain contact with staff and be an advocate •Position changes as possible - side, upright •Encourage voiding and ambulation if possible •Encourage focusing rituals - breathing, relaxation, imagery, movement, vocalization

Factors Affecting Labor 1. Power - Uterine Contractions As the uterus contracts and retracts it pulls on the cervix causing more effacement and dilatation

•AKA primary powers •Involuntary expels the fetus and placenta from uterus •Start at cornua (pacemaker of the uterus) and shifts to the fundus •Fundal dominance - activity of uterine contraction greatest and longest at fundus •Contractions shift downwards as they diminish towards the cervix

Cardinal movements in labor Descent - head enters the inlet in the occiput transverse or oblique position Flexion - as fetus descends it meets resistance of pelvic floor muscles and more flexion occurs, helps with presenting smaller diameters Internal rotation - the fetal head meets resistance of the pelvic floor then rotates 1/8 (45 degrees)anteriorly in anterior positions to lie under the symphysis pubis Extension - the occiput passes the border of the lower boarder of the symphysis pubis and head emerge. First the occiput, then the face, and finally the chin Restitution and external rotation - the head rotates briefly to the position it started with aligning with the shoulders. Shoulders enter the pelvic floor and rotates to midline to lie under se symphysis pubic. The head follows in external rotation Expulsion - after birth of shoulders , the head and shoulders are lifted towards the mothers abdomen

•Aka mechanisms of labor •The process where the fetus must adjust to the passage •Engagement occur during pregnancy in primigravida and may occur during labor for multigravidas •These include •Engagement •Descent •Flexion •Internal rotation •Extension •Restitution and External rotation •Expulsion - lateral flexion

Second stage - Supportive Nursing Care During the second stage (pushing), the patients needs help and support from the nursing staff to push out her baby. This can be exhausting after a long labor and many women are tired and ready to be finished! Women need coaching and the ability to re-focus on the baby.

•Allow woman (not staff) to direct pushing efforts •Avoid supine positions - upright positions preferred •Encourage open glottis pushing (short breath holds and exhalations with grunt/groan) •Support and encourage all bearing down efforts •Instruct in breathing & instruction as needed - panting, slow exhalation, pelvic floor relaxation •Provide feedback about baby - mirror if desired, feedback regarding crowning, head, sensations •Place infant skin to skin immediately if possible

Leopold's Maneuver's NCLEX Leopold's maneuver's are a set of physical assessment techniques used by an examiner (nurse or physician) to determine the position of the baby. This assessment is not done until the third trimester when the fetal parts are palpable. Although this can also be done with an ultrasound, often this is done as a preliminary technique to assess the fetal position and obtain fetal heart tones. He examiner used their hands to palpate where the fetal parts seem to be. The area of largest mass and resistance is usually the fetal back - and this is the best place to auscultate fetal heart tones, the buttocks is soft and moves with the trunk, the head is firm and round and moves independently from the trunk, the extremities feel "knobby".

•Assesses: •Fetal part in the fundus •Fetal part in the cervix •Fetal lie (spines line up) •Degree of presenting part's descent into the pelvis •Expected location Fetal HR

Factors Affecting Labor 3. Passageway

•Bony pelvis: •Station-Level of presenting part (-5cm to +5cm) •Soft tissues: •Lower uterine segment, cervix, and pelvic floor muscles

Assessment of contractions The strength of a contraction can be assessed using the nurse's hand (for how firm the uterus feels) or the fetal monitor (most common method). When using a fetal monitor to assess a contraction, an external monitor is not as accurate a way to assess - that is because the external uterine monitor can be impacted by the position of the baby and the amount of muscle and/or subcutaneous tissue in the maternal abdomen. An internal contraction probe is a more precise way to gauge contraction strength but is not usually indicated unless there is some question about labor progress. Maternal behavior changes in labor in a patient without an epidural can be a good gauge of contraction strength and stage of labor also.

•Can be assessed with a fetal monitor, nurse's hands, maternal behavior •External EFM is not reliable for assessing intensity of contractions •Internal EFM (IUPC) is a reliable way to determine contraction strength •Terms to describe palpation of contractions with nurse's fingers on the uterine fundus (subjective) •Mild - Slightly tense fundus that is easy to indent (tip of nose) •Moderate - Firm fundus that is difficult to indent (chin) •Strong - Rigid, board-like fundus that is almost impossible to indent (forehead)

Maternal Physiologic Changes During Labor NCLEX There are major changes to maternal physiology during labor. These changes may be different from the "normal pregnancy" changes. For example; there is usually a slight decrease in BP during pregnancy however you might see an increase in BP during labor. Blood glucose and GI motility decrease - and nausea and vomiting are common. WBC's often rise in labor and remain elevated in the early postpartum period. Looking at this slide, start thinking about what causes these physiological changes to occur.

•Cardiac changes: •Cardiac Output increases 10-30% in 1st stage, 50% in second stage •Heart Rate increases slightly •Systolic Blood Pressure increases during contractions •Supine hypotension syndrome •WBC increases •Respiratory rate increases •Temperature can be slightly elevated •Proteinuria may occur •Decreased gastric motility & absorption of solid food, nausea & vomiting & burping - especially in transition •Blood glucose decreases

Focused Admission Assessment When we asses the patient's cervix, we do this with sterile gloves to decrease infection risk. We then estimate (with our fingers) just how far dilated and effaced the patient is. Do not perform manual exam if the patient is bleeding or if their waters have broken and they are not contracting.

•Cervical Assessment •External genitalia •Lesions, odor, discharge, fluid if c/o ROM •Internal vaginal exam with sterile glove (limit to < infection) •Effacement •Dilation (with contraction) •Presenting part •Descent •Engagement •ROM - Fluid with exam?

Second Stage There are two ways for the mother to push the baby out. The first is what is called "closed-glottis" or silent pushing. Basically, the patient just holds her breath and pushes down hard (silently). The risks of this technique include a purple face and exhaustion as well as fetal distress. Many providers actually tell patients to push this way. The other way to push a baby out is by using what we call "open-glottis" pushing or pushing with a small amount of air or noise. Letting out a small amount of air results in a "groan" or "grunting" sort of a sound. It is not silent, but it is more effective as it use the muscles of the abdominal wall to assist in helping the baby to move down. We used to think that as soon as the mother was 10cm dilated, she should be encouraged to push. New research has shown us that is it better to wait (as long as the baby is not in distress) until the mother feels an urge to push.

•Closed-glottis, "silent", directed pushing often urged by providers •Maternal Risks: Vasoconstriction, hypotension, decreased cardiac output, petechial hemorrhages, fatigue •Fetal Risks: Decreased blood flow, altered perfusion; decreased descent •Open-glottis pushing is recommended to preserve fetal oxygenation, use abdominal muscles •Benefits include - Improved maternal-fetal circulation, less maternal fatigue, improved gradual descent and decreased tears •Pushing upon full dilation (directed) vs. waiting for woman to feel pushing urge (spontaneous pushing) •Best to wait for women to feel urge to push before beginning to push if fetus is tolerating labor "laboring down" •No increased risk to fetus, better maternal outcomes (e.g., reduced fatigue, vacuum/forceps, perineal trauma/incontinence) - a major change to current practice

Needs of Women in Labor In terms of the specific things that women need during labor and birth, they need physical, emotional, informational and advocacy support throughout the birth process. Upright position is the most common position in labor, however, there are many birth positions a woman can use

•Physical •Positioning, comfortable environment •Pain relief measures •Emotional •Continuous support, sense of control, kindness •Information • labor progress, interventions •Advocacy •Support, trust, listening to needs

Transition Phase Supportive Nursing Care Transition is the phase of labor where women should NEVER be left alone - especially if she is not medicated. Even if the patient is medicated with an epidural, she may start to feel pressure and discomfort during transition. Although the epidural will take away the pain, it may not be able to take away all of the pressure during transition and pushing. Women need the support of every person in the room to cope well with transition and pushing.

•DO NOT LEAVE! NEEDS CONSTANT SUPPORT (especially if not medicated with an epidural)! •Rest periods very short - focus on brief relaxation •Needs help to use breathing techniques, panting •Needs help with pushing - knowledge, information •May need help to provide control - coach can stand, hold hands or face, eye contact, encouragement •Needs constant encouragement - "you can do this"; "you are doing a great job"; "it is almost over" •Enjoy the birth!

Perineal Trauma We used to think that doing an episiotomy was better and safer than allowing the women's perineal tissue to tear during pushing. In the 1980-90's, episiotomy rates were more than 90%! This is a great example of evidence based practice. Research was done that showed us that using an episiotomy actually caused more trauma and damage then allowing the perineal floor to tear slightly. The problem is that once you cut an episiotomy, the cut can extend and tear into the rectal tissue (3rd-4th degree tear) which is much more traumatic and cause long term recover and further problems. Rates of episiotomy are much lower today (10-15%) as evidence suggests it should be avoided whenever possible.

•Episiotomy - incision •Benefits - Straight surgical cut, small decrease in time to delivery •Risks - Can extend into to 3rd or 4th degree tears, cause more perineal trauma, infection, persistent pain postpartum •Evidence (Cochrane) suggests episiotomy should be avoided whenever possible and that episiotomy is likely to be harmful or ineffective •Rates (Friedman, 2015) are 10-15% of births in USA •Risk factors include forceps, vacuum, abnormal presentation, fetal distress, physician •Perineal lacerations - (most are small and less painful and damaging than an episiotomy) •1st degree - extends through the skin •2nd degree - extends through the muscle •3rd degree - extends through the anal sphincter •4th degree - extends through the anal sphincter and anterior rectal wall

Third Stage Supportive Nursing Care

•Explain placenta and process to mother and family •Encourage mother to bear down with placenta •Evaluate vital signs and maternal bleeding •Evaluate infant •Encourage breastfeeding when possible •Examine of observe placenta after birth for fragments •Ask about cultural significance Here is a photo of a nurse examining a placenta after birth to be sure that all of the cotyledons are there. If there are any "missing" pieces, they could be retained inside the mother and cause postpartum hemorrhage. The uterus needs to contract and clamp down to stop bleeding, and retained placenta makes that difficult to do.

Uterine Contractions

•External electronic monitoring (tocotransducer) is placed on mothers abdomen over the fundus to assess uterine activity •Combined with a external fetal monitoring (EFM) with a transducer applied to the abdomen to monitor FHR patterns

False versus True Labor NCLEX Here is a list of how we determine if labor is "true" (dilation is occurring) or "false" (minimal or no dilation). This is a question that often appears on ATI or NCLEX - they want you to know how to counsel a patient about whether or not she is in labor. If the mother is unsure, have her drink a glass or two of water and rest for 30min. If the contractions stop, they were Braxton hicks and not true labor. If the contractions continue and become stronger after a period of time, they are likely true contractions. Also, if a woman is less than 38 weeks gestation and is contracting regularly, she should be assessed for preterm labor.

•FALSE LABOR •Contractions often stop with change in activity (Braxton-Hicks) •Contractions often irregular (or regular only temporarily) •Contractions can often be stopped with hydration, relaxation •No (or minimal) change in cervix (especially dilatation) •Fetal presenting part often not engaged in pelvis •TRUE LABOR •Progressive increase in frequency, intensity, & duration of contractions •Contractions continue regardless of activity, may intensify with walking •Contractions usually start in the back and radiate around the abdomen to the front •Progressive dilation and effacement of cervix

Fourth Stage Supportive Nursing Care In addition to the physical care for the mother and infant, another important role is to place the baby skin to skin. This action promotes bonding, breastfeeding, temperature and glucose regulation. The first hour of life is critical to attachment and breastfeeding and all efforts should be made to encourage skin to skin contact. This is not often done at all hospitals - even though there is significant data on the benefits of skin to skin related to breastfeeding, temperature and glucose regulation.

•Facilitate skin to skin contact whenever possible •Encourage maternal- infant attachment and bonding •Encourage family infant bonding •Encourage breastfeeding •Assess for bleeding - vital signs, fundus, pad

Fetal Responses to Labor

•Fetus also experience labor together with mothers and the labor experience may affect •FHR - decelerations and accelerations •Acid-base balance - blood flow decreased to fetus at peak of contraction resulting in slow decrease in pH •Hemodynamic changes - nutrient and gaseous changes depend on fetal blood pressure - however in normal circumstance the fetus and placenta have enough resources to survive anoxic periods unharmed •Fetal sensation - a term baby is aware of the pressure sensations during labor

Premonitory signs of labor (Precede labor) During the last few weeks of pregnancy, there are things that we call "premonitory" or very early signs that labor will begin soon (impending labor). These signs only mean that labor should be soon - and not that the patient should go do the hospital. The only sign on the list above that means the mother should call her provider and go to the hospital is rupture of membranes (breaking of the waters bag). All of the above symptoms make women uncomfortable and anxious for labor to begin. This is the reason that some women ask to be induced - but induction before full term has risks. Bloody show-loss of the mucus plug that had previously formed in the cervical canal. The loss of this plug may be a sign that the onset of labor may begin in 24-48 hours but not always the case. This is not the same as when someone has blood after a vaginal exam.

•Lightening - descent of fetal head into pelvis •Braxton hicks contractions •Cervical softening, effacement & sometimes dilatation •Increased vaginal discharge •Bloody show •Increased pelvic pressure •Backache, sciatica •Greater urinary frequency •Diarrhea •Surge of energy •Spontaneous rupture of membranes known as "SROM" (call PCP)

Focused breathing and relaxation NCLEX Focused breathing and relaxation techniques can be helpful to women in early labor. They are also often a source of questions on NCLEX. Focused, controlled breathing can provide a distraction, improve relaxation and improve oxygenation. Breathing techniques are easy to learn, and basically all start with a deep cleansing breath in through the nose and out through the mouth - this gives a boost of air to the baby and signals the support team that a contraction is starting. After the cleansing breath, the patient uses a controlled breathing pattern during the contraction and then breathes normally when the contraction ends. Relaxation can also help in early labor by re-focusing the mother from her pain and having her focus on the baby or a positive image (imagery). Effleurage is a light stroking of the maternal abdomen that can be relaxing in early labor (it tends to be annoying in the later stages of labor).

•Focused breathing •Provides distraction •Improves relaxation •Improves oxygenation •Nurses can teach and model (more effective if practiced before L&D) •Initial cleaning breath •Patterned/paced breathing •Slower in early labor •More rapid/changing in later labor •Panting during pushing •Relaxation •Imagery •Re-focusing on baby •Conscious relaxation •Music, distraction •Effleurage - light stroking massage (more effective early in labor process) •Nurses can teach support people to provide

First stage of labor (The average amount of time that a first-time mother spends in the first stage of labor is 16-18 hours. That is how long it usually takes the cervix to efface and dilate to ten centimeters. There are actually new, 2014 ACOG guidelines that say women should be allowed to have even longer first stages - especially if using an epidural (which can lengthen labor). The reason for the new recommendations is that we want to try to decrease C-sections that are done just for a "long labor")

•Further divided into 3 phases •Early/Latent phase: 0 to 3 cm dilation of cervix •Active phase: 4 to 7 cm dilation of cervix •Transition phase: 8 to 10 cm dilation of cervix

Nursing Admission Assessment

•Health history information and all prenatal records •Birth plans or cultural/personal preferences •Plans for support in labor •Current medications •Blood and Rh type (prenatal records or obtain) •CBC (Hg, Hct, WBC, platelets) •Last solid and liquid intake •History of domestic, sexual and substance abuse is applicable •Assessment of substance use and abuse •Plans for breast or bottle feeding •Pediatrician who will care for infant

Factors affecting pain response

•Individual perception and response to pain •Culture •Fatigue and sleep deprivation - less energy means less ability to cope •Previous experience with pain •Anxiety - fear of labor / anticipation/paying more attention on the pain sensation, uncomfortable environment/unfamiliar surroundings •Maternal confidence & childbirth preparation (decrease) pain •Continuous labor support (decrease) pain •Longer labors, pitocin augmentation, posterior presentations, supine positions, arrest of labor & other complications may create additional physiologic pain in labor

Care of a woman in Labor Introduction

•Intrapartum care is the care given to the woman from onset of labor to the birth of the infants, including the first 1-2 hours postpartum when mother transitions post birth •Birth is an experience that involves adaptations from both mother and fetus. •Treat birthing mothers with respect and maintain modesty and appreciate their pain expression •Labor support sources: •Partner •Family members or friends •Doula •Healthcare providers

Assessment of Amniotic Fluid NCLEX In about 10% of women, labor is initiated when the amniotic sac (water bag) ruptures. For other women, the bag of waters breaks or ruptures sometime during labor. When the bag does break (rupture), it can be difficult to determine - especially if it does not rupture with a big "gush." Women sometimes think they may have been incontinent, so do not think they are leaking amniotic fluid. The way that we can determine if the fluid leaking is amniotic fluid (or urine) is to assess the fluid color (amniotic fluid is clear/straw/odorless) and also its pH. The pH of amniotic fluid is more alkaline - it is 6.5-7.5. We have special test strips called "Nitrazine" strips - and they tell us if the fluid is more alkaline. Amniotic fluid also looks very characteristic under a microscope on a slide (see above photo) - it "ferns" in a very specific way. So we do keep microscopes in labor and delivery for assessing fluid.

•Labor is initiated by SROM in 10% of women at term •Difficult for pt to determine if ROM occurs •Membranes may only "leak" and not fully rupture •Women at term may have minor incontinence •Assessment of fluid on admission •Normal amniotic fluid is clear, odorless, pale, straw colored and may have flecks of vernix, lanugo •Two tests to assess for amniotic fluid •NITRAZINE pH test - AF is alkaline (6.5-7.5) urine is acidic (5-6) •FERNING TEST - When examined under a microscope - AF will "fern" and create a "frondlike crystalline pattern"

1st Stage of Labor: Early/Latent phase (0 to 3 cm dilation of cervix)

•Lasts average of 8.5 hours (no more than 20 hours) in nulliparas and 5.3 hours (no more than 14 hours) in multipara - most women not aware of the onset Physiological Adaptations •Cervix dilates from 0 to 3 cm - from onset of labor •Uterine contractions increase in frequency and intensity Psychological adaptations •Anxious, but able to recognize and express feeling •she still has control

Second Stage of labor

•Lasts on average 30min to 2hr in nulliparas and 5-30min in multiparas Physiological adaptations •As woman bears down with mechanism of labor •The perineum will bulge, flatten, and move anteriorly •Amount of bloody show increases •Crowning occurs when occiput passes under the lower border of symphysis pubis - the fetal head is encircled by the vaginal opening and remains visible without receding back in Psychological Adaptations •The woman may still be restless, desire support, and some may experience loss of control

Ongoing Labor Assessment As labor progresses, we need to continue to monitor the mother (comfort, cervical change and contractions) as well as the baby (fetal heart rate baseline, variability, accelerations, decelerations).

•Maternal VS, comfort & support •Pain and coping •Uterine Activity •Frequency of contractions •Duration of contractions •Strength of contractions •Uterine resting tone •Fetal Status •Baseline fetal heart rate •Fetal heart rate accelerations •Fetal heart rate variability •Fetal heart rate decelerations •Cervical change (only prn - minimize to decrease infection risks) •Effacement (0-100%) •Dilatation (0-10cm) •Descent (-5-0-+5)

Factors Affecting Labor 5. Person - Maternal Responses

•Maternal physiological and psychological wellbeing are important for a positive birth experience •Physiology of pain is also influenced by the physiological, social, and psychological factors

Amniotomy - Rupture of membranes by provider with amnihook tool NCLEX If the patient's amniotic sac (bag of waters) has not been broken up to this point in active labor, the provider may choose to rupture it with a plastic tool called an amnihook. It is smooth except for the tip - and it actually "pops" the membranes so that the fluid can escape. The benefit of this is that is can speed up the labor process. The risks are that the labor will become stronger and more painful. If the baby's head is not well applied to the cervix (the baby is higher up), there is also a potential risk of the cord falling down and "prolapsing" or falling out and being compressed. This is a medical emergency and could cause serious fetal distress.

•Potential Benefits- Can speed up and shorten labor, cause stronger contractions •Potential Risks - Stronger, more painful contractions, possible cord prolapse, committed to birth, increased infection risk •Nursing Assessment - #1 is taking FHR and observing for cord prolapse, #2 is documenting time and color of fluid •Nursing Care - Monitoring FHR and maternal temperature

Factors Affecting Labor 2. Passenger

•Potential Issues with Passenger (fetus): •Size of the fetal head •Fetal presentation •Fetal lie •Fetal attitude •Fetal position

Fetal Presentation and Position

•Presentation - Fetal part in the cervix •Vertex (occiput of head) - 96% •Breech (buttocks or feet are presenting part) - 3% •Frank (entire bottom) , footling (one or two feet) •Shoulder (of baby) - 1% or less •Fetal position - relationship of the landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis.

Fourth stage: Recovery (Immediate post delivery) NCLEX The fourth stage begins with the placenta being delivered and ends two hours after that. The most important job the nurse has is to assess the mother for hemorrhage. This is done by palpating the maternal fundus (as shown in the photo) to asses it for firmness/topne and bleeding. We do this every 15 minutes for the first hour and then every 30 minutes for the second hour. If needed, IV or IM Pitocin can be added to control excess bleeding. We also want to control perineal swelling by applying an ice pack on the mother's perineum. . Monitor for signs of blood loss, complications. It is very important to support breastfeeding and use skin to skin positioning with baby whenever possible.

•Recovery stage - 2 hours after the delivery of the placenta •Frequent assessments (every 10 - 15 - 30 minutes) •Vital signs •Fundus •Bleeding •Initiate breastfeeding •Assess neonate •Many mother and babies are wide awake the first hour after birth •Encourage maternal-infant attachment/bonding •Often enter a stage of profound fatigue and may sleep for hours after this initial bonding & feeding period

Third stage: placenta NCLEX The third stage begins with the delivery of the baby and ends with the complete delivery of the placenta (which patients often call the "afterbirth"). This process usually takes 5-30 minutes with an average being 15 minutes. Providers can sometimes get anxious to get the placenta removed if it does not come out spontaneously, but it is very dangerous to pull on the umbilical cord - pulling could cause a uterine inversion (and a massive hemorrhage) or a detached cord. VERY gentle traction can be used. If the placenta does not come out on its own within 30 minutes, the placenta may have to manually removed by the provider. This can cause increased infection, postpartum hemorrhage and significant discomfort. CNMs often use an upright position for a stubborn placenta, with great success.

•Signs of placental separation •Firmly contracted fundus •Sudden gush of blood from vagina •Lengthening of umbilical cord •With signs of separation, VERY gentle traction of cord, mother gives several pushes to expel placenta •Never pull on umbilical cord prior to signs of separation, and do not provide anything more than gentle traction •May administer oxytocin IV/IM to control bleeding with birth of infant shoulder or after birth •Promotes uterine contractions to decrease maternal bleeding

Initial Assessment - Triage or L&D (EMTALA) Once a patient thinks she is in labor, she usually calls her care provider. Hopefully she then speaks to a nurse who can help her to decide what to do. If a patient does decide to go to the ER or the hospital L&D unit - she must be assessed with the above assessment. EMTALA is the Emergency Medical Treatment In Active Labor Act - which is a federal law that states that pregnant women in labor cannot be turned away from an emergency room. Under this law, pregnant women are considered to be in labor until a health care provider determines they are not!

•Specific assessment •Contractions •When started, how long have they been occurring, how often are they, how long are they, how intense are they? •Presence and location of discomfort/pain •Presence of fluid leaking from vagina, vaginal bleeding, or other vaginal discharge •If c/o rupture of membranes, ask when, how much, what was the color and consistency, was there an odor? •Obtain Health History •Allergies •Medical and prenatal history •Obtain prenatal records •Obtain urine specimen - protein, glucose, ketones •Vital Signs - T, P, R, BP •Assess uterine activity and fetal health •Leopolds maneuvers •Palpation of uterus •Auscultation of fetal heart tones •External fetal monitoring

Factors Affecting Labor Many authors talk about the five "P's" of labor and birth - it is a way to look at the elements that impact the labor and birth process.. The uterus pulls on the cervix with each contraction causing effacement and dilatation Fetal axis pressure - Uterus elongates with each contraction decreasing horizontal diameters. The elongation will straighten the fetal body, and the presenting part presses on lower uterine segments and cervix The pelvic floor muscles draw the rectum and vagina upward and forward with each contraction along the curve of the pelvic floor. At the fetus descends into the pelvic flor it thins out and the anus everts exposing the interior rectal wall. Power - Uterine contractions Passenger - Size, position and state of infant - fetal axis pressure Passageway -Pelvis & soft tissues Position - Lie of the presenting part, flexion of presenting part and position of the mother Person - Mother and her ability to manage and tolerate the physical and emotional components of labor

•The 5 'P's of labor •Power - contractions •Passenger - fetus •Passageway - Pelvis & soft tissues •Position of the fetus in relation to passage •Person - maternal physiological and psychological wellbeing

Cervical Changes Effacement- enzymes such as collagenase and elastase break down the collagen fibers of the cervix causing it to thin and draw up into the sides of the uterus causing ripening and effacement Ripening- cervix goes from being rigid and firm at the beginning of pregnancy to being soft and stretchy at the end of pregnancy. Dilation-the opening of the cervix

•The cervix undergoes softening (ripening), it thins out (Effacement), and dilates •Ripening often starts during pregnancy •Effacement is assessed from 0-100 % •Dilatation is assessed from 0-10 cm

Fourth stage of labor Urinary retention increases the risk of uterine atony = postpartum hemorrhage

•The fourth stage is the two-hour period after the placenta is removed. Physiological adaptations •As uterus contact, the myometrium - figure of eight muscles constrict the vessels preventing further blood loss - blood loss ranges from 250 - 500ml •Excess blood volume is pushed to the circulation • Moderate drop in systolic and diastolic pressure (decrease) • HR (moderate tachycardia) (increase) •Nausea and vomiting cease, woman may be hungry and thirsty •Shaking chills occur •Hypotonic bladder due to trauma from birth = uterine retention.

Introduction

•The intrapartum period begins from onset of true labor to the first 2 hours after complete expulsion of a fetus, placenta, and membranes •Labor refers to the process of moving a fetus, placenta, and membranes, out of the uterus through the birth canal •Birth can also be spontaneous through vaginal delivery or assisted birth through cesarean section, vacuum extraction, or forceps delivery

3rd Stage This slide explains the 3rd stage of labor.

•The placenta detaches from the uterine wall 5-20 minutes after birth •You may feel a mild contraction as it detaches •Your healthcare provider will examine the placenta to make sure that it comes out in one complete piece

Third Stages of Labor

•The third stage is the delivery of the placenta - placental separation and expulsion •Physiological signs of placental separation •Uterus becomes more globular, firm, and •Uterus rises in the abdomen approaching the umbilicus •Gush of blood, •Cord lengthens

Stages of Labor

•There are 4 stages of labor •First Stage labor - from onset of regular contractions to full dilation of cervix •Second stage: from full dilation of cervix to birth of baby •Third stage: from birth of baby to delivery of placenta •Fourth stage: This is the recovery phase lasting 2-hours after delivery of placenta (may go up to 3- 4 hours)

Early/Latent Phase - Supportive Nursing Care The nurse (if present) or support person should focus on the above care for patients in early labor. Patients should also be encouraged to stay at home if they are comfortable doing so and have no complications.

•Time contractions, encourage rest and relaxation •Comfort techniques as needed - massage, relaxation, heat, ice, warm shower or bath •Provide education, encouragement, coping techniques •Position changes - pelvic rock, all fours, side-lying, walking may all relieve back pain and pelvic pressure •Offer fluids, ice chips, light foods as needed •Begin to use rituals/focusing techniques as needed •Breathing, relaxation, distraction, vocalizations

Uterine Activity

•Uterine activity is assessed based on the number of contractions that are occurring in a 10-minute segment, averaged over a 30-minute period. •Normal uterine activity is described as 5 or less contractions in a 10-minute segment, averaged over a 30-minute period. •Tachysystole is excessive uterine activity and is described as more than 5 contractions in a 10-minute segment averaged over a 30-minute period. •Tachysystole can be the result of both spontaneous and induced labor patterns.