NURS 247 Ch 13 LABOR AND BIRTH PROCESS

PrepU The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?

8-10 cm

Stages and phases of labor First stage 0 -10 cm dilation; 3 phases 3. TRANSITION PHASE

8-10 cm dilation -cervical dilation from 8-10 cm -cervical effacement from 80% to 100% -nullipara lasts up to 1 hr -multipara lasts up to 30 min -contraction freq q 1-2 min -contraction duration 60-90 sec -contraction intensity strong by palpation

Passenger: Fetal presentation

the presenting part - three main presentations 1. cephalic (head first) 95% of term births AKA vertex presentation (military, brow, facial) 2. breech (pelvis first) 3% of term births 3. shoulder (scapula first) 2% of term births

Stages and phases of labor Fourth stage; 1-4 hrs after birth of the newborn

time of maternal physiologic adjustment

PrepU The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor?

"She is in active labor; she is progressing at this point and we will keep you posted."

PrepU The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?

+4

prostaglandins lead to

-additional contractions -cervical softening -gap junction induction -myometrial sensitization -all leading to CERVICAL DILATION

Passageway: male shaped pelvis, characterized by funnel shape

-android pelvis -occurs in 20% of women -descent of fetal head is slow -failure of fetus to rotate is common -prognosis for labor is poor, leading to c-section

odds of shoulder presentation

1 in 300 births

cardinal movements of labor

1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation 7. Expulsion

PrepU A nurse is monitoring a woman in labor. When interpreting the assessment findings, the nurse incorporates which information about the changes that are occurring?

Cardiac output increases by 50% during the first stage.

true labor

Contractions occurring at regular intervals that incr in frequency, duration and intensity -bring about progressive cervical dilation and effacement

PrepU The nursing instructor is illustrating the various positions the fetus may utilize during the passage through the vaginal canal at birth. The instructor determines the session is successful when the students correctly identify the ROA position, indicating which presentation by the fetus?

Facing the right anterior pelvic quadrant

PREPU Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

Fetal heart rate in relation to contractions

most common fetal position for birthing

LOA followed by ROA

Premonitory signs of labor: cervical changes a. changes occurring 1 mo to 1 hr before labor b. cervix structure changes c. collagen d. ripening and softening are essential for

a. cervical softening + cervical dilation c descent into the presenting part into the pelvis occur b. changes from elongated structure to shortened, thinned segment c. become more flexible fibers that facilitate H2O obsorption, leading to a more stretchable cervix d. effacement and dilation

Passenger: Types of breech presentations

a. frank- butt first c both legs toward face (pike position) b. full/complete - fetus sits crosslegged above cervix c. footling/incomplete - one or both legs are presenting

Passageway: Bony pelvis pelvic inlet

allows entrance to true pelvis

Passageway: pelvis that's common in men and non-white women

anthropoid pelvis -occurs in 25% of women -vaginal birth preferred with anthropoid than android or platypelloid shape

bloody show

at onset or ā, mucus plug expelled -ruptured cervical capillaries release blood that mixes with mucus resulting in pink tinged secretions

PrepU A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.

backache bloody show lightening

Differences between true and false labor: contraction strength true labor

become stronger c time vaginal pressure is usually felt

Uterine contractions: the pause after ea contraction restores

blood flow to the uterus and placenta

Passenger: which head presentation occurs in 95% of all term births

cephalic

psychological response: factors promoting a positive birth experience

clear info about procedures support, not being alone sense of mastery, self confidence trust in staff caring for her positive reaction to the pregnancy personal control over breathing preparation for the childbirth experience

Fetal station relationship of presenting part to the level of the maternal pelvic ischial spines

cm in (-) or (+) -0 station- presenting part at level of maternal ischial spines -when presenting part of is above ischial spines, distance is (-) - below (+)

Stages and phases of labor Third stage; separation and delivery of the placenta; usually takes 5-10 min; may take up to 30 min; 2 phases 2. PLACENTAL EXPULSION PHASE

coming outside the vaginal opening

Stages and phases of labor Third stage; separation and delivery of the placenta; usually takes 5-10 min; may take up to 30 min; 2 phases 1. PLACENTAL SEPARATION PHASE

detaching from the uterine wall the following signs of separation indicate the placenta is ready to deliver: -the uterus rises upward -umbilical cord lengthens -trickle of blood released rom vaginal opening -uterus changes its shape to globular spontaneous birth of placenta occurs in one of 2 ways -the fetal side (shiny gray side) presenting first OR -maternal side (red raw side) AKA duncan's mechanism or dirty duncan

prepU A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which sign marks the termination of the first stage of labor in the client?

dilation of cervix diameter to 10 cm

cardinal movements of labor: 2. descent

downward movement of the fetal head until it is within the pelvic inlet

Differences between true and false labor: stay or go? false labor

drink fluids and walk around to see if there is any change in the intensity of the contractions if contractions diminish in intensity after either or both- stay home

PrepU An OB/GYN care provider has just finished evaluating the 100th client. If the nurse could review all the documentation from each client thus far, which types of pelvis would the nurse predict the care provider has seen the most and the least?

gynecoid and platypelloid, respectively

Passageway: which pelvis is considered the "true female pelvis" occurring in 40% of women

gynecoid pelvis -vaginal with favored with this because inlet is round, outlet is roomy

Passageway: pelvis divided into 4 main shapes

gynecoid, anthropoid, android, platypelloid

frequency of uterine contractions

measured beg of one contraction to beg of next contraction

breech presentations associated with

prematurity placenta previa multiparity uterine abnormalities (fibroids) congenital abnormalities (hydrocephaly)

prepu The assessment of a pregnant client who is toward the end of her third trimester reveals that she has increased prostaglandin levels. For which factors should the nurse assess the client? Select all that apply.

reduction in cervical resistance myometrial contractions softening and thinning of the cervix

Differences between true and false labor: contraction timing true labor

regular, becoming closer together, usually 4-6 min apart, lasting 30-60 sec

Differences between true and false labor: contraction discomfort false labor

usually felt in the front of the abdomen

false labor

uterine contractions felt but cervix not affected

Believed labor is influenced by these events

uterine stretch from fetus and amniotic fluid volume ** progesterone withdrawal to estrogen dominance incr oxytocin sensitivity incr release of prostaglandins

cardinal movements of labor: 1. engagement

when the greatest transverse diameter of the head in vertex (biparietal diameter) passes through the pelvic inlet (usually 0 station)

intensity of uterine contractions

strength of contraction determined by manual palpation or measured by internal intrauterine pressure catheter

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating:

the buttocks are presenting first with both legs extended up toward the face.

Fetal engagement fetus is said to be engaged in the pelvis when the presenting part reaches

0 -engagement is determined by pelvic examination -floating is used when engagement has not occurred, because presenting part is freely movable above pelvic inlet

FETAL responses to labor: decrease in

-circulation and perfusion to the fetus secondary to uterine contractions -fetal breathing movements throughout labor -fetal oxygen pressure with a decrease in the partial pressure of oxygen (PO2) -respiratory changes during labor help to prepare the fetus for extrauterine respiration immediately after birth

pain in labor

-pain in labor is a universal experience -controlling the uterine discomfort without harm to the fetus or labor process is the major focus of pain management during childbirth -subjective experience involving physiologic, spiritual, psychosocial, cultural, and environmental influences -cultural values/learned behaviors influence perception and response to pain, -so do anxiety/fear which heighten pain

Passageway: Bony pelvis a. parts

a. true pelvis- true pelvis lies below linea terminals, bony passageway through which fetus travels, made of 3 parts; pelvic inlet, mid-pelvis, pelvic outlet false pelvis (greater)- upper flared parts of the 2 iliac bones + wings of base of sacrum

Passageway a. incudes b. relaxin + estrogen

a. unyielding maternal bony pelvis + soft tissues b. cause connective tissues to become more relaxed and elastic and cause joints to become more flexible to prepare pelvis for birth

PrepU 1m 48s Report this Question A nurse performs an initial assessment of a laboring woman and reports the following findings to the primary care provider: fetal heart rate is 152 bpm, cervix is 100% effaced and 5 cm dilated, membranes are intact, and presenting part is well applied to the cervix and at -1 station. The nurse recognizes that the client is in which stage of labor?

first, active

Differences between true and false labor: contraction strength false labor

frequently weak not getting stronger with time or alternating (strong one followed by weak one)

Uterine contractions: fully dilated at 10 cm

fully dialated

MATERNAL RESPONCES: GI

gastric motility and food absorption decrease, which may inrc the risk of nausea and vomitting during the transition stage of labor

fetal position determined by

identifying presenting part maternal quadrant the presenting part is facing -first letter- presenting part toward (L) or (R) side of maternal pelvis -sec letter- particular presenting part: O for occiput, S sacrum (butt), M mentum (chin), A acromion process, D dorsal (fetal back) in shoulder presentations -third letter - presenting part in relation to anterior (A) or posterior (P), if presenting part is to the side of the maternal pelvis it is (T) transverse

PrepU A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.

increase in heart rate increase in blood pressure increase in respiratory rate

MATERNAL RESPONCES: heart rate

increases by 10-20 bpm

PrepU A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response?

pain from the dilation or stretching of the cervix

PrepU The five "Ps" of labor are:

passageway, passenger, position, powers, psych

Stages and phases of labor Second stage From complete dilation 10 cm to the birth of the newborn ; may last up to 3 hours; 3 phases 2. PERINEAL PHASE

period of active pushing -nullipara lasts up to 1 hr, multipara lasts up to 30 min -contraction freq q 2-3 min or less -contraction duration 60-90 sec -contraction intensity strong by palpation -strong urge to push during the later perineal phase

Stages and phases of labor Second stage From complete dilation 10 cm to the birth of the newborn ; may last up to 3 hours; 3 phases 1. PELVIC PHASE

period of fetal descent

Differences between true and false labor: contraction discomfort true labor

starts in the back and radiates around toward front of abdomen

A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor?

transition phase

Prepu The nurse is caring for a client in active labor. Which assessment finding requires health care provider notification?

Gross proteinuria

PrepU Which nursing action is a priority when the fetus is at the +4 station?

Have a blue bulb suction and an infant warmer ready

cardinal movements of labor: 6. external rotation

-after the head is born and free of resistance, it untwists, causing the occiput to move about 45 degrees back to its original left or right position (restitution) -external rotation of the fetal head allows the shoulders to rotate internally to fit the maternal pelvis

Braxton Hicks contractions

-can get stronger as preg progresses -feels like tightening/pulling sensation @ top of uterus -occur in abdomen + groin and spread downward ā relaxing -usually last 30 sec, can persist for 2 min IF: -last longer than 30 sec + occur more often than 4-6 times/hr, call DR b/c may be preterm labor -especially if less than 38 wks preg

FETAL responses to labor: increase in:

-periodic fetal heart rate accelerations and slight decelerations related to fetal movement, fundal pressure, and uterine contractions -arterial carbon dioxide pressure (PCO2)

Passageway: least common type of pelvis

-platypelloid (flat) pelvis -occurs 3% in women -labor prognosis poor, arrest happening at inlet occurring frequently -not favorable for vaginal birth

Passenger: fetal attitude

-posturing (flexion/extension) of the joints + relationship of fetal parts to one another -most common and favorable: back rounded, chin on chest, thighs flexed on abdomen, legs flexed at knees

Premonitory signs of labor: lightening

-when the fetal presenting part begins to descend into the true pelvis -uterus moves into more anterior position -c descent breathing is easier -decr in gastric reflux -incr pelvic pressure -leg cramping -dependent edema in lower legs -low back discomfort -incr vaginal discharge - frequent urination -in PRIMIPARAS, this occurs 2 wks before labor begins -in MULTIPARAS may not occur until labor starts

Uterine contractions: cervical canal 2 cm in length would be described as

0% effaced before labor: cervix is not effaced or dilated

Stages and phases of labor First stage 0 -10 cm dilation; 3 phases 1. LATENT PHASE

0-3 cm dilation -cervical dilation from 0-3 cm -cervical effacement from 0% to 40% -nullipara lasts up to 9hr -multipara lasts up to 5-6 hours -contraction freq q 5-10 min -contraction duration 30-45 sec -contraction intensity mild to palpation

factors affecting the labor process "5 p's" + 5 more

1. passageway (birth canal) 2. passenger (fetus and placenta) 3. powers (contractions) 4. position (maternal) 5. psychological response 6. Philosophy (low tech, high touch) 7. Partners (supportive caregivers) 8. patience (natural timing) 9. patient (client) preparation (childbirth knowledge base) 10. pain management (comfort measures)

Uterine contractions: complete effacement, mid dilation to 5 cm

100% effaced

cervical canal 0 cm in length would be

100% effaced

Passageway: If diagonal conjugate measures at least ------- and the true or obstetric conjugate measure ------ then the pelvis is large enough for vaginal birth

11.5 cm 10 cm or more

Stages and phases of labor First stage 0 -10 cm dilation; 3 phases 2. ACTIVE PHASE

4-7 cm dilation -cervical dilation from 4-7 cm -cervical effacement from 40% to 80% -nullipara lasts up to 6hr -multipara lasts up to 4 hours -contraction freq q 2-5 min -contraction duration 45-60 sec -contraction intensity mod to palpation

Uterine contractions: early effacement, early dilation of cervical canal to 1 cm

50% effaced

PrepU 55s Report this Question A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle?

8-12 wks

PrepU A nurse is providing care to a woman in labor. When reviewing the woman's medical record, the nurse notes that fetal position is documented as LSA. The nurse interprets this to mean that which part of the fetus is presenting?

Buttocks

PrepU The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?

Complete cervical dilation and time of fetal birth

PrepU A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis?

Is narrow transversely

prepU A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA

PrepU A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?

The client reports back pain, and the cervix is effacing and dilating.

cardinal movements of labor: 4. internal rotation

after engagement, as the head descends, the lower portion of the head (usually the occiput) meets resistance from one side of the pelvic floor. As a result the head rotates about 45 degrees anteriorly to the midline under the symphysis.

PrepU Which feature would alert the nurse that the client is in the transition phase of labor?

beginning urge to bear down

soft tissues of the passageway consist of

cervix, pelvic floor muscles, vagina -through effacement, the cervix effaces to allow the presenting fetal part to descend into the vagina

PrepU When explaining to a class of pregnant women why labor begins, the nurse will include the fact that there are several theories that have been proposed to explain why labor begins, although none have been proven scientifically. Which idea is one of those theories?

change in estrogen-to-progesterone ratio

Differences between true and false labor: any change in activity true labor

contractions continue no matter what positional change is made

Differences between true and false labor: any change in activity false labor

contractions may stop or slow down with walking or making a position change

PrepU The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process?

crowning

PrepU A nurse is caring for a client in her fourth stage of labor. Which assessments would indicate normal physiologic changes occurring during the fourth stage of labor? Select all that apply.

decreased intra-abdominal pressure well-contracted uterus in the midline mild uterine cramping and shivering

prepu The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

duration

cardinal movements of labor: 7. expulsion

expulsion of the rest of the body occurs more smoothly after the birth of the head and the anterior and posterior shoulders

name for contractions that do not contribute to the goal of birth

false labor prodromal labor braxton hicks

duration of uterine contractions

how long a contraction lasts

MATERNAL RESPONCES: respiratory rate

incr and more oxygen is consumed related to the increase in metabolism

nesting

incr energy level before going into labor thought to be caused by incr in epinephrine release caused by decrease in progesterone

PrepU A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?

increased risk of infection

MATERNAL RESPONCES: basal metabolic rate

increases and blood glucose levels decrease bc of the stress of labor

MATERNAL RESPONCES: cardiac output

increases by 12-31% during the first stage of labor and 50% during the second stage of labor

MATERNAL RESPONCES: WBC count

increases from 25,000 to 30,000 cells/mm, perhaps as result to tissue trauma

MATERNAL RESPONCES: Gastric emptying and gastric pH decrease

increasing the risk of vomitting with respiration

Differences between true and false labor: contraction timing false labor

irregular, not occurring close together

mild uterine contractions

last 30 sec 5-7 min

mod- high intensity

last longer than 60 sec 2-3 min apart

An infant born between 34 0/7 and 36 6/7 wks of gestation is identified as ___________ and experiences many of the same health issues as preterm infants

late preterm

PrepU The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?

latent

PrepU A nurse is conducting a presentation for a group of pregnant women about labor and the importance of being well prepared and having good labor support. The nurse determines that additional discussion is needed when the group identifies which possible outcome as the result of being prepared?

need for someone to control the situation

Passageway: Bony pelvis mid-pelvis

occupies space between inlet and outlet -space through which fetus must pass through to reach outside -as fetus passes through, lung fluid/mucus expelled -this removes space occupying fluid so air can go into lungs at baby's first breath

MATERNAL RESPONCES: muscular aches and cramps

occur as a result of the stressed musculoskeletal system

PrepU A pregnant woman at 37 weeks gestation calls the clinic to say she thinks that she is in labor. The nurse instructs the woman to go to the health care facility based on the client's report of contractions that are:

occurring about every 5 minutes.

cardinal movements of labor: 3. flexion

occurs as the vertex meets resistance of the cervix, the walls of the pelvis, or the pelvic floor

Passageway: Bony pelvis pelvic outlet

outlet must be large enough -measurements must be taken for vaginal birth -diagonal conjugate of inlet -transverse or ischial tuberosity diameter of the outlet -true or obstetric conjugate

Passenger: Fetal lie

relationship of long axis (spine) of the fetus to the long axis (spine) of the mother -3 possible lies: 1. longitudinal (most common) 2. transverse - no vaginal birth 3. oblique - no vaginal birth

cardinal movements of labor: 5. extension

resistance from the pelvic floor causes the fetal head to extend so that it can pass under the pubic arch -the head emerges through extension under the symphysis pubis along with the shoulders

MATERNAL RESPONCES: temp

rises slightly, possibly due to an incr in muscle activity

PROM

rupture of membranes c loss of amniotic fluid ā the onset of labor is called prelabor rupture of membranes -occurs in 8-10% women c term pregnancy, most will begin labor spontaneously within 24 hr -sudden gush/steady leakage of amniotic fluid -ascending infection possible -danger of cord prolapse if engagement has not occurred

Differences between true and false labor: stay or go? true labor

stay home until contractions are 5 min apart last 40-60 sec, and are strong enough so that a conversation during one is not possible then go to hospital