NSG 333 Chap 16-19 Week 3

epidural blood patch

A patch formed by a few milliliters of the mother's blood occluding a tear in the dura mater around the spinal cord that occurs during induction of spinal or epidural block; its purpose is to relieve headache associated with leakage of spinal fluid -most rapid, reliable, and beneficial relief of PDPH (post-dural puncture headache)

Best location for IM

deltoid

Amnioinfusion

introduction of a solution into the amniotic sac; an isotonic solution (saline or LR) up to 1L to relieve fetal distress (cord compression during var decels)

True labor vs False labor

- True: contractions fairly reg and inc with walking, a/w cervical changes (bloody show), lower back pain - False (Braxton-Hicks): Irreg contractions stop when walking or position changes, no cervical changes, lower abd pain

Nonpharmacologic Pain Management

-Methods used to reduce pain. Many need to be learned and added to birthing plan. Some can be taught by nurse as needed. -studies show adding this to birthing plan reduces risk of cesarean sections -Ex. music, meditation, massage, warm baths, hypnosis, patterned breathing, guided imagery, counter pressure, herbal teas

Gate-control theory of pain

-Pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through nerve pathways at one time -providing distractions for pain management: massage, aromatherapy, hypnosis, music, and guided imagery; thought to work by closing down a hypothetical gate in spinal cord to prevent signals from reaching brain

regional anesthesia (local anesthetic)

-complete pain relief and motor block -most drugs in this class end in -caine (from cocaine)

Anesthesia

-encompasses analgesia, amnesia, relaxation, and reflex activity -works by abolishing pain perception by interrupting nerve impulses to brain -loss of sensation may be partial or complete with or without loss of consciousness

regional analgesia (local anesthetic)

-some pain relief and motor block -most drugs in this class end in -caine (from cocaine)

Three essential components of informed consent

1. advantages and disadvantages of procedure explained clearly and understood 2. must have women's agreement with pain management plan 3. consent must be given freely

normal uterine activity

2-5 ctxs or less in 10 min 45-80 sec length 45-60 sec + relax time 40-80mm Hg strength

Biparietal diameter (BPD)

9.25 cm at term; largest transverse diameter and important indicator of fetal head size.

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

Changes in fetal heart rate-Early Deceleration

Early Decel-visually apparent gradual (onset to lowest point (nadir) ≥30 seconds) decrease in and return to baseline FHR; associated with UCs; caused by transient fetal head compression; normal and benign finding (Macones et al., 2008; Miller et al., 2013). mirror image of ctx; no interventions needed

Effacement

Happens during the first stage of labor; the thinning and shortening of the cervix (normally 2-3 cm long and 1cm thick); expressed in % 0-100

Pudendal nerve block

Injection of a local anesthetic at the pudendal nerve root to produce numbness of the genital and perianal region; does not reduce pain from contractions

uterine contractions

Intensity • How Strong: Mild, moderate, strong • Need to palpate fundal area when monitoring externally Duration * measured in seconds from beginning to end Frequency * measured in minutes from beginning of one to beginning of next. * resting tone- after ctx soft or hard

nitrous oxide for analgesia

Nitrous oxide mixed with oxygen can be inhaled in a low concentration (50% or less) to provide analgesia during the first and second stages of labor -rapid onset with quick clearance -safe for mom and baby -common s/e: nausea and dizziness

false pelvis

Not involved in the birthing process

Fetal Scalp Blood Sampling

Not used in US Obtaining blood sample from fetal scalp for acid-base status MOST INVASIVE, requires rupture of membranes Information obtained through sampling a reflection of RECENT past instead of real time or information at birth

Changes in fetal heart rate-Accelerations

Periodic-occur with a contraction Episodic-not associated with uterine contractions accels or decels *Acceleration->=15 bpm above baseline, =>15 seconds, return to baseline < 2 min from the beginning of the acceleration; Normal; fetal scalp rub to stimulate

NICHD definitions of FHR characteristics and patterns

See picture

Lightening

The process or time during late pregnancy when the fetal head begins to descend into the mother's pelvis, resulting in a lessening of pressure on the diaphragm; first time moms have this happen 2 weeks before birth; multiparous women may not have happen until true labor starts

Montevideo units (MVUs)

a method for evaluating the adequacy of uterine activity for achieving progress in labor -usually rage from 100-250 in first stage, 300-400 in second stage

Monica AN24 EFM

approved in 2011. 5 electrodes placed on abd to monitor contractions and FHR. transmits via bluetooth 50ft range. no adjustments needed as mom and baby move. 36 wks+

Opioid agonist analgesics

meperidine, fentanyl, and remifentail -no amnesic effects but create feeling of well being or euphoria -can inhibit uterine contractions so should not be administered until labor is established

Ferguson reflex

stretch receptors in the posterior vagina cause release of endogenous oxytocin that triggers the maternal urge to bear down

Fetal well being

Determined using fundal height, fetal heart tones and rate, fetal movement, and uterine activity

Nursing Assessment in first stage labor

*Latent Every 30-60 minutes-Maternal blood pressure, pulse, and respirations Fetal heart rate (FHR) and pattern Uterine activity Presence of vaginal show *Active FHR 15-30min, Temp 2hrs, Maternal app every 15 min *Transition Same, Maternal appearance every 5 min

Variability fetal heart rate

*Variability- irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater. beats per minute and is measured from the peak to the trough of a single cycle; *Categories absent-undetectable; labeled abnormal or indeterminent; may indicated fetal hypoxia or metabolic acidemia, congenital anomalies/neurologic injury, CNS depressant medications minimal- <= 5 BPM, same as absent except fetus can be in sleep state (normally only 30 min), tachy, or premie moderate- 6-25 BPM normal marked- > 26 BPM unknown *Tachycardia-greater than 160 beats/minute for 10 minutes or longer; early sign of fetal hypoxemia, infection, maternal hyperthyroidism, fetal anemia, meds (atropin...), meth, or cocaine *Bradycardia is a baseline FHR of fewer than 110 beats/minute for 10 minutes or longer; fetal cardiac problem,viral infections, maternal hypoglycemia, and maternal hypothermia.

Umbilical Cord Blood Acid-base Determination

*after delivery. *Umbilical arterial values reflect fetal condition, whereas umbilical vein values indicate placental function

fetal scalp stimulation

*digital, vibroacoustic, or light stimulation to fetal head *acceleration in the FHR of at least 15 beats/minute for at least 15 seconds *if move, indicates absence of metabolic acidemia *contraindicated if FHR decels or bradycardia

Changes in fetal heart rate-Late Deceleration

*gradual decrease in and return to baseline FHR associated with UCs (Macones et al., 2008). The deceleration begins after the contraction has started, and the nadir of the deceleration occurs after the peak of the contraction. The deceleration usually does not return to baseline until after the contraction is over.; *Disruption of oxygen transfer from environment to fetus caused by the following: • Uterine tachysystole • Maternal supine hypotension • Epidural or spinal anesthesia • Placenta previa • Placental abruption • Hypertensive disorders • Postmaturity • Intrauterine growth restriction • Diabetes mellitus • Intraamniotic infection *lie on side with feet elevated, inc IV solution, stop oxytocin, oxygen via non rebreather, notify provider, assist with birth if pattern not corrected

expected maternal progress during first stage of labor

*latent 0-3cm dilated; 6-8hrs; mild to mode, irregular, 5-30 min, 30-45 duration; nulliparous 0, Multiparous -2cm to 0 active phase (4 to 7 cm of dilation) admitted to hospital transition phase (8 to 10 cm of dilation). *active phase 4-7 cm; 3-6hrs; mod-strong, more regular, 3-5min, 40-70 sec; +1-+2cm *transition phase 8-10cm dilated, strong to very strong, regular, 2-3 min apart, 45-90 sec duration; +2-+3 cm; severe back pain...

Fontanels

-Allow closing of areas where more than two bones meet. Remodeling occurs after 3 days. -Largest: anterior at 3 cm by 2 cm and lies at junction of Sagittarius, coronal, and frontal sutures; closes by 18 months -Posterior: lies at junction of two parietal bones and occipital bone; is triangular; closes 6-8 weeks

Internal Fetal Monitoring

-accomplished using an internal electrode, amniotic membranes must be ruptured, cervix must be at least 2 cm -allows for continuous fetal data -usually attaches to scalp -membranes must be ruptured, the cervix sufficiently dilated (at least 2 to 3 cm), and the presenting part low enough -objectively measure the frequency, duration, and intensity of UCs, & uterine resting tone -precisely measures the intensity of individual UCs, the IUPC can be used to evaluate the adequacy of UA for achieving progress in labor. (need 80-120 Montevideo units)

Remifentanil (Ultiva)(analgesia)

-faster onset (3 min) than other drugs -does cross placenta but does not cause neonatal depression due to short half-life -needs to be given via PCA -monitor oxygen saturation and sedation/hypoventilation effects (respiratory issues)

IM disadvantages

-higher doses needed -unpredictable rate of dose is released -may transfer to placenta -delayed pain relief

Common Signs Preceding Labor

-lightening -return of urinary frequency -backache (relaxation of pelvic joints) -stronger Braxton Hicks Contractions -Weight loss (05-1.5 kg or 1-3.5 lbs; caused by electrolyte shifts from changes in estrogen and progesterone levels) -surge of energy -increased vaginal discharge; bloody show -cervical ripening -possible rupture of membranes

Nalbuphine (Nubain)(analgesia)

-opioid agonist-antagonist -less risk of N/V, respiratory depression -can induce withdrawl symptoms of dependent mother -monitor VS for repirations, voiding q 2 hrs, baby if birth occurs 1-4 hrs after dose -lasts 2-4 hrs IV and 4-6 hrs IM

Three main fetal presentations

1. Cephalic: occurs 97% of the time 2. Breech: occurs 3% of the time 3. Shoulder: occurs less than 1%

Seven cardinal movements of labor

1. Engagement: when the biparietal diameter of the head passes pelvic inlet 2. Descent: progress of presenting part through pelvis 3. Flexion: when resistance is felt by pelvis; fetal head bends, chin meets chest 4. Internal Rotation: internal rotation begins at ischial spines and completes at lower pelvis; starts with occiput rotating anterior lay with face rotating posteriorly 5. Extension: causes birth of occiput, then face, then chin 6. External Rotation: rotates head 45* to realign head with back and shoulders 7. Expulsion: after shoulders and head, upper body is lifted to symphysis pubis

Four basic types of pelvis

1. Gynecology- classic type found 50% of births, associated with OA positions 2. Android- heart shaped, found 23% of births, theory says increased risk of CPD 3. anthropoid- oval shape, found 24% of births, associated with OP positions 4. Platypelloid- flat shape, found 3% of births, theory says increased risk of transverse arrest Most women have a mixed pelvis

3 phases of spontaneous birth

1. birth of head-some providers slow head birth to protect maternal tissues, prevent intracranial injury, and reduce perineal pain. (Crowning-widest part of head distends the vulva just prior to birth) 2. birth of shoulders 3. birth of the body and extremities 2 nurses for birth-1 for baby, 1 for mom APGAR 1, 5 min

bloody show

A small amount of blood at the vagina that appears at the beginning of labor and may include a plug of pink-tinged mucus that is discharged when the cervix begins to dilate. Sticky

Variable decelerations

An abrupt (onset to nadir less than 30 seconds) decrease in FHR below the baseline. The decrease is ≥15 bpm, lasting ≥15 secs and <2 minutes from onset to return to baseline. *recurrent variable decels indicate cord compression *shoulders to deceleration-compensatory response to compression of the umbilical vein, sometimes present. *Variable decelerations occur in approximately 50% of all labors and usually are transient and correctable *.Change maternal position (side to side, knee-chest); Discontinue oxytocin if infusing; Administer oxygen at 8 to 10 L/minute by nonrebreather face mask; Notify physician or nurse-midwife; Assist with amnioinfusion; Assist with vaginal or speculum examination to assess for cord prolapse; Assist with birth (vaginal assisted or cesarean) if the pattern cannot be corrected

Blood tests for labor

CBC, hematocrit, 'type and screen'

FHR categories

CATEGORY 1 -Baseline rate of 110-160 BPM -Baseline FHR variability: moderate -Late or variable decelerations: absent -Early decelerations: present or absent -Accelerations: either present or absent CATEGORY II -includes all tracings not in cat. I or III -Baseline tachycardia or bradycardia not accompanied by absent baseline variability -Baseline FHR variability is minimal, absent without recurrent decelerations -Accelerations are absent -Periodic or episodic decelerations with minimal or moderate baseline variability -prolonged decels >- 2 min but <10 min -recurrent late decels w/moderate baseline variability -variable decels w/ other characteristics, such as slow return to baseline CATEGORY III -absent baseline variability -recurrent late decels -recurrent variable decels -bradycardia -sinusoidal pattern

intermittent auscultation

Listening to fetal heart sounds at periodic intervals to assess FHR *use doppler, pinard Fetoscope, transvag Doppler probe (obese or early pregnancy) *Count FHR for 30-60 sec after UC (uterine contraction) *auscultate FHR before, during, and after UC for baseline and changes *feel UC by placing hand over fundus *loudest over baby's back normally *every 15-30 min during 1st stage and 5-10 min during 2nd stage *requires 1-to-1 RN ratio. If unavailable, needs EFM. some patients like because not 'tied to bed'

SROM (spontaneous rupture of membranes)

The breaking of the "water" or membranes marked by the expulsion of amniotic fluid from the vagina. *Fern test *Nitrazine test (pH) *25% of time starts the labor process but may have lag period up to 24hrs *amniotomy-use plastic hook or clamp to rupture.

Goals of intrapartum FHR monitoring:

identify and differentiate the normal (reassuring) patterns from the abnormal (nonreassuring) patterns *associated with fetal hypoxemia, which is a deficiency of oxygen in the arterial blood *fetal hypoxia--If uncorrected, hypoxemia can deteriorate to severe fetal hypoxia *fetal asphyxia-- fetal hypoxia results in metabolic acidosis

electronic fetal monitoring

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 *monitors fetal oxygenation for possible interventions if fetus becomes hypoxic or metabolic acidosis

Perineal Lacerations

non surgical rips or tears in the perineum that occur when the fetal head is born and an episiotomy is not performed First degree---: Laceration that extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle Second degree--Laceration that extends through the fascia and muscles of the perineal body, but not the anal sphincter Third degree-- involves anal spincter Fourth degree-- anal spincter into the rectal mucosa episiotomies discourage-heal longer with more pain and complications than perineal lacerations. Recommend to support perineum manually during birth or use side lying position

analgesia

the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness

first stage of labor

the initial stage of childbirth in which regular contractions begin and the cervix dilates latent (early) phase (through 3 cm of dilation) active phase (4 to 7 cm of dilation) admitted to hospital transition phase (8 to 10 cm of dilation).

External cephalic version (ECV)

ultrasound-guided, hands-on procedure to externally manipulate the fetus into a cephalic lie. It is done at 36 to 37 weeks, in the hospital setting. • Beta stimulants to relax the uterus, such as terbutaline

soft tissues of the passageway

• The soft tissues of the passageway consist of the cervix, the pelvic floor muscles, and the vagina. Through effacement, the cervix effaces (thins) to allow the presenting fetal part to descend into the vagina. As fetus descends, cervix is actually drawn upward and over the body or corpus.

Assessing pain and factors of pain with laboring women

-Question should be stated "what did you feel during your last contraction", NOT what is your level of pain on a scale -Anxiety and fear is normal but when excessive, can increase pain perception due to more catecholamine secretions which adds more tension and pain perception

Opiods

-can be given IV, IM, or PCA -provide sedation, euphoria, but incomplete pain relief -all opioids cause a degree of respiratory depression, sedation, N/V, dizziness, altered mental status, euphoria, decreased gastric motility, delayed gastric emptying (which increases risk of aspiration), and urinary retention -should be used cautiously in women with respiratory and cardiovascular disorders -cross placenta causing absent or minimal FHR variability, respiratory depression -commonly used: meperidine, fentanyl, remifentanil, and nalbuphine

Terms of powers

-frequency: time from beginning of one contraction to the next -duration: length of contraction -intensity: strength of contraction at its peak

Side effects of neuraxial anesthesia

-hypotension -local anesthetic toxicity --light-headedness --dizziness --tinnitus --metallic taste --numbness of tongue and mouth --bizarre behavior --slurred speech --convulsions --loss of consciousness -fever -urinary retention -pruritus -limited movement -longer second-stage labor -increased use of oxytocin -high or total spinal anesthesia

fetal oxygen supply can decrease:

*Reduction of blood flow through the maternal vessels as a result of maternal hypertension, hypotension, or hypovolemia (caused by hemorrhage) • Reduction of the oxygen content in the maternal blood as a result of hemorrhage or severe anemia • Alterations in fetal circulation, occurring with compression of the umbilical cord (transient, during uterine contractions [UCs], or prolonged, resulting from cord prolapse), placental separation or complete abruption, or head compression • Reduction in blood flow to the intervillous space in the placenta secondary to uterine hypertonus

Birth positions and pushing

*use of upright and lateral positions is also associated with less pain and perineal damage, fewer episiotomies and abnormal FHR patterns, and fewer operative vaginal births *Squatting is highly effective in facilitating the descent and birth of the fetus. It is one of the best and most natural positions for second stage labor *encourage to push when feel like it (spontaneous) vs prolonged push on demand which leads to Valsalva maneuver (inc intrathoracic and cardiovascular pressure->dec CO, fetal hypoxia, pelvic floor and perineal damage.

Prolonged deceleration

*visually apparent decrease (may be either gradual or abrupt) in FHR =>15 bpm below the baseline and lasting > 2 minutes < 10 minutes (>10 minutes is considered a baseline change) *can be normal reaction or maternal hypotension, uterine tachysystole or rupture, extreme placental insufficiency, and prolonged cord compression or prolapse

Barbiturates (sedatives)

-Ex: Secobarbital sodium -cross placenta and have long half-life -can cause undesirable s/e of respiratory and vasomotor depression -should be avoided if birth is expected within 12-24 hours

Benzodiazepines (sedatives)

-Ex: diazepam, lorazepam -give with opioids to enhance pain relief and reduce N/V -cause significant maternal amnesia, use should be avoided during labor -diazepam disrupts newborn thermoregulation -flumazenil is the antagonist to reverse sedation effects and respiratory depression

Phenothiazines (Sedatives)

-Ex: promethazine -do not relieve pain -given in past to enhance analgesic effects of opoids -decreases anxiety, apprehension, increase sedation, reduce N/V -Use metoclopramide (antiemetic) to potentiate effects of analgesics

Powers

-Primary uterine contractions: involuntary uterine contractions and beginning of labor. Responsible for effacement and dilation. Starts secondary when presenting part reaches pelvic floor. -Secondary abdominal bearing down efforts to aid the primary contractions; muscles used are diaphragm and abdominal; have no effect on dilation

Spinal nerve block

-injected through third, fourth, or fifth lumbar interspace into subarachnoid space -can be used for vaginal birth or cesarean -for cesarean, numbs T6 (nipple) to feet -for vaginal birth, numbs T10 (hips) to feet; pt must be instructed when to bear down with contraction -after injection, may position upright to deliver dose downward OR for higher level of numbness, have pt. lie supine with supported fetus -distribution will be completed in 5-10 minutes but may continue to move for 20 min more -lasts 1-3 hrs. -WOF marked hypotension, impaired placental perfusion, and ineffective breathing patterns -best practice is to monitor EFM 20 to 30 mins, give bolus of fluids (500-1000) (No added dextrose) prior to dose of block -After dose, assess maternal BP, Pulse, respirations, FHR q 5-10 min -increased risk of episiotomy, forceps-assisted birth, or vacuum-assisted birth with vaginal birth -increased risk of spinal headache -epidural needle (inserted below T5) is a larger gauge than spinal anesthesia (inserted between T3 and T4

Epidural anesthesia or analgesia block

-injection between 4th and 5th lumbar vertebrae -most effective pain relief -large bore needle (16, 17, or 18 gauge) -if obese >300lbs, 75% may end in failure -still need monitoring of VS: After dose, assess maternal BP, Pulse, respirations, FHR q 5-10 min, and bladder elimination q 2h -still requires after injection, may position upright to deliver dose downward OR for higher level of numbness, have pt. lie supine with supported fetus -can be used to allow degree of block and allow walking, pushing, and pain relief -can cause orthostatic hypotension, dizziness, sedation, and weakness of legs -can cause more severe problems if placed incorrectly or high doses are used

True pelvis

-involved in birth -three parts: 1. Inlet or brim 2. Mid pelvis or cavity 3. Outlet (lower boarder; with movable coccyx during later part of birth)

Breathing Techniques History

-it is recommended that women use slow breathing early in labor -In the second stage, breathing is easier at a faster pace (pant, pant, pant, blow (3-1 or 4-1) -Try to keep rate no more than twice her normal rate to decrease chance of hyperventilation

Nalozone (Narcan)

-opoid antagonist -promptly reverse respiratory distress and CNS depression EXCEPT WITH NORMEPERIDINE -don't breast feed until drug has passed system (2hrs after last dose) -don't give is pt is opioid dependent (will cause withdrawl) -pain will suddenly return when given but lasts a short time......monitor for symptoms of respiratory depression to return

Suggested measure for supporting a women in labor

-provide companionship and reassurance -offer positive reinforcement and praise for her efforts -encourage participation in distracting activities and nonpharmacologic measures for comfort -give nourishment (if allowed) -assist with personal hygiene -offer information and advice -involve the women in decision making regarding her care -interpret the women's wishes to other health care providers and to her support group -create a relaxing environment -use a calm and confident approach -support and encourage the woman's support people by role-modeling labor support measures and providing time for breaks

Fetal Attitude

-relationship of fetal body parts to one another -normal: back of fetus is rounded, chin flexed on chest, thighs flexed over abdomen, legs flexed at knee, arms crossed over thorax, umbilical cord lies between arms and legs= termed general flexion

Allergy symptoms to anesthetics

-respiratory depression -hypotension -treat with epinephrine, antihistamines, oxygen, and support

Fentanyl (Sublimaze)(analgesia)

-short acting synthetic opioid -rapidly crosses placenta -less s/e but requires more doses -still assess for respiratory depression, use side rails and assistance with ambulation -MAX DOSE 500-600 ug

Meperidine (Demerol)(analgesia)

-synthetic low cost opioid -cause less respiratory distress in mom -serious s/e for baby: cause prolonged neonatal sedation and neurobehavioral changes that lasts for 2-3 days....can not be reversed with naloxone -use side rails and assistance with ambulation, do not give if birth is expected in 1-4 hrs

Sedatives during birth

-used to relieve anxiety and induce sleep -given when women is in prolonged early phase of labor -given to augment analgesics and reduce nausea with opioid use

Opioid Withdrawal symptoms

-yawning, rhinorrhea (runny nose), sweating, lacrimation (tearing), mydriasis (dilation of pupils) -anorexia -irritability, restlessness, generalized anxiety -tremors -chills and hot flashes -piloerection ("gooseflesh" or "chill bumps") -violent sneezing -weakness, fatigue, and drowsiness -N/V -Diarrhea, abdominal cramps -bone and muscle pain, muscle spasms, kicking movements

fourth stage of labor

1-2 hours after delivery of placenta During this time maternal organs undergo their initial readjustment to the nonpregnant state. BP pulse q15 minutes for the first 2 hours after birth. Temperature every 4 hours for the first 8 hours after birth and then every 8 hours *Bladder • Assess distention by noting location and firmness of uterine fundus and by observing and palpating bladder. A distended bladder is seen as a suprapubic rounded bulge that is dull to percussion and fluctuates like a water-filled balloon. When the bladder is distended, the uterus is usually boggy in consistency, well above the umbilicus, and to the woman's right side. • Assist woman to void spontaneously. Measure amount of urine voided. • Catheterize as necessary. • Reassess after voiding or catheterization to make sure the bladder is not palpable and the fundus is firm and in the midline.

Physiologic adaptations

1. Fetal adaptation -fetal heart rate: 110-160 -fetal circulation: affected by many factors to include contractions -fetal respiration: the change is due to lung fluid being cleared, PO2 decreases, PCO2 increases, pH decreases, Bicarb levels decrease, respiratory movements decrease during labor 2. Maternal Adaptation -cardiovascular changes: CO increases 10-15% in first stage, 30-50% in second; returns to normal within the first hour after birth; HR increases slightly in both stages; BP increases during contractions and returns to baseline between contractions; systolic increase more than diastolic; WBC count increases -respiratory changes: rate increases causing increased pH, hypoxia, hypocapnia (decreased CO2) -renal changes: urination may decrease due to edema and work of labor; proteinuria may occur due to muscle breakdown -integumentary changes: stretching is evident and tearing may occur -musculoskeletal changes: diaphoresis, fatigue, proteinuria (1+), with possible increased temperature, back and joint pain, and leg cramps -neurological changes: euphoria helps seriousness, amnesia between contractions, elation or fatigue after birth; endorphins reduce/ increase pain threshold -gastrointestinal changes: gastric motility and absorption of solid food are decreased; nausea and vomiting may occur during transition to second stage of labor; diarrhea or constipation may occur -endocrine changes: decreased levels of progesterone and increasing estrogen, prostaglandins, and oxytocin; glucose levels decrease

Five P's affecting factors of labor

1. Passengers: Baby-alterations of movement through birth canal (size of head, fetal presentation, fetal lie, fetal attitude, fetal position). Placenta movement is mostly normal except placenta previa (inappropriate attachment to uterus) 2. Passageway: composed of mother's rigid bony pelvis (ilium, ischium, pubis, and sacral bones), soft tissues of cervix, pelvic floor, vagina, and introitus (external opening to vagina) 3. Powers: contractions that serve as pacemaker points along the birth canal. There are primary and secondary powers 4. Position of the mother: reduces fatigue, increases comfort, and circulation 5. Psychologic response

Stages of Labor

1st: starts with regular uterine contractions; dilating stage 3 phases: Latent (0-3cm; little descent but active effacement) Active (4-7cm) Transitional (8-10cm w/ urge to push) 2nd stage: starts at full dilation and ends with delivery; has 2 phases: Latent (passive descent) and active (pushing) 3rd: starts at birth of baby, ends with placental delivery (usually separates from uterine wall during 3 or 4th contraction and can be expelled after birth of baby with next uterine contraction) 4th: Starts with placenta deliver and ends 2 hrs later- primary goal to prevent hemorrhage from uterine atony, 1st void within 1 hour and then q2-3 hrs; monitor for complications

Bloody show

A small amount of blood at the vagina that appears at the beginning of labor and may include a plug of pink-tinged mucus that is discharged when the cervix begins to dilate.

Pharmacologic Control of Discomfort by Stage of Labor and Method of Birth

First Stage -Opioid agonist analgesics -Opioid agonist-antagonist analgesics -Epidural (block) analgesia -Combined spinal-epidural analgesia -Nitrous oxide Second Stage -Nerve block analgesia and anesthesia -nitrous oxide Vaginal Birth -Local infiltration anesthesia -Pudendal block -Epidural (block) analgesia and anesthesia -Spinal (block) anesthesia -CSE analgesia and anesthesia -Nitrous oxide Cesarean Birth -Spinal (block) anesthesia -Epidural (block) anesthesia -General anesthesia

Pain during Labor and Birth

First stage of labor: -pain is visceral and transmitted via T10-T12 and L1 with the nerve originating in uterine body and cervix Second stage of labor: -pain moves to somatic and transmitted via S2 to S4 segments -described as intense, sharp, burning, and localized B-endorphins are released during pregnancy and birth to increase the level of pain tolerance

Descent

Depends on at least 4 forces and size and shape of baby and pelvic planes: 1. Pressure exerted by amniotic fluid 2. Direct pressure exerted by contracting fundus on fetus 3. Force of contraction on diaphragm and abdominal muscles in second stage of labor 4. Extension and straightening of fetal body

Signs of Potential Complications in labor

Intrauterine pressure over 80 mmhg Contractions lasting longer than 90 sec Contractions five or more in 10 minutes or more than every two minutes. Relaxation lasting less than 30 seconds Fetal bradycardia, tachycardia, persistently decreased variability or late or severe variable deceleration Irregular FHR; arrhythmias Meconium stained fluid from vagina Maternal Temp greater than 38C Foul smelling vaginal discharge Vaginal bleeding ( bright red or dark) Arrest in progress of cervical dilation or effacement, descent of fetus.

Tocolytic therapy

drugs, terbutaline (Brethine), used to relax the uterus, can be used to prolong the pregnancy

Fetal position

Relationship of the landmark on the presenting fetal part to the front, sides, or back of the maternal pelvis. -abbreviated as First letter: R- right mothers pelvis, L- left mothers pelvis -Middle fetus presenting parts: O- Occiput, S- Sacrum, M- Mentum (chin), Sc- scapula -Presenting part location: A-anterior, P- posterior, T- transverse -Example: ROA- occiput, right anterior quadrant, LSP- sacrum, Left posterior quadrant

Station

Relationship of the presenting fetal part to an imaginary line drawn between the pelvic ischial spines. -used to measure degree of descent during birth -measured in cm -level of spines is 0 -above is - # -below is +# -range is +-5

Engagement

Term used to indicate that the largest transverse diameter of the presenting part (usually the biparietal diameter) has passed through the maternal pelvic brim or inlet into the true pelvis and usually corresponds to station 0. -occurs in weeks prior to labor in nulliparas anc may occur during labor in multiparas

Fetal Lie

The relationship of the long axis of the fetus to the long axis of the mother 1. longitudinal or transverse: long axis of fetus is parallel to long axis of mother 2. Transverse, horizontal, or oblique: long axis of fetus is at Ruth Angelena diagonal to long axis of mother -Longitudial are either cephalic or breech -Tranverse cannot have vaginal birth -oblique lie usually converts to longitudinal or transverse during labor

second stage of labor

begins with full cervical dilation (10 cm) and complete effacement (100%) and ends with the baby's birth. *50 to 60 minutes in nulliparous women and 20 to 30 minutes in multiparous *latent ("laboring down") phase is a period of rest and relative calm; should be allowed to rest and not push--decreases pushing time, increases duration of second-stage labor, and reduces number of operative vaginal births *active pushing (descent) phase the woman has strong urges to bear down as the Ferguson reflex is activated when the presenting part presses on the stretch receptors of the pelvic floor (+1); oxytocin released from posterior pituitary gland--> inc ctx.; encourage to listen to own body and ability to birth->inc self-esteem and locus of control; validate feeling of stretching, pressure...

Late Deceleration nursing interventions

These include: - 1st turn the patient to left side, if no change, turn back to the right, with no change, give O2, if no change then open the IV wide, then call the MD.

FHR patterns for OB

Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill

Asynclitism

When fetal head (parietal bone) is turned more or less toward sacrum or symphysis. Can be anterior (sacrum) or posterior (symphysis).

combined spinal-epidural (CSE)

aka walking epidural -can be used to block pain and allow walking during labor -common s/e: pruritus and nausea -associated with an increased risk of FHR abnormalities---need close monitoring when in use

Dilation

enlargement or widening of the cervical opening and the cervical canal that occurs once labor has begun; measured from 1 cm to 10 cm -fully dilated (and retracted), cervix can no longer be felt -full dilation marks the END OF THE FIRST STAGE of Labor

third stage of labor

placenta usually expelled within 10 to 15 minutes after the birth of the baby. If the third stage has not been completed within 30 minutes, the placenta is considered to be retained.

External Fetal Monitoring

the FHR is monitored with an ultrasound transducer (over baby HR PMI) and the client's contractions are monitored with a tocotransducer aka toco (placed over fundus above umbilicus) *for preterm, fundus may be below umbilicus. fetus may be too small for UC to show on monitor (mom may have to say when UC happens). Needs to be repositioned more often because of more fetal movement.

Leopold maneuvers

to determine the presentation and position of the fetus, and aid in location of the fetal heart sounds