106 unit 6 Labor (1&2)

types of breathing techniques and when they are used

Cleansing breath: brings O2 to the muscles, helps relax -each contraction begins & ends w/ deep inspiration & expiration Slow paced: helps promote relaxation above all---> LATENT PHASE -woman concentrates on relaxing her body rather than controlling breathing Pattern-paced (pant-blow) "hee-hoo" -focuses on rythmic breathing -used in the transition stage

transition phase nursing interventions

Coaching: breathing/pushing Fetal heart rate monitoring Safety: Encouragement/support/information:

-Stages and Phases of Labor- STAGE 2 CARDINAL MOVEMENTS

D-E-F-IR-E-ER-E "Does Every Female InRural England EnjoyRed Eggpplant?" DESCENT ENGAGE FLEX: so smallest part of the head passes thru pelvis *INTERNAL ROTATION: allows largest part of head to match with largest part of the pelvis *EXTENSION: head passes through pubis *EXTERNAL ROTATION: allows shoulders to rotate EXPLUSION

DRUGS USED IN THE INTRAPARTUM PHASE (ACTIVE)

Demerol - resp depression in neonate at 3-5hr, long half life Nubain - opioid agonist/antagonist; lower neonatal neurobehavioral scores; less nausea and vomiting; may decrease itching Oxytocin - give as secondary piggyback diluted, assure FHR is reassuring before giving, watch for hypertonic contractionS (faster then every 3 min)-->can lead to uterine atony--> hemorrhage/subinvolution

pain control method in the latent phase

*main focus in the Latent phase is non-pharm pain cx* Hydrotherapy, Shower, Tub / Whirlpool, guided imagery -cutaneous: effleurage, sacral pressure, intradermal sterile water injections -mental: guided imagery, focal point, breathing techniques -Repositioning: medicine

The "4 P's"- Psyche how does this affect the laboring process?

-Anxiety, fear decreases ability to cope -Can inhibit uterine contractility and blood flow -Fear-tension-pain cycle

how are contractions assessed?

-Frequency (how often they occur) Start of contraction to start of next contraction. -Duration (how long they last) Beginning of the contraction to the end of the SAME ONE -Intensity (how strong they are as measured by the tightening of the muscle Palpated by hand of RN on fundus

caesarean section (C-section) indications

-HSV1 active lesions -Failure to progress -Fetal distress: meconium? late/variables--> uteroplacental inssuficiency? -presentation: Breech, transverse lie -Previous C-section (possibly): VBAC -Placenta previa/ abruptio -Prolapsed cord -Pelvic disproportion: large head small pelvis/small frame-->Platypelloid pelvis

Premonitory signs of labor

-Lightening - fetus moves down further into pelvis. -Also called false labor -Ripening: the bottom of the uterus becomes soft--> action of prostaglandins -Braxton Hicks contractions - irregular mild contractions. -Bloody show - also called mucous plug which was in the cervix and is expelled -Spontaneous rupture of membranes. -Burst of Energy (a.k.a. Nesting) -Weight loss of 1-3 lbs. (probably water loss).

-Stages and Phases of Labor- STAGE 2- the pushing stage interventions

-Monitor mother- Coaching & positioning Support Second stage breathing: "HEE-HEE-HOO" /bearing down efforts Monitor blood pressure: epidural? hemmoarge? PIH? -baby- FHR: baseline, late/early decels? Amniotic fluid assesment/bloody show: meconium? could mean fetal distress asses station: engaged?

Active phase pain management

-Narcs for pain (keep narcan close), monitor for resp depression, causes constipation - Regional (epidural) Side effects: hypotension; prevent by given iv hydration Monitor: BP's, FHT's, bladder status, safety Coach r/t contractions: they wont feel contractions with this

the 4 P's (critical factors of labor)

-Powers: (forces of labor) relates to the strength and effectiveness of contractions and the maternal effort -Passage: refers to pelvic size, specifically the diameters--> GYNECOID IS BEST -PassENGER: Refers to the fetal skull, (attitude, lie and presentation) and station -Psyche: Parent preparation (i.e. childbirth classes), experiences with previous labors, emotional and physical factors, response factors to stress, support system and cultural influences.

prolapsed cord nursing actions

-can happen after AROM when cord comes through before the head and it can kink causing fetal hypoxia -if fetus is at a high station -hydramnios (excess amniotic fluid) ACTION: have mom lay with chest on the bed and bottom up to shift baby forwarding -Trendelenburg -if this doesn't help use hand to handle cord until -O2 -NO FLUIDS -MAY NEED RAPID CESAREAN

Pitocin (oxytocin) nursing considerations & side effects

-given to get ideal contraction q 3 minutes -anymore than 3 minutes=hypertonic and Pitocin must be decreased/shut off -Carefully monitor IV dosage/fluids -Given until active labor pattern achieved (IF USED FOR AUGM) -Must monitor both mother and fetus side effects Water intoxication: drowsiness, listlessness, confusion, H/A Uterine tetany: Resulting from hyperstimulation; could cause fetal distress or uterine rupture

what are the roles of the following hormones in causing labor? 1. progesterone 2. Estrogen 3. oxytocin 4. Prostaglandins

1- promotes uterine MUSCLE RELAXATION -decreases towards the end of pregnancy thereby, with decreased progesterone and the rise of estrogen, CONTRACTIONS ARE STIMULATED. 2. Estrogen - enhances UTERINE SENSITIVITY 3. Oxytocin - stimulates CONTRACTIONS 4. increases towards end of pregnancy. -prostaglandins stimulate CONTRACTIONS and SOFTEN THE CERVIX

-Stages and Phases of Labor- STAGE 4

1-4 hrs after birth FIRST 2 HRS ARE CRITICAL -MARKS THE BEGINNING OF PP -fundus should be at or a bit below the umbilicus -lochia rubra may be seen -chills are normal: warm blankey, soup or tea -ICE packs on peri area, pericare (bottle) -bonding

Methods of induction of labor/ know indications/contraindications

1. Cervical ripening: prostaglandins -per suppository via intravaginal / intracervical Usually done prior to starting induction. A) CYTOTECH-adverse reaction is tachysytole monitor mom/baby cx and FHR for 30 min beofre 2. Amniotomy (AROM) -May be done to either INDUCE or AUGMENT labor -allowing the baby to drop further into the pelvis and begin stretching the cervix -RISK FOR INFECTION : CHORIOAMNIONANITIS-->watch for fever and cord prolapse! 3. Oxytocin (Pitocin) used to INDUCE or AUGMENT increases contractions -not given until the 4. Balloon thingy--mechanical

1. the process of the cervix shortening and thinning out.

1. Effacement

-breech presentations- 1. fetal legs are extended across the abdomen torward the shoulders 2. head, kneed and shoulders are flexed, buttocks is presenting

1. frank breech 2. complete/full breech

-THE 4 P'S- 1. when the fetus is in the lowest diameter of the pelvis, Engaged and considered to be at the zero station, it is in the--- 2. refers to the position of the fetus in uterus 3. refers to the flexion or extension of the fetal head 4. location of presenting parting relation to maternal pelvis. 5. most common and desired fetal presenation for labor

1. ischial spines 2. fetal lie 3. attitude 4. POSITION 5. cephalic/vertex

fetal lie: 1. considered the traditional or normal lie 2. an angle between the longitudinal and transverse

1. longitudinal 2. oblique

1. what is the role of contractions? 2. optimal contraction pattern

1. stretching out the bottom of the uterus (cervix) to allow passage for the fetus to be delivered 2. 2-3 minutes apart with strong intensity (fundus becomes very firm at the climax of the contraction)

EAQ which assessments and interventions are needed once an epidural anesthesia has been placed? select all that apply a) maintain Iv fluids b) have oxygen available in case of hypotension c) check bladder for distention q 2 hrs d) position client supine for ease of monitoring e) administer an oxytocin infusion to maintain contraction pattern f) monitor fetal HR and labor progress

A,B,C,F an epidural may slow labor progress a bit but oxytocin is NOT needed for a woman to maintain labor progress remeber what oxytocin is used for: given to induce-force contractions to start Augment-to keep the contractions going once labor has been established and failed to progress the question never stated she was failing to progress

Latent phase nursing interventions/ care

Good Time to TEACH: -Review breathing techniques! Activity- walking increases contractions Assess GBS status!! Diet- very light "when was the last meal??"--> cesarean! fluids; IV's--> for dehydration and incase of epidural (hypotension) make them PEE- slows labor! Pain control: focused on nonpharm in the latent phase Position changes: for comfort

-Stages and Phases of Labor- STAGE 2 MEDICAL INTERVENTIONS

INTERVENTIONS EPISIOTOMY: used with shoulder dystocia or macrosomia FORCEPS: could cause fetal hematoma--> bilirubin VACCUM: could cause bruising on the head

what are the indications/ risks for forceps or vaccum assisted delivery?

Indications- baby needs to be delivered faster mom: exhaustion, inability to push, cardiac/pulmonary disease, infection baby: cord compression/variable decels, placental abruptio, non reassuring FHR RISKS mom: laceration, hematoma baby: bruises, bilirubin high, intracranial hemorrhage, chignon (scalp edema/bruising) with vacuum

-Leopold's Maneuvers- steps and purpose

Leopolds helps determine the position (breech/cephalic) and place of heart tones step1: helps determine between cephalic and breech -palpate the top of the fundus to palpate something soft or hard (soft=but, hard=head) step 2: determine which side the fetal back & arms -hold the fetus w/ one hand and use the other to palpate for a smooth convex surface (the back) and nodules (arms/hands) step 3: confirm the presentation (step1) and if the presenting part is engaged -if cephalic (NOT BREECH) then you should feel a hard rounded head in the suprapubic area - If the presenting part is not engaged grasping it with the fingers would move it step 4: ONLY FOR CEPHALIC PRESENATION-used to determing if the head is flexed -if it is flexed the forehead is felt on the opposite side of the fetal back - if the head is extended the forehead is felt on the same side as the fetal back

-Stages and Phases of Labor- STAGE 3

PLACENTAL STAGE- begins with birth of baby and ends with expulsion of the placenta IMMEDIATE CARE OR NB-APGAR -Pitocin/oxytocin is shut off if it was used once baby is born -methergine/ oxytocin may be given AFTER DELIVERY OF PLACENTA (methergine given if oxy causes uterine atony) -pain from uterine contractions, from stretching and passing of the placenta is normal -uterus must contract/remain contracted after placenta is expelled or Hemorrhage signs placenta has separated: gush of blood, change is shape of uterus, cord lengthens -MONITOR MOM BP: RISK FOR HEMMORAGE

NAME ALL THE Stages and Phases of Labor

Stage 1 (Cervical Dilation) • Latent (0-3cm) • Active (4-7cm) • Transition (8-9cm) Stage 2 (Fetal Expulsion) Stage 3 (Placental Expulsion) Stage 4 (Maternal Homeostasis)

-Stages and Phases of Labor- STAGE 2- the pushing stage

THE PUSHING STAGE begins with 100% effacement & dilation and ends with birth of the baby -pressure (bulging) on the anus leads to involuntary pushing, CROWNING occurs and burning sensation -may be oblivious/ appear asleep between contractions -excitement and relief once baby is born

true vs false contractions

TRUE: REGUALR, INCREASING IN FREQUENCY, DURATION AND INTENSITY -MOVE FROM BACK TO FRONT (LIKE A GRIDLE) -CONTINUE REGARDLESS OF ACTIVITY!!!! FALSE: IRREGULAR, disappear w change in activity, DO NOT INCREASE IN DURATION FREQUENCY AND INTESITY, CONTRACTIONS PRIMARILY IN THE FRONT.

EAQ for which reason wouls the nurse encourage the client to void during the first stage of labor?

a full bladder can inhibit labor progress by impeding the descent of the fetal head

EAQ which assessments would be done before administering uterine stimulants to induce labor? SATA a) asses the cervix for readiness for indcution b) assess mothers pulse c) assess contractions and document d) assess FHR and document e) assess moms activity level

a,b,c,d

EAQ Amniomity is performed in a laboring client of 42 weeks. place the nursing actions in order of priority a) aseses characteristics of amniotoc fluis b) checking fetal hr tracings c) inspect the perineum for umbilical cord prolapse d) monitor client for signs of infection

b) cheking FHR is first action c) inspect perineum for cord prolapse-this cord often comes down with the fluid when its ruptured a) assses amniotic fluid d) monitor for signs of infection

EAQ what is the appropriate nursing intervention for the client in active labor who is 4 cm dilated and 100% effaced? a) document FHR every five minutes b) call anesthesia dep to alert of imminent birth c) assist clients coach in helping her with the use of breathing techniques d) suggest as needed PRN meds for pain that have been prescribed

c -its not necessary to document FHR q 5 minutes until thesecond stage of labor d)- suggesting there is discomfort may produce anxiety and more discomfort

EAQ the clients cervix is 3 cm dialted and 50% effaced, her membranes have ruptured and it is clear, fetal HR is stable. which outcome would the nurse anticipate? a) a prolonged second stage b) difficult birth resulting from delayed effacement c) birth of the fetus within a day d) stimulation of labor with oxytocin

c in a healthy pregnancy birth should occur in the next 24 hrs after SROM -if not both are at risk for sepsis

EAQ the nurse is teaching a childbirth preparation class regarding the discomforts of labor, which influence has the greatest influence on the perception of pain? a) partiy of the client b) duration of labor c) tension of the client d) difficulty of the labor

c tension prevents relaxation

EAQ which complication would the nurse consider for a client with a fetus in breech presentation? a) Rapid dialtion of the cervix indicating the precipitate labor b) stronger contractions indivating progression of labor c) nonreasuring fetal signs, indicating prolapsed cord d) cessation of contractions indicating primary uterine inertia

c the feet of buttocks are not effective in blocking the cervical opening and the cord may slip through and be compressed

what can factors can cause dytsocia (difficult labor)?

maternal fatigue, inactivity fluid & electrolyte imbalance HYPOGLYCEMIA EXCESSIVE ANALGESIA UTERINE OVERDISTENTION: multiple babies, polyhydraminos (excessive amniotic fluid) AND A full bladder

Tocolytics indiaction/ contra

may be ordered if labor occurs before the 34th week

what are the second stage bearing down efforts?

pushing 3-4x for 6-8 seconds helps fetal descent

-Stages and Phases of Labor- STAGE 1

starts w/ true labor -Latent: 0-3 cm, gen - station, length approx. 6 hrs, mom is sociable and exited activity: walks, shower whirlpool -Active: 4-7cm, zero station, effacement 0-100%, discomfort increases w/ moderate contractions, anxiety & restlessness, activity: Pain management -Transition: 8-10cm, short and intense phase with intense contractions, increased BLOODY SHOW, mom becomes irritable, inward focus, FETUS REACHES PELVIS FLOOR (ishial spines), leg tremors, N&V are common

Define AUGMENTATION of labor and what is used

stimulation of uterine contractions after labor has started spontaneously and progress is unsatisfactory -oxytocin, AROM, not prostaglandins because shes already dialted and this forces the body into labor!!!