Maternal/Newborn - Module 3

Non-Pharmacologic - Sensory Stimulation

(based on the gate-control theory) used to promote relaxation and pain relief - Aroma therapy - Breathing techniques - Imagery - Music - Use of focal points

Fetal Heart Rate - Early Decelerations

 Decrease in FHR occurring with contractions  Onset occurs before contraction peak  Recovery to baseline rate occurs by contraction end  Possible cause: Fetal head compression

Fetal Heart Rate - Variable Decelerations

 Decrease in FHR occurring without regard to contractions  Can range from mild to severe  Shaped like "V" or "W"  Probable causes: Cord prolapse; umbilical cord compression

Forceps Assisted Birth - Nursing Care

- Assist client to lithotomy position - Assess bladder is empty, catheterize if necessary - Ensure that fetus is engaged and membranes have ruptured - Assess/record FHR before, during, and after - Observe neonate for bruising and abrasions at site of forceps - Check mother for any possible injuries (lacerations, urine retention, hematoma) - Report to postpartum providers that forceps were used

C-Section - Intrarocedure Nursing Actions

- Assist in positioning client - Continue to monitor FHR, vitals, IV fluids, and urinary output

Amniotomy - Nursing Care

- Assure presenting part is engaged prior to an amniotomy to prevent cord prolapsed - Monitor FHR prior to and following to assess for prolapsed (aeb variable or late decelerations) - Assess and document characteristics of amniotic fluid - Document time of rupture - Limit maternal acitivity follow ROM to reduce risk fo infection or malposition of fetus - Obtain temp Q2 hrs

Fetal Heart Rate - Late Decelerations

- Decrease in FHR occurring with contraction - Onset with or after the peak of contraction - Recovery to baseline occurs after contraction ends - Etiology: Decreased uteroplacental blood flow/oxygen  Vena cava syndrome, hyperstimulation of uterus (too much Pit)  Preeclampsia, hypertension, diabetes, anemia, chronic maternal disease

When is the fetus best oxygenated during a contraction?

- Each contraction has a resting phase or uterine relaxation period that allows the woman and uterine muscle a pause for rest. - This pause allows blood flow to the uterus and placenta that was temporarily reduced during the contraction phase. - It is during this pause that much of the fetal exchange of oxygen, nutrients, and waste products occurs. With every contraction, 500 mL of blood leaves the utero-placental unit and moves back into maternal circulation

Forceps Assisted Birth - Indications

- Fetal distress during labor - Abnormal presentations or breech position requiring delivery of head - Arrest of rotation

Non-Pharmacologic - Cutaneous Strategies

(based on the gate-control theory) used to promote relaxation and pain relief - Back rubs and massage - Effleurage --- Light, gentle circular stroking of the client's abdomen with the fingertips in rhythm with breathing during contractions - Sacral counterpressure --- Consistent pressure is applied by the support person using the heel of the hand or fist against the client's sacral area to counteract pain in the lower back - Heat or cold therapy - Hydrotherapy (whirlpool or shower) increases maternal endorphin levels - Intradermal water block - Hypnosis - Acupressure - Transcutaneous electrical nerve stimulation (TENS) unit

Fetal Heart Rate - Types of Variability

- Absent (undetectable) - Minimal (change is < 5 BPM) - Moderate (change is 6-25 BPM) - Marked (change is > 25 BPM)

Epidural Anesthesia - Nursing Actions

- Administer bolus IV to help offset hypotension - Help to position and steady client into sitting or side position with back curved for insertion of catheter - Present compression of vena cava - Monitor maternal vitals - Assess FHR continuously - Maintain IV and have O2 and suction readily available - If ortho hypo present, be prepared to administer an IV vasopressor such as ephedrine, position client laterally, increase fluids, and initiate O2 - Provide client safety measures - Assess bladder for distention, catheterize if necessary - Monitor for return of sensation after delivery

C-Section - Preprocedure Nursing Actions

- Assess and record FHR, maternal vitals - Assist with ultrasound - Position client supine with wedge under hip - Insert urinary catheter - Administer any meds - Prepare surgical site - Insert IV - Obtain informed consent - Determine NPO status (notify anesthesiologist) - Assure pre-op tests are done (esp. Rh factor)

Spinal Anesthesia - Nursing Actions

- Assess maternal vitals Q10 min - Manage hyptension by administering IV vasopressor, positioning mother laterally, increasing fluids, and initiating O2 - Assess FHR, level of anesthesia, and uterine contractions - Provide safety measures - To relieve headache, place client in supine position, promote bed rest in dark room, administer oral analgesics, caffeine, and fluids - Instruct client when to bear down

Vacuum Assisted Birth - Indications

- Maternal exhaustion and ineffective pushing efforts - Fetal distress during second stage of labor

Epidural Anesthesia - Adverse Effects

- Maternal hypotension - Fetal bradycardia - Inability to feel urge to void - Loss of bearing down reflex

Spinal Anesthesia - Adverse Effects

- Maternal hypotension - Fetal bradycardia - Loss of bearing down reflex - Potential headache from CSF leakage at puncture site - Higher incidence of maternal bladder and uterine atony following birth

C-Section - Postprocedure Nursing Actions

- Monitor for signs of infection and excessive bleeding - Assess uterine fundus for firmness/tenderness - Assess lochia - Assess for productive cough or chills - Assess for thrombophlebitis - Monitor I&O and vitals - Provide pain relief/antiemetics - Encourage client to TCDB - Encourage splinting of incision with pillows - Encourage ambulation to prevent VTE - Assess client for symptoms of UTI

During what stages of labor in which it would be appropriate to give the different classes of analgesics?

- Non-pharmacologic: 1st stage latent phase --> 3rd stage - Sedatives: 1st stage latent phase --> 3rd stage - Spinal Block: 2nd stage --> 3rd stage Narcotics: 1st stage (active phase) --> (transition phase) Epidural: 1st stage (active phase) --> 3rd stage Pudenal: 2nd stage --> 3rd stage Local Infiltration: 2nd stage --> 3rd stage

Fetal Intolerance to Labor

- Normal FHR 110-160 bpm - Associated with fetal hypoxia  Fetal bradycardia  Fetal tachycardia  Absence of FHR variability  Early decelerationsà usually normal due to vagal stimulation from head compression  Late decelerationsà more ominous, problem with utero-placental perfusion  Variable decelerations

External Version - Nursing Actions

- Obtain informed consent - Perform NST to evaluate fetal well-being - Ensure RhoGAM was administered at 28 weeks if mother is Rh-neg - Administer fluids and tocolytics for easier manipulation prior to ECV - Monitor vitals, pain, uterine activity (contractions) - Monitor for ROM, bleeding, or decrease in fetal activity

Induction of Labor -

- Posttern pregnancy (>42 weeks) - Dystocia - Prolonged ROM - Maternal medical complications (Rh isoimmunization, diabetes, pulmonary disease, hypertension) - Fetal demise - Chorioaminonitis

Vacuum Assisted Birth - Nursing Care

- Preparation of client (assist client into lithotomy position, education) - Assess and record FHR before and during - Assess for bladder distention and catheterize if necessary - Prepare for forceps assisted birth if vacuum is not successful - Alert postpartum providers that vacuum was used - Observe neonate for lacerations, cephalohematomas, or subdural hematomas - Check neonate for caput seccedaneum (normal, should resolve within 24 hrs)

Induction of Labor - Preparing the Client for Amniotomy

- Record baseline assessment prior to procedure and continuously during and after procedure. - Assess amount, color, consistency, and odor of the fluid. - Document the time and findings of the amniotomy

2nd Stage of Labor

- Time: Duration for primi is usually 30 min to 2 hrs. Duration for multis is 5-30 mins. - Begins with full dilation and ends with birth. - Pushing characterizes this stage, with intense contractions every 1-2 mins.

3rd Stage of Labor

- Time: Duration is 5-30 mins. - Begins with delivery of the neonate and ends with delivery of the placenta. - Schultz is shiny presentation (fetal surface presents). - Duncan is dull presentation (maternal surface presents).

1st Stage of Labor - Transition Phase

- Time: duration is usually 20-40 mins. - Cervix is 8-10 cm dilated (2nd stage begins with full dilation). - Contractions are very strong with a frequency of 2 to 3 mins and a duration of 45-90 seconds. - The patient becomes tired, restless, irritable, feels out of control, feels urge to push, feels like they need to have a bowel movement. - This is the most difficult part of labor

1st Stage of Labor - Active Phase

- Time: primi is usually 3 hrs, multi 2 hrs. - The cervix is 4-7 cm dilated. Contractions become more moderate to strong and more regular. - Frequency is 3 to 5 mins with a duration of 40-70 secs. - There is rapid dilation and effacement, and some fetal descent. - The mother feels helpless and anxiety and restlessness increase.

1st Stage of Labor - Latent Phase

- Time: primi is usually 6 hrs, multi 4 hrs. - The cervix is 0-3cm and contractions are mild to moderate and irregular. - Frequency is usually 5 to 30 min with a duration of 30-45 seconds. - There is some dilation and effacement. - The mother is talkative and eager

Induction of Labor - Ongoing Care for Oxytocin

- maintain oxytocin ose if there is a contraction frequency of 2-3 min with a duration of 60-90 sec. - D/C oxytocin if uterine hyperstimulation occurs. If a nonreassuring FHR is noted, notify the PCP, position the client side lying, keep IV line open, icrease fluid rate up to 200 mL/hr unless contraindicated, administer O2 at 8-10 L/min, administer tocolytic terbulation 0.25 mg SQ, document responses. - If unable to resotre reassuring FHR, an emergency C-sec should be performed.

Induction of Labor - Preparing the Client for Cervical Ripening

- obtain consent - baseline data should be obtained - nurse may initiate oxytocin 6-12 hrs after ripening agent. - The nurse should monitor FHR and uterine activity and should notify the HCP if hyperstimulation or fetal distress is noted.

Induction of Labor - Preparing the Client for Oxytocin

- prior to administration, it is essential that the nurse confirm that the fetus is engaged in the birth canal at a minimum station of 0. - Oxytocin must be administered via infusion pump. IUPC may be used to monitor contractions. - Assessments should include BP, pulse, and RR Q30 min and with every change in dose. - Monitor FHR and contraction pattern Q15 min. assess fluid intake and urinary output. - Take bishop score prior to inducing labor.

Cervical Effacement

Effacement is the shortening and thinning of the cervix. The cervix is 2-3 cm long and approximately 1 cm thick. The degree of effacement is measured in percentage and goes from 0-100%. ***Effacement often precedes dilation in a first time pregnancy. ***Effacement and dilation occur together in subsequent pregnancies (multips)

Ominous Patterns

Absent or minimal variability with tachycardia or bradycardia, recurrent late decelerations, or recurrent variable decelerations of increasing depth and duration

Cephalic Presentation

Accounts for 97% of cases (these are normal presentations, with vertex as the best) - Vertex (occiput is presenting, chin is tucked down to touch chest) - Frontum/brow (frontum is presenting, chin is not tucked down, neck is partially extended) - Face (mentum-chin is presenting, neck is sharply extended with head tilted back)

Bishop Score

A bishop score is used to determine the maternal readiness for labor by evaluating if the cervix is favorable by rating dilation, effacement, consistency, position, and presenting part station. - These factors are assigned a numerical value of 0-3, the total score is calculated, and a score of 9 for nulliparas and 5 or more for multiparas indicates readiness for labor induction

External Version

ECV is the attempt to manipulate the abdominal wall to direct a malpositioned fetus into a normal vertex cephalic presentation after 37 weeks. - There is a high risk of prolapsed of the umbilical cord with this procedure. - Contraindications include uterine anomalies, previous c-sec, cephalopelvis disproportion, placenta previa, multifetal gestation, and/or oligohydraminos.

Non-Reassuring FHR

An abnormal FHR pattern that reflects an unfavorable physiological response to the maternal-fetal environment. Associated with adverse neonatal outcomes. Any one of the following signs lasting more than 15 min are nonreassuring FHR: - Persistent decreased variability - Tachycardia when accompanied by decreased variability - Persistent decreased variability - Persistent late decelerations (>50% contractions) - Recurrent prolonged decelerations - Variable decelerations: --- Associated with decreasing variability ---Variables with slow return of FHR to baseline ---Variables >70 BPM variables with tachycardia

Amnioinfusion

An amnioinfusion of NS or LR, as prescribed, is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. - The instillation will reduce the severity of variable decelerations caused by cord compression or dilute meconium-stained amniotic fluid. Indications: - Oligohydraminios caused by uteroplacental insufficiency, PROM, or postmaturity of fetus - Fetal cord compression caused by macrosomic or postmature fetus

Fetal Heart Rate - Normal

Baseline FHR is the mean fetal heart rate rounded to increments of 5 BPM during a 10 minute window. - The normal range is 110-160 BPM. - Tachycardia is defined as over 160 for over 10 minutes - Bradycardia as less than 110 for more than 10 minutes.

Fetal Heart Rate - Variability

Baseline variability is the fluctuations in the baseline FHR that are irregular in amplitude and frequency. - It is the most important predictor of adequate fetal oxygenation during labor. - Variability reflects the interaction between the fetal sympathetic and parasympathetic nervous system. - The presence of variability reflects well functioning and well oxygenated autonomic nervous system and confirms that the fetus is not in metabolic acidosis.

1st Stage of Labor

Begins with the onset of labor and ends with complete dilation. Cervical dilation is usually 1 cm/hr for primigravida and 1.5 cm/hr for multigravida. It usually lasts 12.5 hrs.

Non-Pharmacologic Pain Management

Childbirth preparation education, sensory and cutaneous strategies, and frequent maternal position changes

Cervical Dilation

Dilation is the enlargement or opening of the cervical ox. The cervix dilates from closed to 10 cm. when the cervix reaches 10 cm dilation it is considered fully or completely dilated and can no longer be palpated on vaginal examination

Mediolateral Episiotomy

Extends from the vaginal outlet posterolateral, either to the left or right of the midline, and is used when posterior extension is likely. - Third-degree laceration may occur - Blood loss is greater and the repair is more difficult - Local anesthetic is administered to the perineum prior to the incision

Median (Midline) Episiotomy

Extends from the vaginal outlet toward the rectum, and is the most commonly used - Much easier to repair - Less blood loss - Associated with a higher incidence of third- and fourth-degree lacerations

Pharmacologic - Epidural and Spinal Regional Analgesia

Fentanyl or sufentanil: - administered as a motor block without anesthesia. - These opioids produce regional analgesia providing rapid pain relief while still allowing the client to sense contractions and maintain ability to bear down. - Adverse effects include decreased gastric emptying, inhibition of bowel/bladder, brady/tachycardia, hypotension, and resp depression. - Provide safety measures. - Monitor N/V and vitals.

Breech Presentation

Head is not down (this is a malpresentation) - Complete (flexion of thighs and legs, sitting Indian style) - Frank (thighs flexed, knees straight, legs straight up instead of bent) - Footling (extension of one or both legs, one or both feet are presenting)

Retained Placenta

When all or part of the placenta or membranes are left behind in the uterus. - usually diagnosed if the placenta or parts have not been expelled within 30 min. - Oxytocin administration can help the uterus contract and push the contents out. - In some cases, manual extraction or curettage may be necessary.

Vacuum Assisted Birth

Involves the use of a cuplike suction device that is attached to the fetal head. - Traction is applied during contractions to assist in the descent and birth of the head, after which, the vacuum cup is released and removed preceding delivery of the fetal body. - The baby must be in vertex presentation, have an absence of cephalopelvic disproportion, and must have ROM

Hypertonic Contractions - Nursing Interventions

It is usually treated by administering terbutaline or another tocolytic. ***Hydrate to improve uterine perfusions. - Provide pain management. - Assess the FHR and UCs frequently.

Non-Pharmacologic - Childbirth Preparation Methods

Lamaze, Bradley, Dick-Read methods and/or pattern breathing methods are used to promote relaxation and pain relief

Pharmacologic - Opiod Analgesics

Meperidine, fentanyl, butophanol, and nalbuphine: - may be given IM or IV, but IV is recommended during labor due to the quicker onset. - Butophanol and nalbuphine provide pain relief without causing significant resp depression. - Adverse effects include resp depression in neonate, increased risk for aspiration, reduced gastric emptying (increases nausea/vomiting), sedation, tachycardia, hypotension, decreased FHR variability, and allergic reaction. - Prior to administration, nurse should verify that labor is well established (cervical dilation >4 cm with an engaged fetus). - Have naloxone available. - Monitor vitals.

Hypertonic Contractions

Nonproductive, uncoordinated, painful, uterine contractions during labor that are too frequent and too long in duration and do not allow for relaxation of uterine muscle between contractions (uterine tetany). Hypertonic contractions do not contribute to the progression of labor (effacement, dilation, fetal descent).

When can a vaginal delivery never be done after a C/S?

PREVIOUS CLASSICAL VERTICAL UTERINE INCISION

When can a vaginal delivery be done safely after a C/S?

PREVIOUS LOW SEGMENT TRANSVERSE UTERINE INCISION

4th Stage of Labor

Physiologic readjustment of mother's body begins - Time: Duration is usually 1-4 hrs. - begins with the delivery of the placents and ends with maternal stabilization of vital signs. - Maternal characteristics include achievement of vital sign homeostasis and lochia scant to moderate rubra. - After the placenta delivers, the primary mechanism by which hemostasis is achieved at the placental site is vasoconstriction produced by a well contracted myometrium. - Nurses should assess the uterus for tone, assess lochia for color, assess maternal vital signs Q15 min and monitor perineum for unusual swelling or hematoma. Remember BUBBLE HE for maternal assessment.

Placental Separation

Placental separation typically occurs within a few minutes after delivery. - Once the placenta separates from the wall of the uterus, the uterus continues to contract until the placenta is expelled. - This process typically takes 5-20 mins post delivery of the baby and occurs spontaneously

Pharmacologic - Phenothiazines

Promethazine or hydroxyzine: - can control N/V. - they do not relieve pain and are used as an adjunct with opioids. - Adverse effects include dry mouth and sedation. - Again, the nurse should verify that labor is well established. - Provide ice chips or mouth swabs. - Provide safety measures

Nursing management associated with fetal assessment and fetal intolerance to labor

SEE ATI Ch. 14

Pharmacologic - Sedatives (barbiturates)

Secobarbital, pentobarbital, and phenobarbital: - not typically used during birth, but can be used during early or latent phase to relieve anxiety and induce sleep. - Adverse effects include neonate resp depression, unsteady ambulation, and inhibition of ability to cope. - Do NOT give if client is experiencing pain. - Be sure to instruct client to request assistance with ambulation. - Provide safety measures

Contractions - Intensity

Strength of the contraction. - evaluated with palpation using the fingertips on maternal abdomen and is described as: - Mild: uterine wall is easily indented during contraction - Moderate: uterine wall is resistant to indentation during a contraction - Strong: uterine wall cannot be indented during a contraction

What is the presenting part?

The presenting part is the specific fetal structure lying nearest to the cervix. It is determined by the attitude or posture of the fetus. - Each presenting part has an identified denominator or reference point that is used to describe the fetal position in the pelvis

Leopold's Maneuvers

The purpose of Leoppold's maneuvers is to inspect and palpate the maternal abdomen to determine fetal position, station, and size. - 1st maneuver: determines what part of the fetus is located in the fundus (top) - 2nd maneuver: determines location of fetal back (sides) - 3rd maneuver: determines the presenting part of the fetus (bottom) - 4th maneuver: determine the location of cephalic prominence (top and bottom)

Hypertonic Contractions - Dangers

They can result in uteroplacental insufficiency leading to fetal hypoxia

Contractions - Frequency

Time from beginning of one contraction to the beginning of another. - recorded in minutes

Contractions - Duration

Time from the beginning of a contraction to the end of the contraction. - recorded in seconds

VEAL/CHOP

Variable --> Cord Early --> Head Acceleration --> OK Late --> Poor Perfusion

Epidural Anesthesia

an epidural block consists of a local anesthetic bupivacaine (Marcaine) along with an analgesic morphine or fentanyl injected into the epidural space at the level of the fourth or fifth vertebrae. - This eliminates all sensation from the level of the umbilicus to the thighs. - It is administered when the client is in active labor and dilated to at least 4 cm. continuous infusion or intermittenet injections may be administered through an indwelling epidural catheter. - PCA is becoming a favored method of acute pain relief management for labor and birth

Episiotomy

an incision made into the perineum to enlarge the vaginal opening to more easily facilitate delivery and minimize soft tissue damage

Spinal Anesthesia

consists of a local anesthetic that is injected into the subarachnoid space into the spinal fluid at the third, fourth, or fifth lumbar interspace. - This can be done alone or in combination with an analgesic such as fentanyl. - The spinal block eliminates all sensations from the level of the nipples to the feet. - It is commonly used for cesarean births. - A low spinal block may be used for a vaginal birth, but is not used for labor. - A spinal block is administered in the late second stage or before a c-sec.

Forceps Assisted Birth

consists of using an instrument to assist in the delivery of the fetal head. - Traction is applied during contractions

Position Used for "Back Labor"

hands and knees

Contractions - Primary Force

o Involuntary uterine contractions o Effacement/Dilation o Associated with the first stage of labor o Normal contractions

Contractions - Secondary Force

o Voluntary pushing in second stage o The urge to push is activated when the presenting part stretches the pelvic floor muscles (usually feel urge around 8-10 cm dilated, but you usually want to push at 10 because earlier will delay delivery via edema of cervix)

Amniotomy

the artificial rupture of membranes by the PCP. - Labor typically begins within 12 hr after membranes rupture. - The client is at an increased risk for cord prolapsed or infection. - Indications include slow labor progression, induction of labor, or an amnioinfusion is indicated for cord compression or meconium stained amniotic fluid.

Induction of Labor

the deliberate initiation of uterine contractions before spontaneous onset. - Methods include prostaglandins applied cervically, administration of IV Pit, amniotomy, or nipple stimulation to trigger endogenous oxytocin.

Engagement

the largest diameter of the presenting part reaches or passes through the pelvic inlet

Transverse Presentation

the presenting part is usually the shoulder and is associated with a transverse lie (this is a malpresentation)

Station

the relationship of the ischial spines to the presenting part of the fetus and assists in assessing for fetal descent during labor. Station 0 is the narrowest diameter the fetus must pass through during a vaginal birth. ***Station is described as 0 at the ischial spines, with -1 through -5 above the spines and +1 through +5 below the spines

Non-Pharmacologic - Frequent maternal position changes

to promote relaxation and pain relief - Semi-sitting - Squatting - Kneeling - Kneeling and rocking back and forth - Supine position only with the placement of a wedge under one of the client's hips to tilt the uterus and avoid supine hypotension syndrome

Interventions for abnormal/bad FHR patterns

 Reposition the client  Turn off oxytocin if infusing  Increase mainline IV rate  O2 at 8-10 L/minute  Vaginal exam to rule out cord prolapse  Notify health care provider  Prepare to administer terbutaline (uterine relaxation)

4th Stage of Labor - BUBBLE HE

 Uterus  Lochia  Perineum  Bladder  Vital signs  Pain  Psychosocial status