Ricci chapter 14

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Analysis of fetal heart rate part 1

Analysis of the FHR is one of the primary evaluation tools used to determine fetal oxygen status indirectly. FHR assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally. The object of FHR monitoring is to reduce the mortality/morbidity by ensuring that all fetal hypoxic insults are identified in time to allow removal or alteration of the reason for it, or to enable a safe birth of the fetus before irreversible asphyxia damage occurs (Hastings, 2015). Intermittent FHR Monitoring Intermittent FHR monitoring involves auscultation via a fetoscope or a handheld Doppler device that uses ultrasound waves that bounce off the fetal heart, producing echoes or clicks that reflect the rate of the fetal heart (Fig. 14.3). Traditionally, a fetoscope was used to assess FHR, but the handheld Doppler device has been found to have a greater sensitivity than the fetoscope. Intermittent auscultation of the fetal heart rate is an acceptable option for low-risk laboring women, yet it is underutilized in the hospital setting. Recently several professional organizations have proposed the use of intermittent auscultation as a means of promoting physiologic births (Wisner, 2015); thus, at present it is used in some clinical settings. See Evidence-Based Practice 14.1 for more information. FIGURE 14.3 Nurse using a handheld Doppler to obtain a fetal heart rate. Take Note! Doppler devices to detect FHRs are relatively low in cost and are used in hospitals and in home births and birthing centers routinely. Many nurses use them in their work settings. Intermittent FHR monitoring allows the woman to be mobile in the first stage of labor. She is free to move around and change position at will since she is not attached to a stationary electronic fetal monitor. However, intermittent monitoring does not provide a continuous FHR recording and does not document how the fetus responds to the stress of labor (unless listening is done during the contraction). The best way to assess fetal well-being would be to start listening to the FHR at the end of the contraction (not after one) so that late decelerations could be detected. However, the pressure of the device during a contraction is uncomfortable and can distract the woman from using her paced-breathing patterns. Intermittent FHR auscultation can be used to detect FHR baseline and rhythm and changes from baseline. However, it cannot detect variability and types of decelerations, as electronic fetal monitoring (EFM) can (Wisner, 2015). During intermittent auscultation to establish a baseline, the FHR is assessed for a full minute after a contraction. From then on, unless there is a problem, listening for 30 seconds and multiplying the value by two is sufficient. If the woman experiences a change in condition during labor, auscultation assessments should be more frequent. Changes in condition include ruptured membranes or the onset of bleeding. In addition, more frequent assessments occur after periods of ambulation, a vaginal examination, administration of pain medications, or other clinically important events (King et al., 2015). The FHR is heard most clearly at the fetal back. In a cephalic presentation, the FHR is best heard in the lower quadrant of the maternal abdomen. In a breech presentation, it is heard at or above the level of the maternal umbilicus (Fig. 14.4). As labor progresses, the FHR location will change accordingly as the fetus descends into the maternal pelvis for the birthing process. To ensure that the maternal heart rate is not confused with the FHR, palpate the client's radial pulse simultaneously while the FHR is being auscultated through the abdomen. (Ricci 455-457) For low risk women, the FHR and contraction characteristics should be assessed every 15 to 30 minutes in active labor and every 5 to 15 minutes while pushing, as well as before and after any digital vaginal examinations, membrane rupture, medication administered, and ambulation to the restroom (Freeman, 2015). Nursing Procedure 12.1 lists detailed steps for using a Doppler device to assess FHR. In brief, a small amount of water-soluble gel is applied to the woman's abdomen or ultrasound device before auscultation with the Doppler device to promote sound wave transmission. Usually the FHR is best heard in the woman's lower abdominal quadrants; if the FHR is not found quickly, it may help to locate the fetal back by performing Leopold's maneuvers. p. 457 p. 458 Although the intermittent method of FHR assessment allows the client to move about during labor, the information obtained fails to provide a complete picture of the well-being of the fetus from moment to moment. This leads to the question of what the fetal status is during the times that are not assessed. For women who are considered at low risk for complications, this period of nonassessment is not a problem. However, for the undiagnosed high-risk woman, it might prove ominous. GUIDELINES FOR ASSESSING FETAL HEART RATE National professional organizations have provided general guidelines for the frequency of assessments based on existing evidence. The American College of Obstetricians and Gynecologists (ACOG), the Institute for Clinical Systems Improvement (ICSI), and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) have published guidelines designed to assist clinicians in caring for laboring clients. Their recommendations are supported by large controlled studies. They recommend the following guidelines for assessing FHR: Initial 10- to 20-minute continuous FHR assessment on entry into labor/birth area Completion of a prenatal and labor risk assessment on all clients Intermittent auscultation every 30 minutes during active labor for a low-risk woman and every 15 minutes for a high-risk woman During the second stage of labor, every 15 minutes for the low-risk woman and every 5 minutes for the high-risk woman and during the pushing stage (Agency for Healthcare Research and Quality [AHRQ, 2014]; Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2015; Institute for Clinical Systems Improvement [ICSI], 2015a). EVIDENCE-BASED RESULTS: INTERMITTENT VERSUS ELECTRONIC MONITORING In several randomized controlled studies comparing intermittent auscultation with electronic monitoring in both low- and high-risk clients, no difference in intrapartum fetal death was found. However, in each study a nurse-client ratio of 1:1 was consistently maintained during labor (ICSI, 2015a). This suggests that adequate staffing is essential with intermittent FHR monitoring to ensure optimal outcomes for the mother and fetus. There is insufficient evidence to indicate specific situations where continuous electronic FHR monitoring might result in better outcomes when compared to intermittent assessment. However, in pregnancies involving an increased risk of perinatal death, cerebral palsy, or neonatal encephalopathy and when oxytocin is used for induction or augmentation, it is recommended that continuous EFM be used rather than intermittent fetal auscultation (Society of Obstetricians and Gynecologists of Canada, 2015). (Ricci 457-458) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Nursing management 4th stage of labor

The fourth stage of labor begins after the placenta is expelled and lasts up to 4 hours after birth, during which time recovery takes place. This recovery period may take place in the same room where the woman gave birth, in a separate recovery area, or in her postpartum room. During this stage, the woman's body is beginning to undergo the many physiologic and psychological changes that occur after birth. The focus of nursing management during the fourth stage of labor involves frequent close observation for hemorrhage, provision of comfort measures, and promotion of family attachment. Assessment Assessments during the fourth stage center on the woman's vital signs, status of the uterine fundus and perineal area, comfort level, lochia amount, and bladder status. During the first hour after birth, vital signs are taken every 15 minutes, then every 30 minutes for the next hour if needed. The woman's blood pressure should remain stable and within normal range after giving birth. A decrease may indicate uterine hemorrhage; an elevation might suggest preeclampsia. The pulse usually is typically slower (60 to 70 bpm) than during labor. This may be associated with a decrease in blood volume following placental separation. An elevated pulse rate may be an early sign of blood loss. The blood pressure usually returns to its prepregnancy level and therefore is not a reliable early indicator of shock. Fever is indicative of dehydration (less than 100.4°F or 38°C) or infection (above 101°F), which may involve the genitourinary tract. Respiratory rate is usually between 16 and 24 breaths per minute and regular. Respirations should be unlabored unless there is an underlying preexisting respiratory condition. Assess fundal height, position, and firmness every 15 minutes during the first hour following birth. The fundus needs to remain firm to prevent excessive postpartum bleeding. The fundus should be firm (feels like the size and consistency of a grapefruit), located in the midline and below the umbilicus. If it is not firm (boggy), gently massage it until it is firm (see Nursing Procedure 22.1 for more information). Once firmness is obtained, stop massaging. Take Note! If the fundus is displaced to the right of the midline, suspect a full bladder as the cause. The vagina and perineal areas are quite stretched and edematous following a vaginal birth. Assess the perineum, including the episiotomy if present, for possible hematoma formation. Suspect a hematoma if the woman reports excruciating pain or cannot void or if a mass is noted in the perineal area. Also assess for hemorrhoids, which can cause discomfort. Assess the woman's comfort level frequently to determine the need for analgesia. Ask the woman to rate her pain on a scale of 1 to 10; it should be less than 3. If it is higher, further evaluation is needed to make sure there aren't any deviations contributing to her discomfort. Assess vaginal discharge (lochia) every 15 minutes for the first hour and every 30 minutes for the next hour. Palpate the fundus at the same time to ascertain its firmness and help to estimate the amount of vaginal discharge. In addition, palpate the bladder for fullness, since many women receiving an epidural block experience limited sensation in the bladder region. Voiding should produce large amounts of urine (diuresis) each time. Palpating the woman's bladder after each voiding helps in assessing it and ensuring complete emptying. A full bladder will displace the uterus to either side of the midline and potentiate uterine hemorrhage secondary to bogginess. Nursing Interventions Nursing interventions during the fourth stage might include: Providing support and information to the woman regarding episiotomy repair and related pain relief and self-care measures Applying an ice pack to the perineum to promote comfort and reduce swelling Assisting with hygiene and perineal care; teaching the woman how to use the perineal bottle after each pad change and voiding; helping the woman into a new gown Monitoring for return of sensation and ability to void (if regional anesthesia was used) Encouraging the woman to void by ambulating to the bathroom, listening to running water, or pouring warm water over the perineal area with the peribottle Monitoring vital signs and fundal and lochia status every 15 minutes and documenting them Assessing for postpartum hemorrhage and urinary retention via uterine palpation Promoting comfort by offering analgesia for afterpains and warm blankets to reduce chilling Offering fluids and nourishment if desired Encouraging parent-infant attachment by providing privacy for the family Being knowledgeable about and sensitive to typical cultural practices after birth Assisting and encouraging the mother to nurse, if she chooses, during the recovery period to promote uterine firmness (the release of oxytocin from the posterior pituitary gland stimulates uterine contractions) Teaching the woman how to assess her fundus for firmness periodically and to massage it if it is boggy Describing the lochia flow and normal parameters to observe for postpartum Teaching safety techniques to prevent newborn abduction Demonstrating the use of the portable sitz bath as a comfort measure for her perineum if she had a laceration or an episiotomy repair Explaining comfort/hygiene measures and when to use them Assisting with ambulation when getting out of bed for the first time Providing information about the routine on the mother-baby unit or nursery for her stay Observing for signs of early parent-infant attachment: fingertip touch to palm touch to enfolding of the infant (Leonard, 2015; Green, 2016). The nurse's role in labor and birth is a privileged one, supporting women at one of their most vulnerable times—childbirth. The nurse's focus during this time should be on supporting, protecting, advocating and empowering women. The nurse should also provide informational support, which would allow the woman to realize her aspirations and goals by making decisions through informed choice. Nurses make a long-term difference in the lives of childbearing women with small things they do for their clients that make a big difference to them. (Ricci 491-492) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Introduction

The laboring and birthing process is a life-changing event for many women. Nurses need to be respectful, available, encouraging, supportive, and professional in dealing with all women. Nursing management for labor and birth involves assessment, comfort measures, emotional support, information and instruction, advocacy, and support for the partner. Providing the highest quality in maternity care is dependent on nurses valuing the childbirth experience and recognizing it as a life-changing experience for women and their families; caring nurse practice encompasses technical skills and caring behaviors; giving care that protects, promotes, and supports physiologic childbirth; providing optimal, evidence-based care; and recognizing health disparity and cultural diversity in all women cared for to improve their childbirth experience across time, settings, and disciplines. One of the components for evidence-based care and woman-centered care is women preferences to guide care for themselves during the birthing process. In a recent study, women's needs and expectations during labor and birth were assessed. Seven themes emerged—physiologic needs (nutrition, room environment, hygiene, comfort, and privacy); psychologic needs (empathy and advocacy, constant emotional support and encouragement); informational needs (about labor process and hospital policies); communication needs (health care provider and familiar attendant); esteem needs (sense of value, confidence, involvement in decisions); security needs (calming fears); and medical needs (pain relief and prevention of unnecessary interventions during labor and birth) (Iravani et al., 2015). It is important that nurses identify the expectations and needs of women in their care, so as to empower them to fully participate in their childbirth experience. The health of mothers and their infants is of critical importance, both as a reflection of the current health status of a large segment of our population and as a predictor of the health of the next generation. The United States Department of Health and Human Services [USDHHS] (2010) addresses maternal health in two objectives: reducing maternal deaths and reducing maternal illness and complications due to pregnancy (complications during hospitalized labor and delivery). In addition, two more objectives address increasing the proportion of pregnant women who receive early and adequate prenatal care. A goal in development seeks to increase the proportion of pregnant women who attend a series of prepared childbirth classes. (See Chapter 12 for more information on these objectives.) This chapter provides information about nursing management during labor and birth. First, the essentials for in-depth assessment of maternal and fetal status during labor and birth are discussed. This is followed by a thorough description of the major methods of promoting comfort and providing pain management during the labor and birth process. The chapter concludes by putting all the information together with a discussion of the nursing care specific to each stage of labor, including the necessary data to be obtained with the admission assessment, methods to evaluate labor progress during the first stage of labor, and key nursing measures (Ricci 451) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Acupuncture and acupressure

Acupuncture and acupressure can be used to relieve pain during labor. Although controlled research studies of these methods are limited, there is adequate evidence that both are useful in relieving pain associated with labor and birth. However, both methods require a trained, certified clinician, and such a person is not available in many birth facilities (Halpern & Garg, 2015). Acupuncture involves stimulating key trigger points with needles. This form of Chinese medicine has been practiced for approximately 3,000 years. Classical Chinese teaching holds that throughout the body there are meridians or channels of energy (qi) that when in balance regulate body functions. Pain reflects an imbalance or obstruction of the flow of energy. The purpose of acupuncture is to restore thus diminishing pain (Adams et al., 2015). Stimulating the trigger points causes the release of endorphins, reducing the perception of pain. Acupressure involves the application of a firm finger or massage used in acupuncture to reduce the pain sensation. The amount of pressure is important. The intensity of the pressure is determined by the needs of the woman. Holding and squeezing the hand of a woman in labor may trigger the point most commonly used for both techniques. Some acupressure points are found along the spine, neck, shoulder, toes, and soles of the feet. Pressure along the side of the spine can help relieve back pain during labor (Fig. 14.10) (Mollart, Adam, & Foureur, 2015). A Cochrane collaboration review found that acupuncture may indeed reduce labor pain, increasing satisfaction with pain management and reduced use of pharmacologic management. However, there is a need for further research (Simkin & Klein, 2015). (Ricci 468) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Ambulation

Ambulation and position changes during labor are another extremely useful comfort measure. Historically, women adopted a variety of positions during labor, rarely using the recumbent position until during the first half of the twentieth century. The medical profession has favored recumbent positions during labor, but without evidence to demonstrate their appropriateness. A recent Cochrane database systematic review reported there is evidence that walking and upright positions in the first stage of labor reduce the length of labor and do not seem to be associated with increased intervention or negative effects on mothers' and babies' well-being. In an upright posture, gravity directs the weight of the fetus and amniotic fluid downwards, successively dilating the cervix and the birth canal. Uterine contractions have been shown to be better spaced, stronger and more efficient in dilating the cervix when the mother is in an upright position than when she is supine (Cox & King, 2015). Women should be encouraged to take up whatever position they find most comfortable in the first stage of labor (Cheng & Caughey, 2015a). Changing position frequently (every 30 minutes or so)—sitting, walking, kneeling, standing, lying down, getting on hands and knees, and using a birthing ball—helps relieve pain (Fig. 14.9). Position changes also may help to speed labor by adding the benefits of gravity and changing the shape of the pelvis. Research has found that the position that the woman assumes and the frequency of position changes have a profound effect on uterine activity and efficiency. Allowing the woman to obtain a position of comfort frequently facilitates a favorable fetal rotation by altering the alignment of the presenting part with the pelvis. As the mother continues to change position based on comfort, the optimal presentation is afforded (King et al., 2015). Supine positions should be avoided, since they may interfere with labor progress and can cause compression of the vena cava and decrease blood return to the heart. FIGURE 14.9 Various positions for use during labor. A. Ambulation. B. Leaning forward. C. Sitting in a chair. D. Using a birthing ball. FIGURE 14.10 Nurse massaging the client's back during a contraction while she ambulates during labor. Swaying from side to side, rocking, or other rhythmic movements may also be comforting. If labor is progressing slowly, ambulating may speed it up again. Upright positions such as walking, kneeling forward, or doing the lunge on the birthing ball give most women a greater sense of control and active movement than just lying down. Table 14.2 highlights some of the more common positions that can be used during labor and birth. (Ricci 467-468) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Amniotic fluid analysis

Amniotic fluid should be clear when the membranes rupture. Rupturing of membranes is either spontaneous or artificial by means of an amniotomy, during which a disposable plastic hook (an amnihook) is used to perforate the amniotic sac. Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction (IUGR), maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation. If it is determined that meconium-stained amniotic fluid is due to fetal hypoxia, the maternity and pediatric teams work together to prevent meconium aspiration syndrome. This would necessitate suctioning after the head is born before the infant takes a breath and perhaps direct tracheal suctioning after birth if the Apgar score is low. In some cases an amnioinfusion (introduction of warmed, sterile normal saline or Ringer's lactate solution into the uterus) is used to dilute moderate to heavy meconium released in utero to assist in preventing meconium aspiration syndrome. (Ricci 455) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Other nonpharmacologic methods

Attention Focusing and Imagery Attention focusing and imagery use many of the senses and the mind to focus on stimuli. The woman can focus on tactile stimuli such as touch, massage, or stroking. She may focus on auditory stimuli such as music, humming, or verbal encouragement. Visual stimuli might be any object in the room, or the woman can imagine the beach, a mountaintop, a happy memory, or even the contractions of the uterine muscle pulling the cervix open and the fetus pressing downward to open the cervix. Some women focus on a particular mental activity such as a song, a chant, counting backwards, or a Bible verse. Breathing, relaxation, positive thinking, and positive visualization work well for mothers in labor. The use of these techniques keeps the sensory input perceived during the contraction from reaching the pain center in the cortex of the brain (Capogna, 2015a). Effleurage and Massage Effleurage is a light, stroking, superficial touch of the abdomen, in rhythm with breathing during contractions. It is used as a relaxation and distraction technique from discomfort. External fetal monitor belts may interfere with the ability to accomplish this. Effleurage and massage use the sense of touch to promote relaxation and pain relief. Massage works as a form of pain relief by increasing the production of endorphins in the body. Endorphins reduce the transmission of signals between nerve cells and thus lower the perception of pain. Because touch receptors go to the brain faster than pain receptors, massage—anywhere on the body—can block the pain message to the brain. In addition, light touch has been found to release endorphins and induce a relaxed state. In addition, touching and massage distract the woman from discomfort. Massage involves manipulation of the body's soft tissues. It is commonly used to help relax tense muscles and to soothe and calm the individual. Massage may help to relieve pain by assisting with relaxation, inhibiting sensory transmission in the pain pathways, or improving blood flow and oxygenation of tissues (Neetu & Panchal, 2015). Breathing Techniques Conscious use of breath by the woman has the power to profoundly influence her labor and how she engages with it. The first action anyone takes in any situation is a breath. The breath affects the lungs, immediately cueing the nervous system. The nervous system responds by sending messages, which impact our entire psycho-physiologic system. Messages sent from the nervous system affect us physically, emotionally, and mentally. If we alter how we breathe, we alter the constellation of messages and reactions in our entire mind-body experience (Cheng & Caughey, 2015a). Breathing techniques are effective in producing relaxation and pain relief through the use of distraction. If the woman is concentrating on slow-paced rhythmic breathing, she is not likely to fully focus on contraction pain. Breathing techniques are often taught in childbirth education classes (see Chapter 12 for additional information). Controlled breathing helps reduce the pain experienced by using stimulus-response conditioning. The woman selects a focal point within her environment to stare at during the first sign of a contraction. This focus creates a visual stimulus that goes directly to her brain. The woman takes a deep cleansing breath, which is followed by rhythmic breathing. Verbal commands from her partner supply an ongoing auditory stimulus to her brain. Benefits of practicing patterned breathing include: breathing becomes an automatic response to pain. increases relaxation and can be used for deal with life's everyday stresses. is calming during labor. provides a sense of well-being and a measure of control. brings purpose to each contraction, making them more productive. provides more oxygen for the mother and fetus (American Pregnancy Association, 2015). Many couples learn patterned-paced breathing during their childbirth education classes. Three levels may be taught, each beginning and ending with a cleansing breath or sigh after each contraction. In the first pattern, also known as slow-paced breathing, the woman inhales slowly through her nose and exhales through pursed lips. The breathing rate is typically 6 to 9 bpm. In the second pattern, the woman inhales and exhales through her mouth at a rate of four breaths every 5 seconds. The rate can be accelerated to two breaths per second to assist her to relax. The third pattern is similar to the second pattern except that the breathing is punctuated every few breaths by a forceful exhalation through pursed lips. All breaths are kept equal and rhythmic and can increase as contractions increase in intensity (Lindholm & Hildingsson, 2015). Many childbirth educators do not recommend specific breathing techniques or try to teach parents to breathe the "right" way during labor and birth. Couples are encouraged to find breathing styles that enhance their relaxation and use them. There are numerous benefits to controlled and rhythmic breathing in childbirth (outlined previously), and many women choose these techniques to manage their discomfort during labor. (Ricci 470-471) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Baseline variability

Periodic baseline changes

Baseline variability is defined as irregular fluctuations in the baseline fetal heart rate, which is measured as the amplitude of the peak to trough in bpm (Sholapurkar, 2015). It represents the interplay between the parasympathetic and sympathetic nervous systems. The constant interplay (push-and-pull effect) on the FHR from the parasympathetic and sympathetic systems produces a moment-to-moment change in the FHR. Because variability is in essence the combined result of autonomic nervous system branch function, its presence implies that the both branches are working and receiving adequate oxygen (Timmins & Clark, 2015). Thus, variability is one of the most important characteristics of the FHR. Variability is described in four categories as follows: fluctuation range undetectable fluctuation range observed at <5 bpm fluctuation range from 6 to 25 bpm fluctuation range >25 bpm Absent or minimal variability typically is caused by fetal acidemia secondary to uteroplacental insufficiency, cord compression, a preterm fetus, maternal hypotension, uterine hyperstimulation, abruptio placenta, or a fetal dysrhythmia. Interventions to improve uteroplacental blood flow and perfusion through the umbilical cord include lateral positioning of the mother, increasing the IV fluid rate to improve maternal circulation, administering oxygen at 8 to 10 L/min by mask, considering internal fetal monitoring, documenting findings, and reporting to the health care provider. Preparation for a surgical birth may be necessary if no changes occur after attempting the interventions. Moderate viability indicates that the autonomic and central nervous systems (CNSs) of the fetus are well developed and well oxygenated. It is considered a good sign of fetal well-being and correlates with the absence of significant metabolic acidosis (Fig. 14.7). Marked variability occurs when there are more than 25 beats of fluctuation in the FHR baseline. Causes of this include cord prolapse or compression, maternal hypotension, uterine hyperstimulation, and abruptio placenta. Interventions include determining the cause if possible, lateral positioning, increasing intravenous fluid rate, administering oxygen at 8 to 10 L/min by mask, discontinuing oxytocin infusion, observing for changes in tracing, considering internal fetal monitoring, communicating an abnormal pattern to the health care provider, and preparing for a surgical birth if no change in pattern is noted (Freeman, 2015). FHR variability is an important clinical indicator that is predictive of fetal acid-base balance and cerebral tissue perfusion. It is influenced by fetal oxygenation status, cardiac output, and drug effects (King et al., 2015). As the CNS is desensitized by hypoxia and acidosis, FHR decreases until a smooth baseline pattern appears. Loss of variability may be associated with a poor outcome. (Ricci 461) deceleration is a transient fall in FHR caused by stimulation of the parasympathetic nervous system. Decelerations are described by their shape and association to a uterine contraction. They are classified as early, late, and variable only (Fig. 14.8). Early decelerations are visually apparent, usually symmetrical, and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They rarely decrease more than 30 to 40 bpm below the baseline. Typically, the onset, nadir, and recovery of the deceleration occur at the same time as the onset, peak, and recovery of the contraction. They are most often seen during the active stage of any normal labor, during pushing, crowning, or vacuum extraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Early decelerations are not indicative of fetal distress and do not require intervention. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs, with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists (Martin, Fanaroff, & Walsh, 2014). Conditions that may decrease uteroplacental perfusion with resultant decelerations include maternal hypotension, gestational hypertension, placental aging secondary to diabetes and postmaturity, hyperstimulation via oxytocin infusion, maternal smoking, anemia, and cardiac disease. They imply some degree of fetal hypoxia. Recurrent or intermittent late decelerations are always category II (indeterminate) or category III (abnormal) regardless of depth of deceleration. Acute episodes with moderate variability are more likely to be correctable, whereas chronic episodes with loss of variability are less likely to be correctable (Sholapurkar, 2015). Box 14.1 highlights interventions for category III decelerations. Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns (Cahill & Spain, 2015). Variable decelerations usually occur abruptly with quick deceleration. They are the most common deceleration pattern found in the laboring woman and are usually transient and correctable (Ugwumadu, 2015). Variable decelerations are associated with cord compression. However, they are classified either as category II or III depending on the accompanying change in baseline variability (ICSI, 2015a). The pattern of variable deceleration consistently related to the contractions with a slow return to FHR baseline warrants further monitoring and evaluation. (Ricci 463) Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes, but less than 10 minutes (NICHD, 2015). The rate usually drops to less than 90 bpm. Many factors are associated with this pattern, including prolonged cord compression, abruptio placenta, cord prolapse, supine maternal position, vaginal examination, fetal blood sampling, maternal seizures, regional anesthesia, or uterine rupture (ACOG & SMFM 2014). Prolonged decelerations can be remedied by identifying the underlying cause and correcting it. A sinusoidal pattern is described as having a visually apparent smooth, sinewave-like undulating pattern in the FHR baseline with a cycle frequency of 3 to 5 bpm that persists for >20 minutes. It is attributed to a derangement of CNS control of FHR and occurs when a severe degree of hypoxia secondary to fetal anemia and hypovolemia is present. It is always considered a Category III pattern, and to correct it a fetal intrauterine transfusion would be needed (Nageotte, 2015). p. 463 p. 464 Combinations of FHR patterns obtained by EFM during labor are not infrequent. Category II and III patterns are more significant if they are mixed, persist for long periods, or have frequent prolonged late decelerations, absent or minimal variability, bradycardia or tachycardia, and prolonged variable decelerations lower than 60 bpm. The likelihood of fetal compromise is increased if Category II and III patterns are associated with decreased baseline variability or abnormal contraction patterns (ICSI, 2015a). (Ricci 463-464) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

continuous labor support

Continuous labor support involves offering a sustained presence to the laboring woman by providing emotional support, comfort measures, advocacy, information and advice, and support for the partner. It is a non-pharmacologic, evidence-based strategy associated with reduced cesarean rates (Jackson & Gregory, 2015). A woman's family, a midwife, a nurse, a doula, or anyone else close to the woman can provide this continuous presence. A support person can assist the woman to ambulate, reposition herself, and use breathing techniques. A support person can also aid with the use of acupressure, massage, music therapy, or therapeutic touch. During the natural course of childbirth, a laboring woman's functional ability is limited secondary to pain, and she often has trouble making decisions. The support person can help make them based on his or her knowledge of the woman's birth plan and personal wishes. Research has validated the value of continuous labor support versus intermittent support in terms of fewer operative deliveries, cesarean births, and requests for pain medication. Continuous labor support has shown to have beneficial effects on the mother and the newborn primarily due to the reduction in anxiety during the laboring experience. Most women expressed greater satisfaction with their childbirth experience (Iravani et al., 2015). (Ricci 465-466) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Nursing management during first stage of labor

Depending on how far advanced the woman's labor is when she arrives at the facility; the nurse will determine assessment parameters of maternal-fetal status and plan care accordingly. The nurse will provide high-touch, low-tech supportive nursing care during the first stage of labor when admitting the woman and orienting her to the labor and birth suite. The nurse is usually the primary gatekeeper of observations, interventions, treatments, and often the management of labor in the inpatient perinatal setting. Nursing care during this stage will include taking an admission history (reviewing the prenatal record); checking the results of routine laboratory tests and any special tests such as chorionic villi sampling, amniocentesis, genetic studies, and biophysical profile done during pregnancy; asking the woman about her childbirth preparation (birth plan, classes taken, coping skills); and completing a physical assessment of the woman to establish baseline values for future comparison. Key nursing interventions include: Identifying the estimated date of birth from the client and the prenatal chart Validating the client's prenatal history to determine fetal risk status Determining fundal height to validate dates and fetal growth Performing Leopold's maneuvers to determine fetal position, lie, and presentation Checking FHR Performing a vaginal examination (as appropriate) to evaluate effacement and dilation progress Instructing the client and her partner about monitoring techniques and equipment Assessing fetal response and FHR to contractions and recovery time Interpreting fetal monitoring strips Checking FHR baseline for accelerations, variability, and decelerations Repositioning the client to obtain an optimal FHR pattern Recognizing FHR problems and initiating corrective measures Checking amniotic fluid for meconium staining, odor, and amount Comforting client throughout testing period and labor Documenting times of notification for team members if problems arise Knowing appropriate interventions when abnormal FHR patterns present Supporting the client's decisions regarding intervention or avoidance of intervention Assessing the client's support system and coping status frequently p. 477 p. 478 In addition to these interventions to promote optimal outcomes for the mother and fetus, the nurse must document care accurately and in a timely fashion. Accurate and timely documentation helps to decrease professional liability exposure, minimize the risk of preventable injuries to women and infants during labor and birth, and preserve families (Simpson, 2015). Guidelines for recording care include documenting: All care rendered, to prove that standards were met Conversations with all providers, including notification times Nursing interventions before and after notifying provider Use of the chain of command and response at each level All flow sheets and forms, to validate care given All education given to client and response to it Facts, not personal opinions detailed descriptions of any adverse outcome Initial nursing assessment, all encounters, and discharge plan All telephone conversations (Callahan, 2016). This standard of documentation is needed to prevent or defend against litigation, which is prevalent in the childbirth arena. Assessing the Woman Upon Admission The nurse usually first comes in contact with the woman either by phone or in person. The nurse should ascertain whether the woman is in true or false labor and whether she should be admitted or sent home. Upon admission to the labor and birth suite, the highest priorities include assessing FHR, assessing cervical dilation/effacement, and determining whether membranes have ruptured or are intact. These assessment data will guide the critical thinking in planning care for the client. If the initial contact is by phone, establish a therapeutic relationship with the woman. Speaking in a calm caring tone facilitates this. Nurses providing a telephone triage service need to have sufficient clinical experience and have clear lines of responsibility to enable sound decision making. When completing a phone assessment, include questions about the following: Estimated date of birth, to determine if term or preterm Fetal movement (frequency in the past few days) Other premonitory signs of labor experienced Parity, gravida, and previous childbirth experiences Time from start of labor to birth in previous labors Characteristics of contractions, including frequency, duration, and intensity Appearance of any vaginal bloody show Membrane status (ruptured or intact) Presence of supportive adult in household or if she is alone When speaking with the woman over the telephone, review the signs and symptoms that denote true versus false labor, and suggest various positions she can assume to provide comfort and increase placental perfusion. Also suggest walking, massage, and taking a warm shower to promote relaxation. Outline what foods and fluids are appropriate for oral intake in early labor. Throughout the phone call, listen to the woman's concerns and answer any questions clearly. Reducing the risk of liability exposure and avoiding preventable injuries to mothers and fetuses during labor and birth can be accomplished by adhering to two basic tenets of clinical practice: (1) use applicable evidence and/or published standards and guidelines as the foundation of care, and (2) whenever a clinical choice is presented, choose client safety (Miller, 2014). With these two tenets in mind, advise the woman on the phone to contact her health care provider for further instructions or to come to the facility to be evaluated, since ruling out true labor and possible maternal-fetal complications cannot be done accurately over the phone. Additional nursing responsibilities associated with a phone assessment include: Consulting the woman's prenatal record for parity status, estimated date of birth, and untoward events Calling the health care provider to inform him or her of the woman's status Preparing for admission to the perinatal unit to ensure adequate staff assignment Notifying the admissions office of a pending admission If the nurse's first encounter with the woman is in person, an assessment is completed to determine whether she should be admitted to the perinatal unit or sent home until her labor advances. Recent research findings suggest that women admitted before active labor are approximately twice as likely to be augmented with oxytocin and give birth via cesarean when compared with women admitted in active labor (Neal et al., 2014). Nurses need to make careful assessment of labor progression prior to labor admission to decrease early admissions and to improve labor safety and birth outcomes. Entering a facility is often an intimidating and stressful event for women since it is an unfamiliar environment. Giving birth for the first time is a pivotal event in the lives of most women. Therefore, demonstrate respect when addressing the client; listen carefully and express interest and concern. Nurses must value and respect women and promote their self-worth and sense of control by allowing them to participate in making decisions. Allowing them a fair amount of autonomy in their childbirth decisions, supporting their personal worth, knowing them holistically, and using caring communication will increase client satisfaction (Ivory, 2014). p. 478 p. 479 An admission assessment includes maternal health history, physical assessment, fetal assessment, laboratory studies, and assessment of psychological status. Usually the facility has a form that can be used throughout labor and birth to document assessment findings (Fig. 14.13). MATERNAL HEALTH HISTORY AND CULTURAL ASSESSMENT A maternal health history should include typical biographical data such as the woman's name and age and the name of the delivering health care provider. Other information that is collected includes reason for admission, such as labor, cesarean birth, or observation for a complication; the prenatal record data, including the estimated date of birth, a history of the current pregnancy, and the results of any laboratory and diagnostic tests, such as blood type, Rh status, and group B streptococcal status; past pregnancy and obstetric history; past health history and family history; prenatal education; list of medications; risk factors such as diabetes, hypertension, and use of tobacco, alcohol, or illicit drugs; pain management plan; history of potential domestic violence; history of previous preterm births; allergies; time of last food ingestion; method chosen for infant feeding; name of birth attendant (MD or midwife)(s) and pediatrician. Ascertaining this information is important so that an individualized plan of care can be developed for the woman. If, for example, the woman's due date is still 2 months away, it is important to establish this information so interventions can be initiated to arrest the labor immediately or notify the intensive perinatal team to be available. In addition, if the woman has diabetes, it is critical to monitor her glucose levels during labor, to prepare for a surgical birth if dystocia of labor occurs, and to alert the newborn nursery of potential hypoglycemia in the newborn after birth. By collecting important information about each woman they care for, nurses can help improve the outcomes for all concerned. Be sure to observe the woman's emotions, support system, verbal interaction, cultural background and language spoken, body language and posture, perceptual acuity, and energy level. This psychosocial information provides cues about the woman's emotional state, culture, and communication systems. For example, if the woman arrives at the labor and birth suite extremely anxious, alone, and unable to communicate in English, how can the nurse meet her needs and plan her care appropriately? It is only by assessing each woman physically and psychosocially that the nurse can make astute decisions regarding proper care. In this case, an interpreter would be needed to assist in the communication process between the staff and the woman to initiate proper care. It is important to acknowledge and try to understand the cultural differences in women with cultural backgrounds different from that of the nurse. Attitudes toward childbirth are heavily influenced by the culture in which the woman has been raised. As a result, within every society, specific attitudes and values shape the woman's childbearing behaviors. Be aware of what these are. When carrying out a cultural assessment during the admission process, ask questions (Box 14.2) to help plan culturally competent care during labor and birth. (Ricci 477-479) PHYSICAL EXAMINATION The physical examination typically includes a generalized assessment of the woman's body systems, including hydration status, vital signs, auscultation of heart and lung sounds, and measurement of height and weight. The physical examination also includes the following assessments: Pain level and coping behaviors demonstrated Uterine activity, including contraction frequency, duration, and intensity Fetal status, including heart rate, position, and station Cervical dilation and degree of effacement Status of membranes (intact or ruptured) Assess vital signs: temperature, pulse, respirations & blood pressure Perform Leopold's maneuvers to determine fetal lie Fundal height measurement Ability to ambulate safely These assessment parameters form a baseline against which the nurse can compare all future values throughout labor. The findings should be similar to those of the woman's prepregnancy and pregnancy findings, with the exception of her pulse rate, which might be elevated secondary to her anxious state with beginning labor. p. 479 p. 480 FIGURE 14.13 Sample documentation form used for admission to the perinatal unit. (Used with permission. Briggs Corporation, 2001.) p. 480 p. 481 LABORATORY STUDIES On admission, laboratory studies typically are done to establish a baseline. Although the exact tests may vary among facilities, they usually include a urinalysis via clean-catch urine specimen and complete blood count. Blood typing and Rh factor analysis may be necessary if the results of these are unknown or unavailable. In addition, if the following test results are not included in the maternal prenatal history, it may be necessary to perform them at this time. They include syphilis screening, hepatitis B (HbsAg) screening, group B streptococcus, human immune deficiency virus (HIV) testing (if woman gives consent), and possible drug screening if the history is positive. Group B streptococcus (GBS) is a gram-positive organism that colonizes in the female genital tract and rectum and is present in 10% to 30% of all healthy women (King et al., 2015). These women are asymptomatic carriers but can cause GBS disease of the newborn through vertical transmission during labor and horizontal transmission after birth. The mortality rate of infected newborns varies according to time of onset (early or late). Risk factors for GBS include maternal intrapartum fever, prolonged ruptured membranes (>12 to 18 hours), previous birth of an infected newborn, and GBS bacteriuria in the present pregnancy. The Centers for Disease Control and Prevention (CDC), ACOG and the American Academy of Pediatrics have guidelines that advised universal screening of pregnant women at 35 to 37 weeks' gestation for GBS and intrapartum antibiotic therapy for GBS carriers. These new guidelines reaffirmed the major prevention strategy—universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture-positive and high-risk women. Also included are new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes, updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn infants (Centers for Disease Control and Prevention [CDC], 2014). Maternal infections associated with GBS include acute chorioamnionitis, endometritis, and urinary tract infection. Neonatal clinical manifestations include pneumonia and sepsis. Identified GBS carriers receive intravenous antibiotic prophylaxis (penicillin G or ampicillin) at the onset of labor or ruptured membranes. The ACOG, CDC, AWHONN and the United States Preventive Services Task Force all recommend that all pregnant women be offered a screening test for HIV antibodies on their first prenatal visit, again during the third trimester if engaging in high-risk behaviors, and on admission to the labor and birth area. The CDC estimates that 50,000 individuals contract HIV in the United States each year, and 250,000 individuals have undiagnosed HIV infections (CDC, 2015). If her HIV status is not documented, the woman being admitted to the labor and birth suite should have rapid HIV testing done. To reduce perinatal transmission, women who are HIV-positive are given zidovudine (2 mg/kg intravenously over an hour, and then a maintenance infusion of 1 mg/kg per hour until birth) or a single 200-mg oral dose of nevirapine at the onset of labor; the newborn is given zidovudine orally (2 mg/kg body weight every 6 hours) and should be continued for 6 weeks (Verklan & Walden, 2014). To further reduce the risk of perinatal transmission, ACOG and the United States Public Health Service recommend that women who are infected with HIV and have plasma viral loads of more than 1,000 copies/mL be counseled regarding the benefits of elective cesarean birth. In the absence of any medical intervention, the rate of vertical transmission of HIV to the fetus can range from 15% to 45% (Ashimi et al., 2015). Additional interventions to reduce the transmission risk would include avoiding use of a scalp electrode for fetal monitoring or doing a scalp blood sampling for fetal pH, delaying amniotomy, encouraging formula feeding after birth, and avoiding invasive procedures such as forceps or vacuum-assisted devices. The nurse stresses the importance of all interventions and the goal to reduce transmission of HIV to the newborn. Continuing Assessment During the First Stage of Labor After the admission assessment is complete and the woman and her support person have been orientated to the room, equipment, and procedures, assessment continues for changes that would indicate that labor is progressing as expected. Assess the woman's knowledge, experience, and expectations of labor. Typically, blood pressure, pulse, and respirations are assessed every hour during the latent phase of labor unless the clinical situation dictates that vital signs be taken more frequently. During the active and transition phases, they are assessed every 30 minutes. The temperature is taken every 4 hours throughout the first stage of labor and every 2 hours after membranes have ruptured to detect an elevation indicating an ascending infection. Vaginal examinations are performed periodically to track labor progress. This assessment information is shared with the woman to reinforce that she is making progress toward the goal of birth. Uterine contractions are monitored for frequency, duration, and intensity every 30 to 60 minutes during the latent phase, every 15 to 30 minutes during the active phase, and every 15 minutes during transition. Note the changes in the character of the contractions as labor progresses, and inform the woman of her progress. Continually determine the woman's level of pain and her ability to cope and use relaxation techniques effectively. p. 481 p. 482 When the fetal membranes rupture, spontaneously or artificially, assess the FHR and check the amniotic fluid for color, odor, and amount. Assess the FHR intermittently or continuously via electronic monitoring. During the latent phase of labor, assess the FHR every 30 to 60 minutes; in the active phase, assess FHR at least every 15 to 30 minutes. Also, be sure to assess the FHR before ambulation, before any procedure, and before administering analgesia or anesthesia to the mother. Table 14.3 summarizes assessments for the first stage of labor. Remember Sheila from the chapter-opening scenario? What is the nurse's role with Sheila in active labor? What additional comfort measures can the labor nurse offer Sheila? Nursing Interventions Nursing interventions during the admission process should include: Asking about the client's expectations of the birthing process Providing information about labor, birth, pain management options, and relaxation techniques Presenting information about fetal monitoring equipment and the procedures needed Monitoring FHR and identifying patterns that need further intervention Monitoring the mother's vital signs to obtain a baseline for later comparison Reassuring the client that her labor progress will be monitored closely and nursing care will focus on ensuring fetal and maternal well-being throughout As the woman progresses through the first stage of labor, nursing interventions include: Encouraging the woman's partner to participate Keeping the woman and her partner up to date on the progress of the labor Orienting the woman and her partner to the labor and birth unit and explaining all of the birthing procedures Providing clear fluids (e.g., ice chips) as needed or requested Maintaining the woman's parenteral fluid intake at the prescribed rate if she has an IV Initiating or encouraging comfort measures, such as backrubs, cool cloths to the forehead, frequent position changes, ambulation, showers, slow dancing, leaning over a birth ball, side-lying, or counterpressure on lower back (Teaching Guidelines 14.1) (Ricci 479-482) Encouraging the partner's involvement with breathing techniques Assisting the woman and her partner to focus on breathing techniques Informing the woman that the discomfort will be intermittent and of limited duration; urging her to rest between contractions to preserve her strength; and encouraging her to use distracting activities to lessen the focus on contractions Changing bed linens and gown as needed Keeping the perineal area clean and dry Supporting the woman's decisions about pain management Monitoring maternal vital signs frequently and reporting any abnormal values Ensuring that the woman takes deep cleansing breaths before and after each contraction to enhance gas exchange and oxygen to the fetus Educating the woman and her partner about the need for rest and helping them plan strategies to conserve strength Monitoring FHR for baseline, accelerations, variability, and decelerations Checking on bladder status and encouraging voiding at least every 2 hours to make room for birth Repositioning the woman as needed to obtain optimal heart rate pattern Communicating requests from the woman to appropriate personnel Respecting the woman's sense of privacy by covering her when appropriate Offering human presence by being present with the woman, not leaving her alone for long periods Being patient with the natural labor pattern to allow time for change Encouraging maternal movement throughout labor to increase the woman's level of comfort Dimming the lights in the room when pushing and request softened voices be used to maintain a calm and centered ambiance Reporting any deviations from normal to the health care professional so that interventions can be initiated early to be effective (Green, 2016; Lucas et al., 2015; Nagtalon-Ramos, 2014). See Nursing Care Plan 14.1. (Ricci 483) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Determining FHR patterns

Due to the rising costs of litigations related to birth asphyxia of the newborn and increasing complexity of obstetric populations, it has become absolutely mandatory that all nurses responsible for the care of women in labor are trained adequately in interpretation and documentation of CTG tracings, as well as the guidelines for interventions based on the assessment of the tracing and overall clinical situation. Assessment parameters of the FHR include baseline FHR and variability, presence of accelerations, periodic or episodic decelerations, and changes or trends of FHR patterns over time. The nurse must be able to interpret the various parameters to determine if the FHR pattern is a category I, which is strongly predictive of normal fetal acid-base status at the time of observation and needs no intervention; a category II, which is not predictive of abnormal fetal acid-base status and but does require evaluation and continued monitoring; or a category III, which is predictive of abnormal fetal acid-base status at the time of observation and requires prompt evaluation and interventions, such as giving maternal oxygen, changing maternal position, discontinuing labor augmentation medication, and/or treating maternal hypotension (Freeman, 2015). Table 14.1 summarizes these categories. BASELINE FHR Baseline fetal heart rate refers to the average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. It is assessed when the woman has no contractions and the fetus is not experiencing episodic FHR changes. The normal baseline FHR ranges between 110 and 160 beats per minute (bpm) (National Institute of Child Health and Human Development [NICHD], 2015). The normal baseline FHR can be obtained by auscultation, ultrasound, or Doppler, or by a continuous internal direct fetal electrode. Fetal bradycardia occurs when the FHR is below 110 bpm and lasts 10 minutes or longer (Maso et al., 2015). It can be the initial response of a healthy fetus to asphyxia. Causes of fetal bradycardia might include fetal hypoxia, prolonged maternal hypoglycemia, fetal acidosis, administration of analgesic drugs to the mother, hypothermia, anesthetic agents (epidural), maternal hypotension, fetal hypothermia, prolonged umbilical cord compression, and fetal congenital heart block (Nageotte, 2015). Bradycardia may be benign if it is an isolated event, but it is considered an ominous sign when accompanied by a decrease in baseline variability and late decelerations. Fetal tachycardia is a baseline FHR greater than 160 bpm that lasts for 10 minutes or longer (NICHD, 2015). It can represent an early compensatory response to asphyxia. Other causes of fetal tachycardia include fetal hypoxia, maternal fever, maternal dehydration, amnionitis, drugs (e.g., cocaine, amphetamines, nicotine), maternal hyperthyroidism, maternal anxiety, fetal anemia, prematurity, fetal infection, chronic hypoxemia, congenital anomalies, fetal heart failure, and fetal arrhythmias. Fetal tachycardia is considered an ominous sign if it is accompanied by a decrease in variability and late decelerations (Yuan, 2015). (Ricci 460) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Maternal assessment during labor and birth

During labor and birth, various techniques are used to assess maternal status. These techniques provide an ongoing source of data to determine the woman's response and her progress in labor: Assess maternal vital signs, including temperature, blood pressure, pulse, respiration, and pain, which are primary components of the physical examination and ongoing assessment. Also review the prenatal record to identify risk factors that may contribute to a decrease in uteroplacental circulation during labor. If there is no vaginal bleeding on admission, a vaginal examination is performed to assess cervical dilation, after which it is monitored periodically as necessary to identify progress. Evaluate maternal pain and the effectiveness of pain management strategies at regular intervals during labor and birth. (Ricci 451) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Continuous fetal monitoring

EFM detects the fetal pulse by sensing and analyzing tissue movements via Doppler ultrasound. The machine uses a transducer that is capable of both sending and receiving ultrasound waves. The waves travel through the ultrasound gel, then body tissues, and are eventually reflected by any tissue. The fast reflections are analyzed and software in the machine determines the FHR. EFM is the recommended method of intrapartum fetal surveillance for high-risk pregnancies. Despite the questions about its efficacy and controversy regarding increased rates of surgical births associated with its use, continuous cardiotocography (CTG) remains the predominant method of fetal monitoring today (Nageotte, 2015). The indications for offering women continuous fetal monitoring in labor are documented in the National Institute for Health and Care Excellence (NICE) guidelines. These include women receiving oxytocin infusing; women having epidural analgesia; and a variety of problems related to a compromise in either fetal or maternal health—prolonged rupture of membranes (>24 hours), moderate hypertension (>150/100), confirmed delay in the first or second stage of labor; and the presence of meconium (National Institute for Health and care Excellence [NICE], 2014). Electronic fetal monitoring (EFM) uses a machine to produce a continuous tracing of the FHR. When the monitoring device is in place, a sound is produced with each heartbeat. In addition, a graphic record of the FHR pattern is produced. The primary objective of EFM is to provide information about fetal oxygenation and prevent fetal injury that could result from impaired fetal oxygenation during labor. The purpose of EFM is to detect FHR changes early before they are prolonged and profound. Fetal hypoxia is demonstrated in a heart rate pattern change and is by far the most common etiology of fetal injury and death that can be prevented with optimal fetal surveillance during labor and early interventions (Cox & King, 2015). Current methods of continuous EFM were introduced in the United States during the 1970s, specifically for use in clients considered to be at high risk. However, the use of these methods gradually increased and they eventually came to be used for women other than just those at high risk. This increased use has become controversial because it is suspected of being associated with the steadily increasing rates of cesarean births with no decrease in the rate of cerebral palsy (Omo-Aghoja, 2015). Many studies suggest that when compared with standardized intermittent auscultation, the use of intrapartum continuous EFM seems to increase the number of preterm and surgical births but has no significant effect on reducing the incidence of intrapartum death or long-term neurologic injury. When a woman is admitted to the labor unit, a fetal monitor is applied and the FHR is monitored continuously. An impetus for this is the litigious nature of current society, but the benefits have not been proven scientifically. EFM has been given excessive importance in legal cases. Before assigning fault on events at birth, a better understanding of developmental neurobiology and limitations of the present biomarkers is warranted (Freeman, 2015). To date, continuous EFM is not evidence-based for determining fetal health status. With EFM, there is a continuous record of the FHR: no gaps exist, as they do with intermittent auscultation. The concept of hearing and evaluating every beat of the fetus's heart to allow for early intervention seems logical. On the downside, however, using continuous monitoring can limit maternal movement and encourages the woman to lie in the supine position, which reduces placental perfusion. Despite the criticisms, EFM remains an accurate method for determining fetal health status by providing a moment-to-moment printout of FHR status. Various groups within the medical community have criticized the use of continuous fetal monitoring for all pregnant clients, whether high risk or low risk. Concerns about the efficiency and safety of routine EFM in labor have led expert panels in the United States to recommend that such monitoring be limited to high-risk pregnancies. However, its use in low-risk pregnancies continues globally (Maso et al., 2015). This remains an important research issue. Continuous EFM can be performed externally (indirectly), with the equipment attached to the maternal abdominal wall, or internally (directly), with the equipment attached to the fetus. Both methods provide a continuous printout of the FHR, but they differ in their specificity. The efficacy of EFM depends on the accurate interpretation of the tracings, not necessarily which method (external vs. internal) is used. CONTINUOUS EXTERNAL MONITORING In external or indirect monitoring, two ultrasound transducers, each of which is attached to a belt, are applied around the woman's abdomen. They are similar to the handheld Doppler device. One transducer is called a tocotransducer, a pressure-sensitive device that is applied against the uterine fundus. It detects changes in uterine pressure and converts the pressure registered into an electronic signal that is recorded on graph paper (Farine, 2015). The tocotransducer is placed over the uterine fundus in the area of greatest contractility to monitor uterine contractions. The other ultrasound transducer records the baseline FHR, long-term variability, accelerations, and decelerations. It is positioned on the maternal abdomen in the midline between the umbilicus and the symphysis pubis. The diaphragm of the ultrasound transducer is moved to either side of the abdomen to obtain a stronger sound and is then attached to the second elastic belt. This transducer converts the fetal heart movements into beeping sounds and records them on graph paper (Fig. 14.5). Good continuous data are provided on the FHR. External monitoring can be used while the membranes are still intact and the cervix is not yet dilated, but also can be used with ruptured membranes and a dilating cervix. It is noninvasive and can detect relative changes in abdominal pressure between uterine resting tone and contractions. External monitoring also measures the approximate duration and frequency of contractions, providing a permanent record of FHR (Casanova, 2015). FIGURE 14.5 Continuous external electronic fetal monitoring device applied to the woman in labor. However, external monitoring can restrict the mother's movements. It also cannot detect short-term variability. Signal disruptions can occur due to maternal obesity, fetal malpresentation, and fetal movement as well as by artifact. The term artifact is used to describe irregular variations or absence of the FHR on the fetal monitor record that result from mechanical limitations of the monitor or electrical interference. For instance, the monitor may pick up transmissions from citizen's band (CB) radios used by truck drivers on nearby roads and translate them into a signal. Additionally, gaps in the monitor strip can occur periodically without explanation. CONTINUOUS INTERNAL MONITORING Continuous internal monitoring is usually indicated for women or fetuses considered to be at high risk. Possible conditions might include multiple gestation, decreased fetal movement, abnormal FHR on auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm birth, or medical conditions such as diabetes or hypertension. It involves the placement of a spiral electrode into the fetal presenting part, usually the head, to assess FHR, and a pressure transducer placed internally within the uterus to record uterine contractions (Fig. 14.6). The fetal spiral electrode is considered the most accurate method of detecting fetal heart characteristics and patterns because it involves receiving a signal directly from the fetus (Nageotte, 2015). Specially trained labor and birth nurses are permitted to place the spiral electrode on the fetal head when the membranes rupture to assess the FHR in some health care facilities, but they do not place the intrauterine pressure catheter in the uterus. Internal monitoring does not have to include both an intrauterine pressure catheter and a scalp electrode. A fetal scalp electrode can be used to monitor the fetal heartbeat without monitoring the maternal intrauterine pressure. FIGURE 14.6 Continuous internal electronic fetal monitoring. Both the FHR and the duration and interval of uterine contractions are recorded on the graph paper. This method permits evaluation of baseline heart rate and changes in rate and pattern. Four specific criteria must be met for this type of monitoring to be used: Ruptured membranes Cervical dilation of at least 2 cm Presenting fetal part low enough to allow placement of the scalp electrode Skilled practitioner available to insert spiral electrode (ICSI, 2015b) Compared with external monitoring, continuous internal monitoring can accurately detect both short-term (moment-to-moment) changes and variability (fluctuations within the baseline) and FHR dysrhythmias. In addition, maternal position changes and movement do not interfere with the quality of the tracing. (Ricci 458-460) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Hydrotherapy

Hydrotherapy is a nonpharmacologic measure that may involve showering or soaking in a regular tub or whirlpool bath. When showering is the selected method of hydrotherapy, the woman stands or sits in a shower chair in a warm shower and allows the water to gently glide over her abdomen and back. If a tub or whirlpool is chosen, the woman immerses herself in warm water for relaxation and relief of discomfort. When the woman enters the warm water, the warmth and buoyancy help to release muscle tension and can impart a sense of well-being (Taghavi, Barband, & Khaki, 2015). Warm water provides soothing stimulation of nerves in the skin, promoting vasodilation, reversal of sympathetic nervous response, and a reduction in catecholamines (Dalal, 2015). Contractions are usually less painful in warm water because the warmth and buoyancy of the water have a relaxing effect. Recent research findings reported that women who used hydrotherapy had significantly reduced surgical birth rates, a shorter second stage of labor, reduced analgesic requirements, and a lower incidence of perineal trauma (Taghavi, Barband, & Khaki, 2015). The research concluded that hydrotherapy during labor significantly aids the labor process, minimizes the use of analgesic medications, offers fast- and short-acting pain and anxiety relief, and should he considered as a safe and effective birthing aid (Taghavi, Barband, & Khaki, 2015). A wide range of hydrotherapy options are available, from ordinary bathtubs to whirlpool baths and showers, combined with low lighting and music. Many hospitals provide showers and whirlpool baths for laboring women for pain relief. However, hydrotherapy is more commonly practiced in birthing centers managed by midwives. The recommendation for initiating hydrotherapy is that the woman be in active labor (more than 5 cm dilated) to prevent the slowing of labor contractions secondary to muscular relaxation. The woman's membranes can be intact or ruptured. Women are encouraged to stay in the bath or shower as long as they feel they are comfortable. The water temperature should not exceed body temperature. Hydrotherapy is an effective pain management option for many women. Women who are experiencing a healthy pregnancy can be offered this option. The potential risks associated with hydrotherapy including hyperthermia, hypothermia, changes in maternal heart rate, fetal tachycardia, and unplanned underwater birth. The benefits include reducing pain, relieving anxiety, and promoting a sense of control during labor (Nutter, 2016). (Ricci 466) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Leopold's Maneuvers

Leopold's maneuvers are a method for determining the presentation, position, and lie of the fetus through the use of four specific steps. This method involves inspection and palpation of the maternal abdomen as a screening assessment for malpresentation. A longitudinal lie is expected, and the presentation can be cephalic, breech, or shoulder. Each maneuver answers a question: Maneuver 1: What fetal part (head or buttocks) is located in the fundus (top of the uterus)? Maneuver 2: On which maternal side is the fetal back located? (Fetal heart tones are best auscultated through the back of the fetus.) Maneuver 3: What is the presenting part? Maneuver 4: Is the fetal head flexed and engaged in the pelvis? Leopold's maneuvers are described in Nursing Procedure 14.1. Also see Chapter 12. (Ricci 453) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Nursing management second stage of labor

Management of the second stage of labor often follows tradition-based routines rather than evidence-based practices. Current evidence for management of the second stage of labor supports the practices of delayed pushing, spontaneous (nondirected) pushing, and maternal choice positions (Cox & King, 2015). To be able to help women through the second stage of labor requires the nurse to have a comprehensive understanding of physiology and be aware of the latest evidence-based research and apply it to practice (Green, 2016). Nursing care during the second stage of labor focuses on supporting the woman and her partner in making active decisions about her care and labor management, implementing strategies to prolong the early passive phase of fetal descent, supporting involuntary bearing-down efforts, providing instruction and assistance, and using maternal positions that can enhance descent and reduce pain (King et al., 2015). Women in the past gave birth unaided by following their bodies signals to birth their babies, so the role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her maternal instinct of when and how to push. In the absence of any complications, nurses should not be controlling this stage of labor, but empowering women to achieve a satisfying experience. The primary rationale for directing women to push is to shorten the second stage of labor. Common practice in many labor units is still to coach women to use closed glottis pushing with every contraction, starting at 10 cm of dilation, a practice that is not supported by research. Research suggests that directed pushing during the second stage may be accompanied by a significant decline in fetal pH and may cause maternal muscle and nerve damage if done too early (Reed, 2015). Shortening the phase of active pushing and lengthening the early phase of passive descent can be achieved by encouraging the woman not to push until she has a strong desire to do so and until the descent and rotation of the fetal head are well advanced. Effective pushing can be achieved by assisting the woman to assume a more upright or squatting position. Supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice (Cheng & Caughey, 2015b). (Ricci 483-485) Perineal lacerations or tears can occur during the second stage when the fetal head emerges through the vaginal introitus. The extent of the laceration is defined by depth: a first-degree laceration extends through the skin; a second-degree laceration extends through the muscles of the perineal body; a third-degree laceration continues through the anal sphincter muscle; and a fourth-degree laceration also involves the anterior rectal wall. Special attention needs to be paid to third- and fourth-degree lacerations to prevent fecal incontinence. Risks for third- or fourth-degree lacerations included nulliparity, being Asian or Pacific Islander, increased birth weight of newborn, operative vaginal birth, episiotomy, and longer second stage of labor. Increasing body mass index was associated with fewer lacerations (Sides et al., 2015). The primary care provider should repair any lacerations during the third stage of labor. An episiotomy is an incision made in the perineum to enlarge the vaginal outlet and theoretically to shorten the second stage of labor. Alternative measures such as warm compresses and continual massage with oil have been successful in stretching the perineal area to prevent cutting it. Certified nurse midwives can cut and repair episiotomies, but they frequently use alternative measures if possible. (Ricci 485-486) The midline episiotomy has been the most commonly used one in the United States because it can be easily repaired and causes the least amount of pain. The application of warmed compresses and/or intrapartum perineal massage is associated with a decrease in trauma to the perineal area and reduced the need for an episiotomy (Green, 2016). Routine episiotomy has declined since liberal usage has been discouraged by ACOG, except to avoid several maternal lacerations or to expedite difficult births Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds with a sharp increase in cesarean births, which may indicate that health care providers are favoring cesarean births for difficult births (Faisal-Cury et al., 2015). Figure 14.14 shows episiotomy locations. FIGURE 14.14 Location of an episiotomy. A. Midline episiotomy. B. Right and left mediolateral episiotomies. Continuous Assessment During the Second Stage of Labor Assessment is continuous during the second stage of labor. Hospital policies dictate the specific type and timing of assessments, as well as the way in which they are documented. Assessment involves identifying the signs typical of the second stage of labor, including: Increase in apprehension or irritability Spontaneous rupture of membranes Sudden appearance of sweat on upper lip Increase in blood-tinged show Low grunting sounds from the woman Complaints of rectal and perineal pressure Beginning of involuntary bearing-down efforts Other ongoing assessments include the contraction frequency, duration, and intensity; maternal vital signs every 5 to 15 minutes; fetal response to labor as indicated by FHR monitor strips; amniotic fluid for color, odor, and amount when membranes are ruptured; and the copying status of the woman and her partner (Table 14.4). Assessment also focuses on determining the progress of labor. Associated signs include bulging of the perineum, labial separation, advancing and retreating of the newborn's head during and between bearing-down efforts, and crowning (fetal head is visible at vaginal opening; Fig. 14.15). A vaginal examination is completed to determine if it is appropriate for the woman to push. Pushing is appropriate if the cervix has fully dilated to 10 cm and the woman feels the urge to do so. Nursing Interventions Nursing interventions during this stage focus on motivating the woman, assisting with positioning and encouraging her to put all her efforts to pushing this newborn to the outside world, and giving her feedback on her progress. If the woman is pushing without progress, suggest that she keep her eyes open during the contractions and look toward where the newborn is coming out. Changing positions frequently will also help in making progress. Positioning a mirror so the woman can visualize the birthing process and how successful her pushing efforts are can help motivate her. (Ricci 486-487) During the second stage of labor, an ideal position would be one that opens the pelvic outlet as wide as possible, provides a smooth pathway for the fetus to descend through the birth canal, takes advantage of gravity to assist the fetus to descend, and gives the mother a sense of being safe and in control of the labor process (Capogna, 2015a). Some suggestions for positions in the second stage include: Lithotomy with feet up in stirrups: most convenient position for caregivers, although EBP findings do not support this position physiologically Semi-sitting with pillows underneath knees, arms, and back Lateral/side-lying with curved back and upper leg supported by partner Sitting on birthing stool: opens pelvis, enhances the pull of gravity, and helps with pushing Squatting/supported squatting: gives the woman a sense of control Kneeling with hands on bed and knees comfortably apart Other important nursing interventions during the second stage include: Providing continuous comfort measures such as mouth care, encouraging position changes, changing bed linen and underpads, and providing a quiet, focused environment Instructing the woman on the following bearing-down positions and techniques: Pushing only when she feels an urge to do so Delaying pushing for up to 90 minutes after complete dilation Using abdominal muscles when bearing down Using short pushes of 6 to 7 seconds Focusing attention on the perineal area to visualize the newborn Relaxing and conserving energy between contractions Pushing several times with each contraction Pushing with an open glottis and slight exhalation (Petrocnik & Marshall, 2015) Continuing to monitor contraction and FHR patterns to identify problems Providing brief, explicit directions throughout this stage Continuing to provide psychosocial support by reassuring and coaching Facilitating the upright position to encourage the fetus to descend Continuing to assess blood pressure, pulse, respirations, uterine contractions, bearing-down efforts, FHR, and coping status of the client and her partner Providing pain management if needed Providing a continuous nursing presence Offering praise for the client's efforts Preparing for and assisting with delivery by: Notifying the health care provider of the estimated time frame for birth Preparing the delivery bed and positioning client Preparing the perineal area according to the facility's protocol Offering a mirror and adjusting it so the woman can watch the birth Explaining all procedures and equipment to the client and her partner Setting up delivery instruments needed while maintaining sterility Using standard precautions during the birthing process to avoid body fluid splashes Recording the time of birth, time of placenta, and type of birth Receiving newborn and transporting him or her to a warming environment, or covering the newborn with a warmed blanket on the woman's abdomen Providing initial care and assessment of the newborn (see the Birth section that follows) Sheila is completely dilated now and experiencing the urge to push. How can the nurse help Sheila with her pushing efforts? What additional interventions can the labor nurse offer Sheila now? In addition to encouraging Sheila to rest between pushing and offering praise for her efforts, what is the nurse's role during the birthing process? BIRTH The second stage of labor ends with the birth of the newborn. The maternal position for birth varies from the standard lithotomy position to side-lying to squatting to standing or kneeling, depending on the birthing location, the woman's preference, and standard protocols. Once the woman is positioned for birth, cleanse the vulva and perineal areas. The primary health care provider then takes charge after donning protective eyewear, masks, gowns, and gloves and performing hand hygiene. Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. As soon as the head emerges, the health care provider suctions the newborn's mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium (Fig. 14.16). The umbilical cord is double-clamped and cut between the clamps by the birth attendant or the woman's partner if desired. With the first cries of the newborn, the second stage of labor ends. For care of the woman undergoing a surgical birth, the reader is referred to Chapter 21. In addition to encouraging Sheila to rest between pushing and offering praise for her efforts, what is the nurse's role during the birthing process? IMMEDIATE CARE OF THE NEWBORN Once birth takes place, the newborn is placed under a radiant warmer, dried, assessed, wrapped in warmed blankets, and placed on the woman's abdomen for warmth and closeness. In some health care facilities, the newborn is placed on the woman's abdomen immediately after birth and covered with a warmed blanket without being dried or assessed. In either scenario, the stability of the newborn dictates the location of aftercare. The nurse can also assist the mother with breast-feeding her newborn for the first time. p. 488 p. 489 FIGURE 14.16 Suctioning the newborn immediately after birth. Assessment of the newborn begins at the moment of birth and continues until the newborn is discharged. Drying the newborn and providing warmth to prevent heat loss by evaporation is essential to help support thermoregulation and provide stimulation. Placing the newborn under a radiant heat source and putting on a stockinette/knitted cap will further reduce heat loss after drying. Assess the newborn by assigning an Apgar score at 1 and 5 minutes. The Apgar score assesses five parameters—(1) heart rate (absent, slow, or fast), (2)respiratory effort (absent, weak cry, or good strong yell), (3) muscle tone (limp, or lively and active), (4) response to irritation stimulus, and (5) color—that evaluate a newborn's cardiorespiratory adaptation after birth. The parameters are arranged from the most important (heart rate) to the least important (color). The newborn is assigned a score of 0 to 2 in each of the five parameters. The purpose of the Apgar assessment is to evaluate the physiologic status of the newborn; see Chapter 18 for additional information on Apgar scoring. Secure two identification bands on the newborn's wrist and ankle that match the band on the mother's wrist to ensure the newborn's identity. This identification process is completed in the birthing suite before anyone leaves the room. Some health care agencies also take an early photo of the newborn for identification in the event of abduction (National Center for Missing and Exploited Children [NCMEC], 2015). FIGURE 14.17 An example of a security sensor applied to a newborn's arm. Other types of newborn security systems can also be used to prevent abduction. Some systems have sensors that are attached to the newborn's identification bracelet or cord clamp. An alarm is set off if the bracelet or clamp activates receivers near exits. Others have an alarm that is activated when the sensor is removed from the newborn (Fig. 14.17). Even with the use of electronic sensors, the parents, nursing staff, and security personnel are responsible for prevention strategies and ensuring the safety and protection of all newborns (NCMEC, 2015). Nurses can help in preventing newborn abduction by educating parents about abduction risks, using identically numbered bands on the baby and parents, by instructing couples to keep their newborn in their direct line of vision within their hospital room at all times, taking color photographs of the infant, wearing color photograph ID badges themselves, discouraging parents/families from publishing birth notices in the public media with mother's name and address, controlling access to nursery/postpartum unit with locked doors, and utilizing infant security tags or abduction alarm systems (NCMEC, 2015). (Ricci 487-489) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBoo During the third stage of labor, strong uterine contractions continue at regular intervals under the continuing influence of oxytocin. The uterine muscle fibers shorten, or retract, with each contraction, leading to a gradual decrease in the size of the uterus, which helps shear the placenta away from its attachment site. The third stage is complete when the placenta is delivered. Nursing care during the third stage of labor primarily focuses on immediate newborn care and assessment and observing for signs of placental separation, being available to assist with the delivery of the placenta, recording the time of expulsion and inspecting it for intactness. The nurse should also be assessing by palpating the uterus before and after placental expulsion. Three hormones play important roles in the third stage. During this stage the woman experiences peak levels of oxytocin and endorphins, while the high adrenaline levels that occurred during the second stage of labor to aid with pushing begin falling. The hormone oxytocin causes uterine contractions and helps the woman to enact instinctive mothering behaviors such as holding the newborn close to her body and cuddling the baby. Skin-to-skin contact immediately after birth and the newborn's first attempt at breast-feeding further augment maternal oxytocin levels, strengthening the uterine contractions that will help the placenta to separate and the uterus to contract to prevent hemorrhage. Endorphins, the body's natural opiates, produce an altered state of consciousness and aid in blocking out pain. In addition, the drop in adrenaline level from the second stage, which had kept the mother and baby alert at first contact, causes most women to shiver and feel cold shortly after giving birth. Take Note! A crucial role for nurses during this time is to protect the natural hormonal process by ensuring unhurried and uninterrupted contact between mother and newborn after birth, providing warmed blankets to prevent shivering, and allowing skin-to-skin contact with initial breast-feeding. Continuing Assessment During the Third Stage of Labor Assessment during the third stage of labor includes: Monitoring placental separation by looking for the following signs: Firmly contracting uterus Change in uterine shape from discoid to globular ovoid Sudden gush of dark blood from vaginal opening Lengthening of umbilical cord protruding from vagina Examining placenta and fetal membranes for intactness the second time (the health care provider assesses the placenta for intactness the first time) (Fig. 14.18) Assessing for any perineal trauma, such as the following, before allowing the birth attendant to leave: Firm fundus with bright-red blood trickling: laceration Boggy fundus with red blood flowing: uterine atony Boggy fundus with dark blood and clots: retained placenta Inspecting the perineum for condition of episiotomy, if performed Assessing for perineal lacerations and ensuring repair by birth attendant Nursing Interventions Interventions during the third stage of labor include: Describing the process of placental separation to the couple Instructing the woman to push when signs of separation are apparent Administering an oxytocic agent if ordered and indicated after placental expulsion Providing support and information about episiotomy and/or laceration if applicable Cleaning and assisting client into a comfortable position after birth, making sure to lift both legs out of stirrups (if used) simultaneously to prevent strain FIGURE 14.18 Placenta. A. Fetal side. B. Maternal side. p. 490 p. 491 Assess the woman's knowledge of breast-feeding to determine educational needs Instruct her about latching on, positioning, infant sucking and swallowing Repositioning the birthing bed to serve as a recovery bed if applicable Assisting with transfer to the recovery area if applicable Providing warmth by replacing warmed blankets over the woman Applying an ice pack to the perineal area to provide comfort to episiotomy if indicated Explaining what assessments will be carried out over the next hour and offering positive reinforcement for actions Ascertaining any needs Monitoring maternal physical status by assessing: Vaginal bleeding: amount, consistency, and color Vital signs: blood pressure, pulse, and respirations taken every 15 minutes Uterine fundus, which should be firm, in the midline, and at the level of the umbilicus Recording all birthing statistics and securing primary caregiver's signature Documenting birthing event in the birth book (official record of the facility that outlines every birth event), detailing any deviations (Ricci 489-491) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Non pharmacological measures

Nonpharmacologic measures may include continuous labor support, hydrotherapy, hypnosis, ambulation and maternal position changes, transcutaneous electrical nerve stimulation (TENS), acupuncture and acupressure, attention focusing and imagery, therapeutic touch and massage, breathing techniques, and effleurage. Most of these methods are based on the gate control theory of pain, which proposes that local physical stimulation can interfere with pain stimuli by closing a hypothetical gate in the spinal cord, thus blocking pain signals from reaching the brain (McGeary, Swanholm, & Gatchel, 2015). It has long been a standard of care for labor nurses to first provide or encourage a variety of nonpharmacologic measures before moving to the pharmacologic interventions. Nonpharmacologic measures are usually simple, safe, and inexpensive to use. Many of these measures are taught in childbirth classes, and women should be encouraged to try a variety of methods prior to the real labor. Many of the measures need to be practiced for best results and coordinated with the partner/coach. The nurse provides support and encouragement for the woman and her partner using nonpharmacologic methods. Although women cannot consciously direct the labor contractions, they can control how they respond to them, thereby enhancing their feelings of control. See Evidence-Based Practice 14.2 for more information. (Ricci 465) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Other analgesic

OPIOIDS Opioids are morphine-like medications that are most effective for the relief of moderate to severe pain. Opioids typically are administered intravenously. All opioids are lipophilic and cross the placental barrier, but do not affect labor progress in the active phase. Opioids are associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding (King et al., 2015). Opioids decrease the transmission of pain impulses by binding to receptor site pathways that transmit the pain signals to the brain. The effect is increased tolerance to pain and respiratory depression related to a decrease in sensitivity to carbon dioxide (Skidmore-Roth, 2015). All opioids are considered good analgesics. However, respiratory depression can occur in the mother and fetus depending on the dose given. They may also cause a decrease in FHR variability identified on the fetal monitor strip. This FHR pattern change is usually transient. Other systemic side effects include nausea, vomiting, pruritus, delayed gastric emptying, drowsiness, hypoventilation, and newborn depression. To reduce the incidence of newborn depression, birth should occur within 1 hour or after 4 hours of administration to prevent the fetus from receiving the peak concentration (Cheng & Caughey, 2015a). A recent study reported that parenteral opioids provide some relief from pain in labor, but are associated with neonatal respiratory distress. Maternal satisfaction with opioid analgesia appeared moderate at best (Kerr, Taylor, & Evans, 2015). Opioid antagonists such as naloxone (Narcan) are given to reverse the effects of the CNS depression, including respiratory depression, caused by opioids. Opioid antagonists also are used to reverse the side effects of neuraxial opioids, such as pruritus, urinary retention, nausea, and vomiting, without significantly decreasing analgesia (Skidmore-Roth, 2015). Consult a current drug guide for more specifics on these drug categories. ANTIEMETICS The antiemetic group of medications is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. These adjunct drugs potentiate the effectiveness of the opioid so that a lesser dose can be given. They may also be used to increase sedation. Promethazine (Phenergan) can be given intravenously, but hydroxyzine (Vistaril) must be given by mouth or by intramuscular injection into a large muscle mass. Neither drug affects the progress of labor, but either may cause a decrease in FHR variability and possible newborn depression (Skidmore-Roth, 2015). Prochlorperazine (Compazine) is typically given intravenously or intramuscularly with morphine sulfate for sleep during a prolonged latent phase. It counteracts the nausea associated with opioids (King et al., 2015). BENZODIAZEPINES Benzodiazepines are used for minor tranquilizing and sedative effects. Diazepam (Valium) also is given intravenously to stop seizures resulting from eclampsia. It can be administered to calm a woman who is out of control, thereby enabling her to relax enough so that she can participate effectively during her labor process rather than fighting against it. Lorazepam (Ativan) can also be used for its tranquilizing effect, but increased sedation is experienced with this medication (Skidmore-Roth, 2015). Midazolam (Versed), also given intravenously, produces good amnesia but no analgesia. It is most commonly used as an adjunct for anesthesia. Diazepam and midazolam cause CNS depression for both the woman and the newborn. Inhaled Analgesics Nitrous oxide is known by most people as "laughing gas." For labor pain, half nitrous oxide gas (50%) is mixed with half oxygen (50%) and breathed through a mask or mouthpiece. This has been recently introduced in the United States, but has been in widespread use in Europe and Canada for many years. Women have generally reported satisfaction with the use of nitrous oxide for pain relief in labor. An additional factor that may contribute to the decreased perception of pain is maternal control—it is self-administered. Self-administration is not only empowering for women, but it also acts as a safety mechanism because it is almost impossible to overdose when it is self-administered (Halpern & Garg, 2015). Potential side effects of N2O/O2 include nausea and vomiting, dizziness, and dysphoria, although these are rare. No FHR abnormalities have been attributed to its use (Badve & Vallejo, 2015). Regional Analgesia/Anesthesia Regional analgesia/anesthesia provides pain relief without loss of consciousness. It involves the use of local anesthetic agents, with or without added opioids, to bring about pain relief or numbness through the drug's effects on the spinal cord and nerve roots. Obstetric regional analgesia generally refers to a partial or complete loss of pain sensation below the T8 to T10 level of the spinal cord (Stocks & Griffiths, 2015). The routes for regional pain relief include epidural block, combined spinal-epidural, local infiltration, pudendal block, and intrathecal (spinal) analgesia/anesthesia. Local and pudendal routes are used during birth for episiotomies (surgical incision into the perineum to facilitate birth); epidural and intrathecal routes are used for pain relief during active labor and birth. The major advantage of regional pain management techniques is that the woman can participate in the birthing process and still have good pain control. EPIDURAL ANALGESIA Women requesting epidural analgesia in labor will do so when they feel they need pain relief, and for some it might be quite early in their labor. Epidural analgesia for labor and birth involves the injection of a local anesthetic agent (e.g., lidocaine or bupivacaine) and an opioid analgesic agent (e.g., morphine or fentanyl) into the lumbar epidural space. A small catheter is then passed through the epidural needle to provide continuous access to the epidural space for maintenance of analgesia throughout labor and birth (Fig. 14.11). Epidural analgesia does increase the duration of the second stage of labor and may increase the rate of instrument-assisted vaginal deliveries as well as that of oxytocin administration (Camorcia, 2015). Approximately 60% of laboring women in the United States receive an epidural for pain relief during labor, but one in eight women who have an epidural during labor still need to use other methods of pain relief In urban areas, many hospitals approach 90% use of epidurals (Capogna, 2015b). FIGURE 14.11 Epidural catheter insertion. A. A needle is inserted into the epidural space. B. A catheter is threaded into the epidural space; the needle is then removed. The catheter allows medication to be administered intermittently or continuously to relieve pain during labor and childbirth. An epidural involves the injection of a drug into the epidural space, which is located outside the dura mater between the dura and the spinal canal. The epidural space is typically entered through the third and fourth lumbar vertebrae with a needle, and a catheter is threaded into the epidural space. An epidural can be used for both vaginal and cesarean births. It has evolved from a regional block producing total loss of sensation to analgesia with minimal blockade. The effectiveness of epidural analgesia depends on the technique and medications used. Theoretically, epidural local anesthetics could block all labor pain if used in large volumes and high concentrations. However, pain relief is balanced against other goals such as walking during the first stage of labor, pushing effectively in the second stage, and minimizing maternal and fetal side effects. An epidural is contraindicated for women with a previous history of spinal surgery or spinal abnormalities, coagulation defects cardiac disease, obesity, infections, and hypovolemia. It also is contraindicated for the woman who is receiving anticoagulation therapy. Complications include nausea and vomiting, hypotension, fever, pruritus, intravascular injection, maternal fever, allergic reaction, and respiratory depression. Effects on the fetus during labor include fetal distress secondary to maternal hypotension (Ibrahim et al., 2015). Ensuring that the woman avoids a supine position after an epidural catheter has been placed will help to minimize hypotension. The addition of opioids, such as fentanyl or morphine, to the local anesthetic helps decrease the amount of motor block obtained. Continuous infusion pumps can be used to administer the epidural analgesia, allowing the woman to be in control and administer a bolus dose on demand (Patkar et al., 2015). COMBINED SPINAL-EPIDURAL ANALGESIA Another epidural technique is combined spinal-epidural (CSE) analgesia. This technique involves inserting the epidural needle into the epidural space and subsequently inserting a small-gauge spinal needle through the epidural needle into the subarachnoid space. An opioid, without a local anesthetic, is injected into this space. The spinal needle is then removed and an epidural catheter is inserted for later use. CSE is advantageous because of its rapid onset of pain relief (within 3 to 5 minutes) that can last up to 3 hours. It also allows the woman's motor function to remain active. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost, and her motor power remains intact. The CSE technique provides greater flexibility and reliability for labor than either spinal or epidural analgesia alone (Stocks & Griffiths, 2015). When compared with traditional epidural or spinal analgesia, which often keeps the woman lying in bed, CSE allows her to ambulate ("walking epidural"). A recent Cochrane review contrasting the CSE analgesia approach with traditional and low-dose epidural analgesia in labor identified that CSE analgesia was associated with a greater incidence of pruritus, but a lower incidence of urinary retention and need for rescue analgesia, than epidural along. In addition, CSE analgesia had a faster onset of pain relief, and there were no differences in labor outcomes (Heesen et al., 2015). Ambulating during labor provides several benefits: it may help control pain better, shorten the first stage of labor, increase the intensity of the contractions, and decrease the possibility of an operative vaginal or cesarean birth. Although women can walk with CSE, they often choose not to because of sedation and fatigue. Often health care providers do not encourage or assist women to ambulate for fear of injury. Nurses need to evaluate for ambulation safety that includes no postural hypotension and normal leg strength by demonstrating a partial knee bend while standing; they also need to assist with ambulation at all times (Capogna, 2015b). Currently, anesthesiologists are performing walking epidurals using continuous infusion techniques as well as CSE and client-controlled epidural analgesia (Grant et al., 2015). Complications include maternal hypotension, intravascular injection, accidental intrathecal blockade, postdural puncture headache, pruitis, inadequate or failed block, maternal fever, and pruritus. Hypotension and associated FHR changes are managed with maternal positioning (semi-Fowler's position), intravenous hydration, and supplemental oxygen (Ibrahim et al., 2015). Misconception Alert: Spinal-Epidural Analgesia Click To Show Consider This When I was expecting my first child, I was determined to put my best foot forward and do everything right. I was an experienced OB nurse, and in my mind doing everything right was expected behavior. I was already 2 weeks past my calculated due date and I was becoming increasingly worried. That particular day I went to work with a backache but felt no contractions. I managed to finish my shift but felt completely wiped out. As I walked to my car outside the hospital, my water broke and I felt the warm fluid run down my legs. I went back inside to be admitted for this much-awaited event. Although I had helped thousands of women go through their childbirth experience, I was now the one in the bed and not standing alongside it. My husband and I had practiced our breathing techniques to cope with the discomfort of labor, but this "discomfort" in my mind was more than I could tolerate. So despite my best intentions of doing everything right, within an hour I begged for a painkiller to ease the pain. While the medication took the edge off my pain, I still felt every contraction and truly now appreciate the meaning of the word "labor." Although I wanted to use natural childbirth without any medication, I know that I was a full participant in my son's birthing experience, and that is what "doing everything right" was for me! Thoughts: Doing what is right varies for each individual, and as nurses we need to support whatever that is. Having a positive outcome from the childbirth experience is the goal; the means it takes to achieve it is less important. How can nurses support women in making their personal choices to achieve a healthy outcome? Are any women "failures" if they ask for pain medication to tolerate labor? How can nurses help women overcome this stigma of being a "wimp"? PATIENT-CONTROLLED EPIDURAL ANALGESIA Patient-controlled epidural analgesia (PCEA) involves the use of an indwelling epidural catheter with an infusion of medication and a programmed pump that allows the woman to control the dosing. This method allows the woman to have a sense of control over her pain and reach her own individually acceptable analgesia level. When compared with traditional epidural analgesia, PCEA provides equivalent analgesia with lower anesthetic use, lower rates of supplementation, and higher client satisfaction (Van De Velde, 2015). With PCEA, the woman uses a handheld device connected to an analgesic agent that is attached to an epidural catheter. When she pushes the button, a bolus dose of agent is administered via the catheter to reduce her pain. This method allows her to manage her pain at will without having to ask a staff member to provide pain relief. Evidence supports the use of PCEA which appears to result in greater maternal satisfaction and lower overall medication use (Sng et al., 2015). LOCAL INFILTRATION Local infiltration involves the injection of a local anesthetic, such as lidocaine, into the superficial perineal nerves to numb the perineal area. This technique is done by the physician or midwife just before performing an episiotomy or before suturing a laceration. Local infiltration does not alter the pain of uterine contractions, but it does numb the immediate area of the episiotomy or laceration. Local infiltration does not cause side effects for the woman or her newborn. PUDENDAL NERVE BLOCK A pudendal nerve block refers to the injection of a local anesthetic agent (e.g., bupivacaine, ropivacaine) into the pudendal nerves near each ischial spine. It provides pain relief in the lower vagina, vulva, and perineum (Fig. 14.12). A pudendal block is used for the second stage of labor, an episiotomy, or an operative vaginal birth with outlet forceps or vacuum extractor. It must be administered about 15 minutes before it would be needed to ensure its full effect. A transvaginal approach is generally used to inject an anesthetic agent at or near the pudendal nerve branch. Neither maternal nor fetal complications are common. FIGURE 14.12 Pudendal nerve block. SPINAL (INTRATHECAL) ANALGESIA/ANESTHESIA The spinal (intrathecal) pain management technique involves injection of an anesthetic "caine" agent, with or without opioids, into the subarachnoid space to provide pain relief during labor or cesarean birth. The subarachnoid space is a fluid-filled area located between the dura mater and the spinal cord. Spinal anesthesia is frequently used for elective and emergent cesarean births. The contraindications are similar to those for an epidural block. Adverse reactions for the woman include hypotension and spinal headache. The subarachnoid injection of opioids alone, a technique termed intrathecal narcotics, has been gaining popularity since it was introduced in the 1980s. A narcotic is injected into the subarachnoid space, providing rapid pain relief while still maintaining motor function and sensation (Sng, Kwok, & Sia, 2015). An intrathecal narcotic is given during the active phase (more than 5 cm of dilation) of labor. Compared with epidural blocks, intrathecal narcotics are easy to administer, require a smaller volume of medication, produce excellent muscular relaxation, provide rapid-onset pain relief, are less likely to cause newborn respiratory depression, and do not cause motor blockade (Badve & Vallejo, 2015). Although pain relief is rapid with this technique, it is limited by the narcotic's duration of action, which may be only a few hours and not last through the labor. Additional pain measures may be needed to sustain pain management. General Anesthesia (Ricci 473-476) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Providing comfort and pain mangement during labor

Pain during labor is a universal experience, although the intensity of the pain may vary. Labor pain is unique to every woman based on various contributing physiologic, emotional, social, and cultural factors. Although labor and childbirth are viewed as natural processes, both can produce significant pain and discomfort. The physical causes of pain during labor include cervical stretching, hypoxia of the uterine muscle due to a decrease in perfusion during contractions, pressure on the urethra, bladder, and rectum, and distention of the muscles of the pelvic floor (Leonard, 2015). Pain during labor is a physiological phenomenon. The etiology of pain during the first stage of labor is associated with ischemia of the uterus during contractions. In the second stage, pain is caused by the stretching of the vagina and perineum and compression of the pelvic structures. A woman's pain perception can be influenced by her previous experiences with pain, fatigue, pain anticipation, genetics, positive or negative support system, health care provider's presence and encouragement, labor and birth environment, cultural expectations, and level of emotional stress and anxiety. Pain perception during labor changes in intensity and nature as labor progresses, and this is associated with behavioral changes in the laboring woman (Liu, Fernando, & Mon, 2015). p. 464 p. 465 The techniques used to manage the pain of labor vary according to geography and culture. For example, some Appalachian women believe that placing a hatchet or knife under the bed of a laboring woman may help "cut the pain of childbirth," and a woman from this background may wish to do so in the hospital setting (Bowers, 2015). Asian, Latino, and Orthodox Jewish women may request that their own mothers, not their husbands, attend their births; husbands do not actively participate in the birthing process. Cherokee, Hmong, and Japanese women will often remain quiet during labor and birth and not complain of pain because outwardly expressing pain is not appropriate in their cultures. Never interpret their quietness as freedom from pain. The concept of pain and pain expression during labor has different meanings for women of different cultures. Several points for the nurse to consider when caring for diverse cultural clients include using a qualified interpreter to communicate about pain as needed, offer and support culturally acceptable forms of pain relief, and assess for pain frequently (Wojnar & Narruhn, 2016). Immigrating to a new country is a stressful process of readjustment and change. Effective verbal communication and understanding nonverbal social cues are invaluable when providing care to diverse cultures. Culturally diverse childbearing families present to the labor and birth suites with the same needs and desires of all families. Give them the same respect and sense of welcome shown to all families. Make sure they have a high-quality birth experience: uphold their religious, ethnic, and cultural values and integrate them into care. Today, women have many safe nonpharmacologic and pharmacologic choices for the management of pain during labor and birth, which may be used separately or in combination with one another. Pharmacologic approaches are directed at eliminating the physical sensation of labor pain, whereas nonpharmacologic approaches are largely directed at prevention of suffering. Nurses are in an ideal position to provide childbearing women with balanced, clear, concise information about effective nonpharmacologic and pharmacologic measures to relieve pain. Pain management standards issued by the Joint Commission mandate that pain be assessed in all clients admitted to a health care facility. Attention to the pain that occurs during labor and childbirth should be a priority of care for all nurses (Jones et al., 2015). A pain assessment tool named the Coping with Labor Algorithm uses the FOCUS format "Plan, Do, Check, and Act" cycle in laboring women. This tool provides a mechanism for pain documentation and links it to nursing care interventions (Roberts et al., 2010). Thus, it is important for nurses to be knowledgeable about the most recent scientific research on labor pain relief modalities, to make sure that accurate and unbiased information about effective pain relief measures is available to laboring women, to be sure that the woman determines what is an acceptable labor pain level for her, and to allow the woman the choice of pain relief method. (Ricci 464-465) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Application of heat and cold

Superficial applications of heat and/or cold, in various forms, are popular with laboring women. They are easy to use, inexpensive, require no prior practice, and have minimal negative side effects when used properly. Heat is typically applied to the woman's back, lower abdomen, groin, and/or perineum. Heat sources include a hot water bottle, heated rice-filled sock, warm compress (washcloth soaked in warm water and wrung out), electric heating pad, warm blanket, and warm bath or shower. In addition to being used for pain relief, heat is used to relieve chills or trembling, decrease joint stiffness, reduce muscle spasm, and increase connective tissue extensibility (Liu, Fernando, & Mon, 2015). Cold therapy, or cryotherapy, is usually applied on the woman's back, chest, and/or face during labor. Forms of cold include a bag or surgical glove filled with ice, a frozen gel pack, camper's "ice," a hollow, plastic rolling pin or bottle filled with ice, a washcloth dipped in cold water, soda cans chilled in ice, and even a frozen bag of vegetables. "Instant" cold packs, often available in hospitals, usually are not cold enough to effectively relieve labor pain. Women who feel cold usually need to feel warm before they can comfortably tolerate using a cold pack. Chilled soda cans and rolling pins filled with ice give the added benefit of mechanical pressure when rolled on the low back. Cold has the additional effects of relieving muscle spasms and reducing inflammation and edema (Tharpe, Farley, & Jordan, 2016). (Ricci 468-470) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Systemic analgesia

Systemic analgesia involves the use of one or more drugs administered orally, intramuscularly, or intravenously; they become distributed throughout the body via the circulatory system. Depending on which administration method is used, the therapeutic effect of pain relief can occur within minutes and last for several hours. The most important complication associated with the use of this class of drugs is respiratory depression. Therefore, women given these drugs require careful monitoring. Opioids given close to the time of birth can cause CNS depression in the newborn, necessitating the administration of naloxone (Narcan) to reverse the depressant effects of the opioids. Several drug categories may be used for systemic analgesia: Opioids, such as butorphanol (Stadol), nalbuphine (Nubain), meperidine (Demerol), morphine, or fentanyl (Sublimaze) Ataractics, such as hydroxyzine (Vistaril), promethazine (Phenergan), or prochlorperazine (Compazine) Benzodiazepines, such as diazepam (Valium) or midazolam (Versed) Drug Guide 14.1 highlights some of the major drugs used for systemic analgesia. Systemic analgesics are typically administered parenterally, usually through an existing intravenous line. Nearly all medications given during labor cross the placenta and have a depressant effect on the fetus; therefore, it is important for the woman to receive the least amount of systemic medication that relieves her discomfort so that it does not cause any harm to the fetus (Cheng & Caughey, 2015a). Historically opioids have been administered by nurses, but in the past decade there has been increasing use of client-controlled intravenous analgesia (patient-controlled analgesia). With this system, the woman is given a button connected to a computerized pump on the intravenous line. When the woman desires analgesia, she presses the button and the pump delivers a preset amount of medication. This system provides the woman with a sense of control over her own pain management and active participation in the childbirth process. (Ricci 471-473) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Vaginal examination

The World Health Organization (WHO) recommends digital vaginal examinations at intervals of 4 hours for routine assessment and identification of a delay in active labor (2014). Although not all nurses perform vaginal examinations on laboring women in all practice settings, most nurses working in community hospitals do so because physicians are not routinely present in labor and birth suites. Since most newborns in the United States are born in community hospitals, nurses are performing vaginal examinations along with midwives and physicians (American Hospital Association, 2015). Take Note! A vaginal examination is an assessment skill that takes time and experience to develop; only by doing it frequently in clinical practice can the practitioner's skill level improve. The purpose of performing a vaginal examination is to assess the amount of cervical dilation, the percentage of cervical effacement, and the fetal membrane status and to gather information on presentation, position, station, degree of fetal head flexion, and presence of fetal skull swelling or molding (Fig. 14.1). Prepare the woman by informing her about the procedure, what information will be obtained from it, how she can assist with the procedure, how it will be performed, and who will be performing it. FIGURE 14.1 Vaginal examination to determine cervical dilation and effacement. The woman is typically on her back during the vaginal examination. The vaginal examination is performed gently, with concern for the woman's comfort. If it is the initial vaginal examination to check for membrane status, water is used as a lubricant. After donning sterile gloves, the examiner inserts his or her index and middle fingers into the vaginal introitus. Next, the cervix is palpated to assess dilation, effacement, and position (e.g., posterior or anterior). If the cervix is open to any degree, the presenting fetal part, fetal position, station, and presence of molding can be assessed. In addition, the membranes can be evaluated and described as intact, bulging, or ruptured. At the conclusion of the vaginal examination, the findings are discussed with the woman and her partner to bring them up to date about labor progress. In addition, the findings are documented either electronically or in writing and reported to the primary health care provider in charge of the case. Cervical Dilation and Effacement The amount of cervical dilation (opening) and the degree of cervical effacement (thinning) are key areas assessed during the vaginal examination as the cervix is palpated with the gloved index finger. Although this finding is somewhat subjective, experienced examiners typically come up with similar findings. The width of the cervical opening determines dilation, and the length of the cervix assesses effacement. Effacement and dilation are used to assess cervical changes as follows: Effacement: 0%: cervical canal is 2 cm long 50%: cervical canal is 1 cm long 100%: cervical canal is obliterated Dilation: 0 cm: external cervical os is closed 5 cm: external cervical os is halfway dilated 10 cm: external os is fully dilated and ready for birth passage The information yielded by this examination serves as a basis for determining which stage of labor the woman is in and what her ongoing care should be. Fetal Descent and Presenting Part In addition to cervical dilation and effacement findings, the vaginal examination can also determine fetal descent (station) and presenting part. During the vaginal examination, the gloved index finger is used to palpate the fetal skull (if vertex presentation) through the opened cervix or the buttocks in the case of a breech presentation. Station is assessed in relation to the maternal ischial spines and the presenting fetal part. These spines are not sharp protrusions but rather blunted prominences at the midpelvis. The ischial spines serve as landmarks and have been designated as zero station. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned; if the presenting fetal part is felt below the maternal ischial spines, a plus number is assigned, denoting how many centimeters below zero station (see Chapter 13 for a more detailed discussion). Progressive fetal descent (−5 to +4) is the expected norm during labor—moving downward from the negative stations to zero station to the positive stations in a timely manner. If progressive fetal descent does not occur, a disproportion between the maternal pelvis and the fetus might exist and needs to be investigated. Rupture of Membranes The integrity of the membranes can be determined during the vaginal examination. Typically, if intact, the membranes will be felt as a soft bulge that is more prominent during a contraction. If the membranes have ruptured, the woman may have reported a sudden gush of fluid. Membrane rupture also may occur as a slow trickle of fluid. When membranes rupture, the priority focus should be on assessing fetal heart rate (FHR) first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. If the membranes are ruptured when the woman comes to the hospital, the health care provider should ascertain when it occurred. Prolonged ruptured membranes increase the risk of infection as a result of ascending vaginal pathological organisms for both mother and fetus. Signs of intrauterine infection to be alert for include maternal fever, fetal and maternal tachycardia, foul odor of vaginal discharge, and an increase in white blood cell count. To confirm that membranes have ruptured, a sample of fluid is taken from the vagina via a nitrazine yellow dye swab to determine the fluid's pH. Vaginal fluid is acidic, whereas amniotic fluid is alkaline and turns a nitrazine swab blue. Sometimes, however, false-positive results can occur, especially in women experiencing a large amount of bloody show, because blood is alkaline. The membranes are most likely intact if the nitrazine swab remains yellow to olive green, with pH between 5 and 6. The membranes are probably ruptured if the nitrazine swab turns a blue-green to deep blue, with pH ranging from 6.5 to 7.5 (Tharpe, Farley, & Jordan, 2016). If the nitrazine test is inconclusive, an additional test, called the fern test, can be used to confirm rupture of membranes. With this test, a sample of vaginal fluid is obtained, applied to a microscope slide, and allowed to dry. Using a microscope, the slide is examined for a characteristic fern pattern that indicates the presence of amniotic fluid. (Ricci 451-453) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Uterine contractions

The primary power of labor is uterine contractions, which are involuntary. Uterine contractions increase intrauterine pressure, causing tension on the cervix. This tension leads to cervical dilation and thinning, which in turn eventually forces the fetus through the birth canal. Normal uterine contractions have a contraction (systole) and a relaxation (diastole) phase. The contraction resembles a wave, moving downward to the cervix and upward to the fundus of the uterus. Each contraction starts with a building up (increment), gradually reaching an acme (peak intensity), and then a letting down (decrement). Each contraction is followed by an interval of rest, which ends when the next contraction begins. At the acme (peak) of the contraction, the entire uterus is contracting, with the greatest intensity in the fundal area. The relaxation phase follows and occurs simultaneously throughout the uterus. Uterine contractions during labor are monitored by palpation and by electronic monitoring. Assessment of the contractions includes frequency; duration, intensity, and uterine resting tone (see Chapter 13 for a more detailed discussion). Uterine contractions with intensity of 30 mm Hg or greater initiate cervical dilation. During active labor, the intensity usually reaches 50 to 80 mm Hg. Resting tone is normally between 5 and 10 mm Hg in early labor and between 12 and 18 mm Hg in active labor (Hiersch et al., 2015). To palpate the fundus for contraction intensity, place the pads of your fingers on the fundus and describe how it feels: like the tip of the nose (mild), like the chin (moderate), or like the forehead (strong). Palpation of intensity is a subjective judgment of the indentability of the uterine wall; a descriptive term is assigned (mild, moderate, or strong) (Fig. 14.2). FIGURE 14.2 Nurse palpating the woman's fundus during a contraction. Take Note! Frequent clinical experience is needed to gain accuracy in assessing the intensity of uterine contractions. The second method used to assess the intensity of uterine contractions is electronic monitoring, either external or internal. Both methods provide a reasonable measurement of the intensity of uterine contractions. Although the external fetal monitor is sometimes used to estimate the intensity of uterine contractions, it is not as accurate an assessment tool. (Ricci 453) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Pharmacological measures

With varying degrees of success, generations of women have sought ways to relieve the pain of childbirth. Pharmacologic pain relief during labor includes systemic analgesia and regional or local anesthesia. Women have seen dramatic changes in pharmacologic pain management options over the years. Methods have evolved from biting down on a stick to control their pain, experiencing 'twilight sleep' during their labors and not remembering what happened, to a more complex pharmacologic approach such as epidural/intrathecal analgesia. Systemic analgesia and regional analgesia/anesthesia have become less common, while newer neuraxial analgesia/anesthesia techniques involving minimal motor blockade have become more popular. Neuraxial analgesia/anesthesia is the administration of analgesic (opioids) or anesthetic (capable of producing a loss of sensation in an area of the body) agents, either continuously or intermittently, into the epidural or intrathecal space to relieve pain. Low-dose and ultra-low-dose epidural analgesia, spinal analgesia, and combined spinal-epidural analgesia have replaced the traditional epidural for labor. Neuraxial analgesia does not interfere with the progress or outcome of labor. There is no need to withhold neuraxial analgesia until the active stage of labor (Grant et al., 2015). This shift in pain management techniques allows a woman to be an active participant in labor. (Ricci 471) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Other fetal assessment methods

n situations suggesting the possibility of fetal compromise, such as Category II or Category III FHR patterns, further ancillary testing such as umbilical cord blood analysis and fetal scalp stimulation may be used to validate the FHR findings and assist in planning interventions. Take Note! In recent years, the use of fetal scalp sampling has decreased, being replaced by techniques that yield similar information. It has been shown to have a poor positive predictive value for intrapartum hypoxia and recent systematic reviews have reported no evidence of benefit in reducing cesarean section rates (Chandraharan, 2014). Umbilical Cord Blood Analysis Neonatal and childhood mortality and morbidity, including cerebral palsy, are often attributed to fetal acidosis, as defined by a low cord pH at birth. Umbilical cord blood acid-base analysis drawn at birth provides an objective method of evaluating a newborn's condition, identifying the presence of intrapartum hypoxia and acidemia. This test is considered a good indicator of fetal oxygenation and acid-base condition at birth (Martin, Fanaroff, & Walsh, 2014). The normal mean pH value range is 7.2 to 7.3. The pH values are useful for planning interventions for the newborn born with low 5-minute Apgar scores, severe FGR, Category II and III patterns during labor, umbilical cord prolapse, uterine rupture, maternal fever, placental abruption, meconium-stained amniotic fluid, and post-term births (Gujral & Nayar, 2015). The interventions needed for the compromised newborn might include providing an optimal extrauterine environment, fluids, oxygen, medications, and other treatments. Fetal Scalp Stimulation An indirect method used to evaluate fetal oxygenation and acid-base balance to identify fetal hypoxia is fetal scalp stimulation or vibroacoustic stimulation. If the fetus does not have adequate oxygen reserves, carbon dioxide builds up, leading to acidemia and hypoxemia. These metabolic states are reflected in abnormal FHR patterns as well as fetal inactivity. Fetal stimulation is performed to promote fetal movement with the hope that FHR accelerations will accompany the movement. Fetal movement can be stimulated with a vibroacoustic stimulator (artificial larynx) applied to the woman's lower abdomen and turned on for 3 to 5 seconds to produce sound and vibration or by placing a gloved finger on the fetal scalp and applying firm pressure. A well-oxygenated fetus will respond when stimulated (tactile or by noise) by moving in conjunction with an acceleration of 15 bpm above the baseline heart rate that lasts at least 15 seconds. This FHR acceleration reflects a pH of more than 7 and a fetus with an intact CNS. Fetal scalp stimulation is not done if the fetus is preterm, or if the woman has an intrauterine infection, a diagnosis of placenta previa (which could lead to hemorrhage), or a fever (which increases the risk of an ascending infection) (King et al., 2015). If no acceleratory response by the fetus is exhibited with either scalp stimulation or vibroacoustic stimulation, further evaluation of the fetus is warranted. Nurses play an essential role in the evaluation of maternal and fetal status during labor, continued surveillance, initiation of corrective measures when indicated, and reevaluation. A vital attribute of nursing surveillance is that it is a systematic process for assessment, intervention, and evaluation. (Ricci 464) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Ricci chapter 14

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