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Childbirth

• Childbirth represents a normal physiological process
• Nursing care during childbirth involves considering the welfare of two individuals
• It is a family affair
• The overall experience is memorable
• Sensitivity towards cultural needs is crucial

Nursing Care Priorities

• Monitoring of the mother by observing the progress of labor and noting complications
• Monitoring of the fetus by observing tolerance of labor and signs of distress
• Managing pain to ensure a safe and satisfactory experience

Labor

• Labor involves the physiologic process of expelling the fetus, umbilical cord, placenta, and amniotic membranes
• This expulsion results from uterine contractions and cervical effacement and dilation
• The exact trigger for labor is not known
• Labor typically occurs when the fetus is mature enough, around 38-40 weeks after the last normal menstrual period (LNMP)

Signs of Impending Labor

• Bloody show involves the loss of the mucus plug
• A burst of energy, often referred to as nesting, can occur 24-48 hours before labor
• Spontaneous rupture of membranes (SROM) requires a visit to the hospital, even without other signs of labor
• Lightening is the descent of the fetus into the pelvis
• Contractions, including Braxton-Hicks (false labor) and true labor, which is regular and progressively more intense, indicate impending labor.

Cervical Changes

• During pregnancy, the cervix is thick and closed
• During labor, the cervix undergoes effacement, or thinning, which is expressed as a percentage, with 100% indicating full effacement
• The cervix also undergoes dilation, or opening, measured in centimeters, with 10 cm indicating full dilation.

True Vs. False/ Prodromal Labor

• True labor results in progressive effacement and dilation of the cervix
• False or prodromal labor does not produce progressive effacement and dilation of the cervix
• The best way to differentiate between true and false labor is to assess dilation
• Reassuring the woman is important to ensure that she does not feel foolish if labor is false

Critical Factors of the Birth Process

• The success of the birth process hinges on what is called the "Four + Ps"
• These involve Passage, Passenger, Powers, and Psyche
• Further factors for a positive birth also include the correct Position of the mother, Pain management, Patience, Preparation, Professional help, having a suitable Place, appropriate Procedures, and supportive People

Passage

• The pelvis is more important to consider during birth as it is less flexible
• The cartilage softens due to relaxin
• Soft tissues, including the cervix, muscles, ligaments, and perineum, yield to the pressure of the presenting part of the fetus.

Passenger: Fetus

• The fetal head has sutures that allow molding
• Fontanelles are intersections between bones
• Lie is the alignment between the fetal spine and the maternal spine
• 99% of fetuses are longitudinal, meaning parallel to the maternal spine.

Relationship of Presenting Part & Passage

• Fetal presentation determines which part of the fetus enters the pelvis first
• Cephalic presentation is head first (96%)
• Breech presentation is buttocks first (3%)
• Shoulder presentation is when the shoulder comes first

Fetal Presentation Variations

• Cephalic variations are often Vertex
  • Vertex indicates complete flexion, which is the most common and presents with the smallest diameter
  • Face indicates full extension, and brow or military indicates poor flexion and partial extension
• Breech variations include
  • Full or complete when hips and knees are flexed; Frank when hips are flexed and knees are extended
  • Footling when hip(s) and knee(s) are extended

Passenger: Fetus

• Fetal position defines the relationship of a landmark on the presenting fetal part to the front, side, or back of the maternal pelvis, indicated by three letters
  • LOA (left occiput anterior) is the most common position
• Attitude is the degree of flexion
  • A flexed attitude occupies less space

Passenger: Fetus

• Fetal station defines the relationship of a landmark on the presenting fetal part to the ischial spines
• Fetal station provides information regarding fetal descent
• The level of the ischial spines is considered station 0
• Above the ischial spines is a negative number in centimeters, and below is a positive number in centimeters.

Powers: Uterine Contractions

• Uterine contractions are the primary force of labor during the 1st stage
• Contractions affect the cervix by effacement and dilation
• Contractions are involuntary
  • They cannot be consciously started or stopped
  • Many factors influence contractions

Describing Uterine Contractions

• Onset: Describes the beginning of a contraction
• Duration: Is the time from the beginning to the end of a contraction
• Frequency: Is the time from the beginning of one contraction to the beginning of the next contraction
• Intensity: Refers to the strength of contraction at its acme/peak

Maternal Pushing

• Most women feel the urge to push once the cervix is fully dilated
• The addition of voluntary pushing to involuntary uterine contractions increases the powers that propel the baby down through the pelvis
  • This indicates fetal station

Maternal Position

• Maternal position influences the progress of labor
• An upright position can reduce the length of labor
• Encourage women to find a comfortable position
  • Avoid the supine position
• Place a wedge under the lower back to displace the uterus off the inferior vena cava

Psyche

• The state of mind can influence the course of labor
• There are many influences
  • Confidence in self and trust in providers, cultural and individual values, coping mechanisms, and preparation for childbirth can all affect labour.
  • Preparation decreases pain and satisfaction
• The nurse provides reassurance, praise, information, and support

Basic Principles for Maternity Care

• Labor should begin on its own
• There should be freedom of movement
• A birth support person or doula present
• No "routine" interventions
• Non-supine position
• The infant should not be separated
• There should be in-person nursing

4 Stages of Labor (Overview)

• First stage: From the beginning of true labor to 10 cm
• The first stage includes the Latent, Active, and Transition phases
• Second stage: From 10 cm to birth of the infant through pushing
• Third stage: From the birth of the infant to the delivery of the placenta
• Fourth stage: From 1 to 4 hours after birth representing the recovery phase

Latent Phase: 1 - 3 cm

• Characteristics include contractions that are mild and infrequent, increasing to every 5 minutes by the end
• There is excitment, although there is some anxienty, this phase can last 10-20 hours
• Nursing care involves establishing a relationship
  • Orienting the patents to the unit
  • Reviewing birth plans and request
  • Monitoring the mother and fetus intermittently
  • And encouraging ambulation

Active Phase: 4 - 6 cm

• Characteristics encompass more frequent and intense contractions
  • (q2-3, >60 sec)
• The woman is more inwardly focused but still cooperative
• Analgesia or anesthesia may be needed (epidural)
• Nursing care involves monitoring
  • Providing comfort measures and hygiene, keeping the bladder empty, and supporting/assisting in breathing/relaxation

Transition Phase: 7 - 10 cm

• Characteristics include intense, frequent contractions
• (q2-3, 60-90 sec)
• Women may become irritable and uncooperative
• Nursing care encompasses continuing maternal and fetal assessments
  • Continuing comfort measures
  • Reassuring the woman
  • Keeping and not leaving her alone

Birth Settings

• Hospitals for around to 99% of births
  • They're more expensive and intimidating
  • They have ready access to services and personnel
• Birthing Centers are more homelike with less expense
  • There may be delays when complications occur
• Home births come with greater control and fewer pathogens
  • There are fewer attendants willing to assist and a possible delay in emergencies

Need for Admission

• Teach the pregnant woman when to seek admission
• Regular uterine contractions, where a nullipara/primipara experiences contractions every 5 minutes for 1 hour, or a multipara w/hx rapid; q7-10 min x1 hr
• Admission is needed if there is a rupture of membranes
• Admission is needed for vaginal bleeding, other than a "bloody show"
• Admission is needed for the urge to push during contractions
• Admission is needed for any other concerns

Admission Data Collection

• Collect maternal vital signs and data around the maternal condition and assessment of the cervix
• Collect fetal condition data such as FHR and amniotic fluid condition
• Assess for signs of impending birth
• Admission procedures, including completed paperwork, consents, labs, IV access, and review of prenatal records such as blood type and Rh, EDD, and birth plan
• This should be completed ahead of time

Observation without Admission

• Observation of the mother if they are in "False" or early labor
• Monitoring for 20 min is required to verify fetal well-being
• Ambulating can help start labor
• If there is no cervical change return home to await true labor
• Reassure the mother and reinforce instructions when sending them home

After Admission to Labor Unit

• Priority nursing actions: monitoring the fetus, monitoring the laboring woman, and helping the woman cope with labor

Evaluating Progress of Labor

• Contractions and vaginal exam, with assessment of the cervix for effacement and dilation
• Fetal station regarding descent is imporatnt
• No set interval is imporatnt as it requires watching for signs of progress and to minimize exams
• Minimizing exams reduces infection and avoids patient discomfort

Maternal Response to Labor

• Assessments of a respnose to labor will include breathing and relaxation techniques
• The patient can develop tension and difficulty in coping
• Adaptive responses will require open communication
  • Maintaining hygiene and comfort
  • Keeping the patient informed of progress
  • Providing encouragement and care for partner(s)

Amniotic Fluid

• The color, odor, and amount needs to be recorded
• The color/odor:
  • Clear, straw colored, with flecks of white vernix is considered normal
  • Green, meconium indicates fetal distress
  • Cloudy with odor indicates an infection
• A Nitrazine test verifies alkaline pH
• The amount is subjective

Ongoing Maternal Physical Assessment

• Consistently monitor vital signs
• The first measurement may be elevated due to excitement, repeat later
• Temp q4h, q2h after membranes rupture
• Report Temp ≥100.4
• O and I (output and intake)
  • Encourage voiding q 1-2 hrs
  • A full bladder interferes with descent

Assisting the Laboring Woman

• Promote comfort by adjusting the environment
  • Ensuring light, room temperature and covers
• Assist with hygiene to frequently change underpads
• Change their position to ambulate durng early labor
• Try upright, hands & knees, squatting
• Prevent Supine position

Assisting the Laboring Woman

• Teaching involves reinforcing childbirth preparation class
• Teaching breathing techniques & positioning
• Coaching pushing when fully dilated
• Provide encouragement by keeping informed of progress Provide a caring presence and support the partner

Fetal Heart Rate

• Monitor the fetus for early signs of hypoxia with rapid response
• Intermittent auscultation or continuous electronic fetal monitoring
• External: ultrasound transducer, Internal: fetal scalp (spiral) electrode

Electronic Fetal Monitoring

• Continuous monitoring of data
• Rapid identification of non-reassuring patterns
• Prompt intervention
• All documented interventions & additional information needs to be documented since EFM is part of the medical record

Fetal Heart Rate

• Normal baseline rate: 110 - 160
• Tachycardia: >160
• Maternal fever
• Bradycardia: 110 and 160 bpm.

Early Decelerations

• Have a rate that decreases with contraction
• Typically recovers upon the rate deceasing during contractions Head compression
• No response needed since baby may be getting closer

Late Decelerations

• Rates slow and don't return to baseline until after contraction is over
• Placenta is not delivering enough O₂ to the fetus
• Uteroplacental insufficiency (UPI)
• Side-lying, O₂, IV, stop oxytocin, notify MD

Variable Decelerations

• Rates drop abruptly in irregular V, W, or U shaped pattern
• May become prolonged; can be an emergency
• Related to cord compression
• Reposition patient and potentially use amnioinfusion

Pain in Childbirth

• Pain is an unpleasant and distressing symptom that is personal and subjective
• Childbirth pain
  • Is part of the normal birth process
  • There are Months to prepare
  • Self limiting in nature
• Can motivate a woman to seek help from others and facilitate birth

Psychosocial Pain Factors

• Culture, learned can express pain in a stoic fashion
• Anxiety increases tension & decreases tolerance
• Experience
• Preparation many types; helpful if realistic Support of significant other(s)

Pain In Childbirth

• Causes - contractions, dilation, stretching, ischemia, pressure
• Women's experiences of pain vary
• Supportive care enhances pain coping
• Prenatal education includes pain control options for labor in both Non-pharmacological and Pharmacological avenues
• Patient has choice regarding pain management interventions

Non-pharmacologic Pain Relief

• The advantages are There is no harm to mother or fetus and it does not slow labor There are no side effects
• The limitations are It may not provide adequate pain relief no matter how well prepared and practiced and the increases in Poor pain relief increases fear and anxiety Most require preparation prior to labor

Analgesia & Anesthesia

Narcotic analgesia during labor crosses the placenta and may cause neonatal respiratory depression but that can be combated with Naloxone (Narcan) antagonist Anesthesia is Regional epidural for labor or cesarean causes Hypotension which is the most common adverse rxn and General anesthesia rarely used

Nurse's Role in Pain Management

• The nurse provides: non-pharmacologic support and assesses effectiveness
• The nurse assesses pharmacologic appropriateness
• Nurse administers or assist and monitors for adverse reactions in both the maternal and neonatal patient base

Second Stage Characteristics

• Cervix should be dilated to only 10 cm to reach birth
• Pushing should coincide with Urge to bear down (feels like BM) and in Bulging conditions of the perineum
• Contraction can still be intense but less than during transition times
• If Mother is in distress she will need to regain control and Pushing feels good/useful

Nursing Care: Second Stage

• Coach pushing efforts
• Evaluate progress & monitor fetus
• Communicate with provider
• Assist with positioning
• Prep perineum (usually cleansing only)
• Support woman & partner

Nursing Care During Birth

• Prepare the operating room by setting up sterile instruments
• Prepare the equipment by setting up a Radiant warmer & baby supplies to stabilize and assess the newborn
• Identify mother & infant
• Promote parent-infant bonding and Encourage early breastfeeding

Episiotomy

• Episiotomy: Surgical incision to enlarge vaginal opening has risks but is Not routinely used against Vs. laceration with absorbsble sutures
• Nursing care is Cold against packs first 12 hours and Warmth after 12 - 24 hours with heat packs or sitz bath
• Risks: Extension and Infection

Infection Control: Birth

• Standard precautions are necessary as there is a lot of Body fluids such as:
• Blood, Amniotic fluid, Vaginal secretions
• PPE needed:
• Clean (or sterile) gloves, Water repellent cover gown, and Mask & eye shield

Third Stage: Expulsion of Placenta

• Slight cramp with delivery of placenta
• Uterus must contract firmly to control bleeding
• Nursing care includes Administering oxytocin after birth, monitor blood pressure, and initial new born by either Bonding/Initiate breastfeeding

Fourth Stage: Recovery

• Characteristics during the stage:
  • Firm uterus and little bleeding
  • The patient may present with Cramping, perineal burning or pain and have shaking chills
• Nursing care for this stage includes: Assessing the patient every so often, Providing hygiene and nutrition, Maintaining an empty bladder, and Encouraging the bonding with the fetus

Nursing Care of Mother Immediately After Birth

• Assess frequently (q 15 min x 1 hr) for hemorrhage
  • Bleeding < 1 pad / hour, no clots
  • Firm fundus is needed to continue blood pressuring
  • Check VS - BP, P, R signs of shock and determine temp
• Promote bladder emptying and comfort by Providing patients with a warm blanket and placing Perineal ice pack

Initial Care of Newborn (1st hour)

• Maintain warmth: Remove wet linens, Baby is less efficient at generating heat, prevent Hypothermia can lead to other problems
• Establish needed respiratory with assistance
• Provide cardio-respiratory function assistance with Cord clamped, Suction mouth & nose, Rub back or flick soles of feet to stimulate cry
• Use APGAR score at 1 & 5 minute marks

Amniotomy (AROM)

• Artificially used to stimulate contractions after being manually performed
• There are multiple complications with these:
• Infection, Prolapse of the Umbilical Cord
• If a physician has committed this procedure be thorough
• Maintain proper Monitor FHT and assess color, odor of fluid and maintain temps on monitors and give time for Promote comfort & hygiene

Amnioinfusion

• Medical intervention is there is In-fusion to compress and remove meconium from area
• There are complications during this: Prolapse of umbilical cord, infection Nursing Care must observe for Monitor UCs (IUPC) and Promote comfort & hygiene

Labor Induction

• The Initiation of labor (UCs) can begin naturally or artificially with GH, PROM, Uterine Infection depending on the health and complications
• There are Contraindications during the processes such as cord prolapse, previa, which requires specific Techniques Cervical ripening must be done and Stimulate contractions; oxytocin This is done through Non-drug, walking, nipple stimulation This does come however with risks and requires intense levels of observation during Stimulation and for FHT patients who administer oxytocin safely according to agency policy to enhance labor

Additional Procedures

Procedures such as Vacuum or Forceps can enhance situations with proper medical expertise If there is No replacement you put in place a CS protocol to ensure proper medical care

Cesarean Birth

Medical and surgical options are: placentia Previa/abruptio Indications may include cord prolapse, abnormal labor, active herpes, breech or transverse lie, fetal distress and Contradictions: few can limit medical capabilities Risks must include: Maternal - surgery, anesthesia, and Fetus - as lung fluid can cause several medical set backs, This procedure requires -Preparation with NPO, labs, foley, VS,

Cesarean Section

• The Procedures include: Transverse skin incision, lower uterine segment but the VBAC is available: if cause does not repeat Roles for nurses are prep, support, and provide basic medical care when the medical practitioner is performing surgery techniques

TOLACT / VBAC

• Medical intervention for Vaginal birth after cesarean
• With the Nursing medical team giving proper medical care similar to woman with no previous cesarean
• Concerns over this would include Rupture of the Uterus but the possibility of them delivering can become a life threatening decision that requires proper consideration