TEST ONE MATERIAL.docx

Care of the well Newborn Newborns do feel pain and Painful stimuli are transmitted to the fetus as early as the 2nd and 3rd trimester of gestation. Pain to a newborn can cause physiological changes such as intercranial pressure, and increased risk for intraventricular hemorrhaging. Can also increase...

Care of the well Newborn Newborns do feel pain and Painful stimuli are transmitted to the fetus as early as the 2nd and 3rd trimester of gestation. Pain to a newborn can cause physiological changes such as intercranial pressure, and increased risk for intraventricular hemorrhaging. Can also increase Heart rate, respiration rate, oxygen saturation and increase levels of stress hormones such as cortisol in the blood. Repeated painful stimuli can contribute to emotion, behavioral and even learning disabilities. May also cause threshold alteration and cause permanent change in neural pathways. Series tissue injury may lead to infants to respond to non-painful touch as though they were in pain. Circumcision is no longer required but is considered an elective procedure with many health benefits. Procedural analgesia and local anesthesia will be provided if elected to do circumcision. As with any patient, assessment of pain in the newborn is an essential component of providing therapeutic nursing care. It is important to remember that newborns are not small adults and may react quite differently to the presence of painful stimuli. Some common signs of pain in the newborn include but are not limited to the following: High-pitched, intense, harsh cry Whimpering, moaning "Cry face" Eyes squeezed shut Mouth open Grimacing Furrowing or bulging of the brow Tense, rigid muscles OR flaccid muscle tone Rigidity or flailing of extremities Color changes: red, dusky, pale Increased or decreased heart and respiratory rates, apnea Increased blood pressure Decreased oxygen saturation Sleep-wake patterns change There are many Newborn pain assessment instruments available. A common one is Neonatal Infant Pain Scale (NIPS). Should be used for infants 1 year and younger. The CRIES instrument should be used for infants 6 months and younger. Scores may range from 0-10 with a score of 4 that indicates a pain medication is needed. Comfort measures for a new borne experiencing pain. Gently wake the newborn from sleep and provide containment such as swaddling. This stimulates the intra-uterine environment that the infant has become accustomed to and prevents the infant from flailing. Limbs should be relaxed and close to the body (facilitated tucking). Non-nutritive sucking with a pacifier or infants’ hands may also comfort the infant. Sometimes a sucrose solution (Sweet Ease ) dripped into the infant’s mouth may also provide some pain relief. Talking softly, holding and rocking may also comfort infant. Infant Formula Preparation: Wash hands before preparing bottles and clean the workspace where you’ll be preparing the formula. Bottles must be cleaned and sanitized. Milk or formula does not need to be warmed up. Some people like to do it. NEVER USE A MICROWAVE, they heat bottle unevenly which result in hotspots that can burn the baby. TO WARM PLACE BOTTLE UNDER RUNNING WARM WATER. Make sure nothing gets into the bottle. Put drops on hand to test it. If using formula us a safe source of water, if you are unaware of tap water safety call you local health department. ALWAYS MEASURE THE WATER FIRST AND POOR INTO BOTTLE BEFORE FRMULA. Too much water can dilute the bottle of nutrients. Too little water may cause the babies kidneys and digestive system to work too hard and cause the baby to become dehydrated. If not cleaned right germs from bottle can cause Cronobacter. Used prepared infant formula within 2 hours of prep, or 1 hour within the beginning of feeding. If not used within 2 hours, store for 24 hours. Throw out left over formula, saliva can mix and cause bacteria to grow. Store unopened formula containers in a cool, dry, indoor place. NEVER IN VEHICHLS, GARAGES OR OUTDOORS. Many factors can effect how the formula is prepared such as water source and baby’s age. To kill germs in powdered formula, it must be mixed with very hot boiling water, wait about 5 minutes then mix in formula. Infants who are more likely to get sick include: Infants younger than 2 months. These infants are most likely to develop meningitis if they get sick from Cronobacter. Infants are born prematurely. Infants with weakened immune systems. Babies with this condition can’t fight germs as well because of illness or medical treatment, such as chemotherapy for cancer. STEPS TO PROTECTING BABY FROM CRONOBACTER: Breastfeed if you can. Clean, Sanitize, and store feeding items safely. Such as baby bottles, breast pumps, nipples, caps, rings and valves. Keep hands and surfaces clean! Wash hands for at least 20 seconds. You should also wash your hands during these key times: Before touching your baby’s mouth Before touching pacifiers or other things that go into your baby’s mouth After using the toilet or changing diapers Use hand sanitizer with at least 60% alcohol content. Consider using liquid baby formula if baby is high risk But if your baby is at higher risk, consider taking these extra steps to prepare your powdered formula with hot water (at least 158°F/70°C): Boil water and let it cool for about 5 minutes. It is important to mix the formula while the water is still very hot so that the heat can kill any germs. Pour the water into a clean bottle or feeding cup. Add the exact amount of formula listed on the container. Then, put a cap on the bottle and shake to mix. Don’t use a spoon or other utensil to stir because this could introduce germs. Cool the formula to body temperature to ensure it is not too hot before feeding your baby. Hold the capped bottle under cool water or place it into an ice bath. Do not let the cooling water get into the bottle or on the nipple. Test the formula’s temperature by putting a few drops on the inside of your wrist. It should feel warm, not hot. Use prepared infant formula within 1 hour from start of feeding and within 2 hours of preparing it. Throw away any formula your baby does not finish. Don’t refrigerate leftover formula to save it for later. The combination of the formula and your baby’s saliva can allow germs to grow. If you do not plan to start feeding your baby with the prepared formula right away, put it in the refrigerator immediately. Use formula in the refrigerator within 24 hours. Throw out formula if you can’t remember how long you have kept it in the refrigerator.  Do not feed it to your baby. It is important to remember that the effects of teratogens depend on the the maternal and fetal genotype, stage of development when exposure occurs dose duration of exposure of the agent. Air pollution, saunas and steam rooms show a correlation with low birth weight Vitamins and folic acid supplements taken before conception can reduce the incidence of neural tube defects. The first 6 hours of life, in which the newborn stabilizes respiratory and circulatory functions, is called transition. In utero, the placenta is the organ of gas exchange. In summary, the four major cardiopulmonary actions of cardiopulmonary adaptation (Figure 22–3) are as follows: 1. Increased systemic vascular resistance and decreased pulmonary vascular resistance. With the loss of the low-resistance placenta, systemic vascular resistance increases, resulting in greater systemic pressure. At the same time, lung expansion and exposure to high oxygen concentrations increase pulmonary blood flow and dilate pulmonary blood vessels. The combination of vasodilation and increased pulmonary blood flow decreases pulmonary vascular resistance. As the pulmonary vascular beds open, the systemic vascular pressure increases, enhancing perfusion of the other body systems. 2. Closure of the foramen ovale. Closure of the foramen ovale is a function of changing arterial pressures. In utero, pressure is greater in the right atrium, and the foramen ovale is open after birth, shunting blood from the right atrium tothe left. The decreased pulmonary vascular resistance and the decreased umbilical venous return to the right atrium also cause a decrease in right atrial pressure. The pressure gradients across the atria are now reversed, with left atrial pressure greater; this causes the foramen ovale to functionally close 1 to 2 hours after birth. Anatomic closure of the foramen ovale is typically achieved by 2.5 years (Blackburn, 2018; Hoffman, Thompson-Bowie, & Jnah, 2019). 3. Closure of the ductus arteriosus. Initial elevation of the systemic vascular pressure above the pulmonary vascular pressure increases pulmonary blood flow by reversing the flow through the ductus arteriosus. Blood now flows from the aorta into the pulmonary artery. An increase in blood PO2 triggers the ductus arteriosus to constrict. In utero, the placenta produces prostaglandin E2 (PGE2), which causes ductus vasodilation. With the loss of the placenta and increased pulmonary blood flow, PGE2 levels drop, leaving the active constriction by PO2 unopposed. Functional closure of the ductus arteriosus in the well newborn starts within 24 hours after birth; fibrosis or anatomic closure occurs within weeks to months after birth (Hoffman et al., 2019; Swanson & Erickson, 2021). 4. Closure of the ductus venosus. Closure of the ductus venosus is related to mechanical pressure changes that result from severing the cord, redistribution of blood, and cardiac output. Closure of the ductus venosus forces perfusion of the liver. Fibrosis or anatomic closure of the ductus venosus occurs within 2 weeks, at which time it becomes known as the ligamentum venosum (Blackburn, 2018). Periodic breathing, which is defined as “vigorous respirations followed by up to a 20-seconds pause,” is common in preterm newborns, but can also be seen in term babies (Fraser, 2019, p. 82). Acrocyanosis is normal for the first 24 hours. Institutions may perform pulse oximetry, which should be greater than 95% in term newborns; Blood pressure values during the first 12 hours of life vary with the birth weight and gestational age. Crying may cause an elevation in both the systolic and diastolic blood pressure; thus accuracy is more likely in the quiet newborn. Capillary refill should be less than 3 seconds when the skin is blanched. In the preterm newborn, the average mean blood pressure varies according to weight and degree of illness. Blood pressure in the lower extremities is usually higher than that in the upper extremities. Reviews of multiple clinical trials found that delayed umbilical cord clamping had both positive and negative effects on neonatal outcomes. Newborns in the delayed umbilical cord clamping group had significantly higher levels of hemoglobin compared with newborns in the immediate umbilical cord clamping group. Newborns in the delayed umbilical cord clamping group also had higher ferritin levels until 6 months of age, and fewer suffered from iron deficiency anemia. Placing the newborn skin-to-skin with the mother after bathing is a good way to help rewarm and maintain body temperature. The newborn develops jaundice in cephalocaudal progression, which means that jaundice is first seen in the face and then travels down the trunk. Several newborn care procedures will decrease the probability of high bilirubin levels. • Maintain the newborn’s skin temperature at 36.5°C (97.8°F) or above; cold stress results in acidosis. Acidosis decreases available serum albumin-binding sites, weakens albuminbinding powers, and causes elevated unconjugated bilirubin levels. • Monitor stool for amount and characteristics. Bilirubin is eliminated in the feces; inadequate stooling may result in reabsorption and recycling of bilirubin. Early breastfeeding should be encouraged because the laxative effect of colostrum increases excretion of meconium and transitional stool. • Encourage early feedings to promote intestinal elimination and bacterial colonization and provide caloric intake necessary for hepatic binding proteins to form. Acute Care Environment: Critical care nursing manages human responses to life threatening problems. We utilize the nursing process to: Assess life threatening conditions. Prioritize nursing diagnosis. Develop a plan alongside other medical disciplines to align with patient goal of care. Implement appropriate interventions. Evaluate outcomes and reassess alignment with goals. Educate patients and families. ADPIE 4 major critical care structures: Disease condition (Age group vs. Combined) Rapid /Critical response teams Early response to patient instability Advanced technology Monitoring Life sustaining technology Progressive Care units Expectations of the critical care nurse In-depth knowledge of 3 Ps Physical/health assessment Physiology and pathology Pharmacology Ability to use advanced tech. Frequent assessments. Monitor Trends Diligently responds to subtle changes. Care for the needs of caregivers and families. Communicate and collaborate with patients, families, and team. Provide respectful, culturally sensitive care to the dying patient. Patient Criteria for admission Risk for serious complications and need frequent assessments/ interventions Physiologically unstable and need advanced clinical judgment. Intensive and complicated nursing support with medications and technologies Common Problems in Critical Care: Respiratory failure requiring mechanical ventilation High risk for DVT, skin breakdown, HAI Sepsis and MODS Myocardial infarction Post-cardiac arrest Major surgery Common Nursing Diagnosis Anxiety Fear Death Anxiety Acute Pain Chronic Pain Impaired verbal Communication Sleep deprivation Imbalanced nutrition: less than body requirements Common signs of Delirium: High prevalence Acute and ~reversible Related to physiological and environmental conditions. High Risk Elderly Pre-existing dementia HTN ETOH (alcohol) Severe illness Manifestations Changes in mentation (the process of using your mind to consider something carefully) Increased psychomotor behaviors Altered sleep-wake cycle Interventions Address physiologic factors Regulate environment Reorientation Ensure safety Medications are last resort Critical Care Interventions: Diligent pain assessment and management Assume pain present Education for patients and families Honest communication, empathy, presence, listening, hope Facilitate communication. Sedation vacations A balancing act of tightly titrating the sedative dose to provide agitation-free, comfortable sedation in the lowest dosage. Stress reduction techniques Control environmental stimuli to promote sleep and reduce anxiety. Work with dietician to provide nutrition to meet metabolic needs. About resuscitation: When educated , most people with serial illness choose to be DNR. Families should be allowed to be granted to bedside during resuscitation efforts. If code blue happens < 20% survival in hospital <10% in outpatient Common ethical Issues Artificial hydration/ Nutrition debate Pain med usage Aggressive Intervention with poor prognosis Plan of care that opposes patient goals of care. Disagreements about plan of care. Supporting the caregivers and families: Needs: Physically exhausting and impacts health Psychologically feel lost, lacking control, anxious, distressed Socially concerned about finances, loss of routine, role as caregiver Spiritually may experience distress about the patient’s condition Interventions: Consult with case manager, social work, chaplain Engage in patient-centered, family-focused care Listen, use presence, acknowledge feelings Educate Provide access to the patient and opportunities for care Family conversations and point person Hospitalized Children: Common stressors of the family and reactions: Disbelief, anger, guilt especially if its sudden Fear and anxiety, related to child’s pain, seriousness of illness. Frustration (focused on communication) Depression Siblings: Guilt Anger Resentment Jealous Fear Worry Loneliness Children’s perception of illness is more important than intellectual maturity in predicting anxiety. Effects can be seen before, during and after hospitalization. Benefits of Hospital Stay: Increased Coping skills New Socialization experiences Master stress and feel competent in coping. Recovery from illness. We are maximizing potential benefits: Foster parent-child relationship Provide education. Promote self-mastery! Providing socialization Support family members Infant needs: Trust Consistent, loving caregivers. Daily routine Toddlers needs: Autonomy Dailey routine and rituals Negativity Temper Tantrums Regression of behavior Preschoolers: Egocentric (Me, myself and I) and magical thinking normal. May view illness or hospitalizations as punishment for misdeeds. Preoperational thought School Age: Striving for independence and productivity Fears of death, abandonment, permanent injury. Boredom Adolescents: Struggle for independence and liberation Separation from peer group May respond with anger, frustration. Need for info about condition. Worry about being “Different “ than peers. All kids fear of bodily injury and pain: Common fears among children May persist into adulthood and result in avoidance of needed care. How young infants respond to pain are: Rigidity or Thrashing Loud Crying Facial expression of pain No understanding of the relationship between stimuli and subsequent pain. Older infants Withdraw from pain. Loud crying Grimace Physical resistance Turning away. Young Children(preschools) response to pain: Loud crying, screaming. (Scream with me) Verbalization Thrashing of limbs Attempts to push away stimuli! School age children response to pain: Stalling behavior Rigidity May use all behaviors of young child. Parent presence may influence child to act tough so may not disclose pain. Adolescents’ response to pain: Less vocal protest, less motor activity Increased muscle tension and body control More verbalization May try to appear tough. For the hospital admission procedures, we: Nursing admission history Physical assessment Room assignments or placement Adolescents’ unit. Ambulatory/ Outpatient: Benefits Preparation of child can be challenging. Stress of waiting Explicit discharge and follow up instructions. Isolation: Added stressors Child may have limited understandings. Dealing with child’s fear Potential for sensory deprivation. Emergency Admission Essential of admission counseling “Postvention” – counseling subsequent to the event Participation of child and family as appropriate to situation Intensive care unit: Increased stress for child and parents Emotional needs of the family Parents needs of the family. Parents need for information Perception of security from constant monitoring and individual care. Health Promotion: 1. Discuss major issues in health promotion and prevention for children. 2. Describe Family Centered Care 3. Describe Atraumatic Care 4 .Describe the role of the pediatric nurse in health promotion of the child. Neonate: Birth to 28 days Preterm: 20 weeks-36 6/7 weeks Term: 37-42 weeks gestation Postterm: After 42 weeks Healthy People 2030: Essential compononetns for child health promotion Trying to prevent child health problems High Priority: Strong reliable data available for accurate measurement of changes. Evidence-based strategies are available to address the desired change. Funding sources may use these to determine priorities. Infants goals: Goal - Reduce the rate of infant deaths within 1 year of age Baseline: 5.8 infant deaths per 1,000 live births occurred within the first year of life in 2017 Target: 5.0 infant deaths per 1,000 live births Strategies: SIDS education Access to Maternal/OB care Reduce disparities. Children Goals: Children and adolescents with obesity Goal - Reduce the proportion of children and adolescents with obesity Baseline: 17.8 percent of children and adolescents aged 2 to 19 years had obesity in 2013-16 Target: 15.5 percent Strategies: Intensive behavioral programs that use more than 1 strategy are effective. Policy and school curriculum changes can make it easier for children and adolescents to eat healthily and get physical activity. Adolescence: Current use of any tobacco products among adolescents Reduce current use of any tobacco products among adolescents. Baseline: 18.3 percent of students in grades 6 through 12 used cigarettes, e-cigarettes, cigars, smokeless tobacco, hookah, pipe tobacco, and/or bidis in the past 30 days in 2018 Target: 11.3 percent Strategies: Nearly all tobacco use begins in childhood and adolescence. Population-level interventions include price increases, mass media campaigns, and smoke-free policies. Additional Team members: Mental Health Professionals School Nurse and Counselors Teachers Home Health Staff Faith Community leaders Atraumatic Care: Care activities that focus on minimizing the distress of a child and family. OB scenarios: Why we monitor: We mainly monitor the fetus to watch for any indications of hypoxia. We monitor the fetal pulse rate and the uterine activity because uterine activity effects oxygen to the fetus. We usually use continuous monitoring to monitor fetus, but it depends on patient population. We have many ways to monitor one low tech way is Auscultation and palpation: We can use a fetal scoop or a doppler to listen. It is easy, noninvasive, nonrestrictive. Some disadvantages is that they it is not continuous and no visual of baby. We would use this on low-risk patients. Electronic monitoring: Technique: WE must locate the fetal back when placing Ultrasound inducer (FHR). (Fetal BACK) Toco doesn’t matter how the baby is positioned. We place on TOCO. Advantages: Non-invasive Continuous/visual of heart rate and contractions Frequency of contractions Disadvantages: Does not give us contraction strength: Mild: Nose Moderate: Chin Strong: Forehead Limits mobility of mom Affected by feta and maternal movement. Direct/Internal monitoring: Technique: Rupture membrane Locate fetal presenting part and place monitor (head, or butt whatever is present) Advantages: Continuous tracing Fetal/maternal movement Able to quantify contractions strength. Disadvantages: Invasive Increased chance of infection Patient must deliver Normal HR: 110-160 Variability is moderate at base line (6-25 -) Non-stress test: We must have 2 accelerations with 20minute period. Acceleration = 15 bpm above base line, MUST last for 15 seconds. Normal respirations: 30-60 NST: The purpose of the NST is to make sure the baby is we oxygenated. We want at least 2 accelerations last 15 seconds above 15 baselines. Early decelerations are ok, they are head compressions. Changes in fetal heart rate that’s bad: Late deceleration means poor placental perfusion. Variable decelerations Caused by cord compressions (May not associate with contractions) Accelerations: Happy baby Early Decelerations: Think of 2 heads going together in conjunctions with the contractions. Responses to head compressions. Variable Decelerations: CORD COMPRESSION The drop off is SHARP, unlike early decelerations. The drop off is less than 30 seconds, 3 blocks so it is a variable. Late Decelerations: After the top of contractions. Indicate poor placenta perfusion. We need to fix this Alterations How we fix late and variable decelerations: Change mom’s position. Give oxygen by nonrebreather mask at 10ml. Increase IV fluids may she’s dehydrated. Contractions: How to & Norms Frequency – How do we measure? Start of one contraction to start of the next Duration – How do we measure? Start of one contraction to the end of that contraction Intensity – How do we measure? Palpation - Mild / Moderate / Strong The 5 Ps of labor: Passenger (fetus and placenta) Size of fetal head Fetal presentation The more extended the baby’s head is the higher in diameter that will be during pregnancy. Vertex position is the most common. Any form of breach or shoulder presentation will be delivered C-Section. Fetal position Relationship of the occipital bone on baby’s head to one of the 4 quadrants on mom’s pelvis. We want the babies to be FACING the Posterior side of mom. The small part in this picture is the occipital bone. A s right occipital anterior (This is what we want) B is Right Occipital Posterior (This will be a more difficult/longer birth) (Sunny side Up) Fetal lie (The relationship between the baby’s spine and the mothers spine.) There are only two options here. Transverse or Longitudinal Fetal attitude Refers to how flexed or extended the baby is. The relationship of the babies’ parts to each other. The more flex (Tucked) (A) the baby is in the easier it is to deliver. The more extended (D) the tougher it is to deliver the baby. Passageway (birth canal) This is comprised of Cervix Pelvic floor muscles Vagina Introitus Bony pelvis How the baby looks coming out. Fetal station in relation to the ischial spine. Presenting part of baby can be above or below the ischial spine. The true pelvis is separated by 3 parts. If the baby can pass the ischial spine we will most likely have a vaginal delivery. Powers (contractions) Primary powers Effacement Dilation Ferguson reflex These initiate at the top of the uterus and up in the fundus. The cervix softens to allow the baby to pass through. Contractions move baby to the upper pelvic floor. (Primary power) Once the baby reaches the pelvic floor the FERGUSON reflex takes over which makes mom want to push. Secondary powers Bearing-down efforts If she has an epidural, she will not feel Ferguson reflex. She can still bear down and assist the baby. This is secondary power. Position of mother Position change can benefit mothers’ comfortability. It will help the baby move into a position that will facilitate birthing. It can improve circulation. Psychologic response of the mother to labor Laten Labor: Excited Able to follow instructions. Pain is controlled. Alert Focused on self and baby Active Labor: More serious and apprehensive Pain has increased and need more encouragement. May have difficulty following instructions. Transition: Most fearful Irritable Expresses feelings of doubt and continuing Vague communications. Process of labor continue: Signs of labor is that the baby will drop prior to contractions , mothers will be able to breath better but will be in the restroom more due to the baby being on the bladder. Blood show may also be present. THE ONLY SIGN OF TRUE LABOR IS STRONG CONTRACTIONS THAT RESULT INTO CERVIX DILIATIN. IF THE CERVIX IS NOT OPENING WITH CONTRACTIONS MOM IS NOT IN LABOR. Stages of labor First stage Onset of contractions to full dilation of the cervix Has three phases The first phase is the latent phase. During the latent phase the cervix effaces as contractions become more regular and closer together. Dilation progresses more slowly. In the second phase is the active phase. Contractions are closer together, stronger, and regular and the cervix dilates more rapidly. The third phase is transition. This is the phase right before complete dilation. Contractions are frequent, regular and strong. This phase is the shortest, but it’s also the most intense. Second stage Full dilation to birth Latent phase In the latent phase the baby continues to descend through the pelvis but the mom hasn’t felt the urge to push yet. Active Phase The active phase of the second stage is when the baby has reached the pelvic floor and the Fergusons reflect is activated. Ends at the birth of the baby. Third stage End of the Birth of the fetus until delivery of the (Birth of placenta) placenta Fourth stage (Recovery) 2 hours post-delivery of the placenta. Seven cardinal movements of mechanism of labor that occur in vertex presentation: Engagement Descent Flexion Internal rotation Extension Restitution and external rotation Expulsion (birth) The Baby adapts physiologically by: Fetal adaptation These changes occur in: Fetal heart rate Fetal circulation Fetal respiration Emotional Support: We want to always maintain privacy and practice with a nonjudgmental attitude. Process of labor: Labor: process of moving fetus, placenta, and membranes out of uterus and through birth canal. Various changes take place in a woman’s reproductive system in days and weeks before labor begins. Labor can be discussed in terms of mechanisms involved in process and stages woman moves through. We use the Leopold’s maneuvers to allow us where the fetal head is and where the fetal spin is. First two maneuvers will help us find the fetus upper back. We first put our hand on moms Fondus and feel. We feel for the head or hips/butt Second we find where the fetal back is: Brings hands to abdomen. May feel knobby or long smooth back( Where the ultrasound transducer goes) There are 3 stages of labor: We measure contraction strength by palpation. Mild chin Severe forehead The first priority of the nurse after the birth of the baby is Clear airway Establish respirations. Prevent cold stress. Collect cord blood. Check the mom and baby during any labor and delivery appointment. (NST) 2 accelerations above the base line lasting 15 seconds within 20 minutes. Normal base line is 110-160 Impending labor signs Baby drops into pelvis. Burst energy. leg cramps Pelvic pressure True labor: Will progress in strength. The only way to check if someone is truly in labor it is check the cervix False labor: Contractions mild, irregular Does not increase in strength. Prestage Stomach drops Pressure Practice Braxton Hicks Mucus plug 1st stage of labor: Latent Cervical changes, goes from closed or open. Contractions are mild and regular. 0-3 cm for cervix Active Cervix changes from about 4-7cm Contractions are usually about 2-3 minutes apart. (Moderate to strong) Transition Most painful Move around a lot 2nd stage: Latent stage: Ends when the cervix is completely dilated. Active: Feels the urge to push. 3rd stage: Starts with delivery of baby and ends with the delivery of placenta. 4th stage: Starts from delivery of placenta to hemodynamic resolved. What are they: What are the 5 P’s of labor and what do are they for: Passenger(baby), Passageway(Maternal Pelvis) , Powers (Contractions, Bearing down), Position(frequent changes) and Psyche (How well client is dealing with labor). Labor Progression Variable Cord Early Head Acceleration OK Late Placenta Labor and Birthing Power Point: We have some main hormones during pregnancy: Good ones: Oxytocin: Promotes contractions. Endorphins: Natural pain reliever , this helps mom deal with pain. Bad ones: Catecholamines (Epi and Nor-epi) This shunts blood to all vital organs and the uterus is not considered one. This can cause High blood pressure, fast breathing, dilated eyes, shivering. Is Mom’s labor Real: TRUE LABOR: Contractions: Felt in lower back and radiate to the front. REGULAR, INCREASE IN STREAGTH AND DURATION Increase in intensity with activity They continue despite comfort measure. Cervix: Progressive change, softening and dilation. Blood show may be presented. Amniotic Membranes May impacted, bulging, or ruptured. Fetus: The presenting part can be engaged if it may have to pee more. FLASE LABOR: May have Braxton Hacks, Irregular and don’t continue to develop strength. Often stop when resting or changing position. Cervix may be soft but not dilating. May seem a pink tinge but no bloody show. The membrane will be intact. Assessment: During Contractions the belly elevates up. Contractions need to be just right. Too many contractions to often tell us the baby is being short of blood supply. Too far apart they’re not effective and labor is slow and increase a chance for infection. This tires the baby and mom. First stage of Labor (Changes in cervix): Latent: Mild contraction and pain are easily regulated. 0-3 cm Active: 4-7cm Transition: 8-10 cm Second Stage of Labor (Starts from dilation and ends with birth of baby) Birth can be anywhere. Third stage of labor (Begins with the birth of baby and ends with birth of placenta) : Shortes stage Ends with the placenta birth. NEVER PULL-ON CORD Fourth stage of labor: 1-4 hour stage Make sure post-partum hemorrhage is stopped. Can be caused by fast labor, large baby, induced. We want to check uterine toned and level, vital signs, perineum in general, bladder. Lots of mom shiver after labor, and it’s normal. This phase is super important for attachment, it’s time to breastfeed, helps with temp regulation, Blood sugar regulation, let mom have at least an hour of skin to skin with baby. After that first hour, anyone can hold the baby. Pushing: Latent phase: No pushing Active Pushing: Ferguson reflex We want to encourage open glottis pushing, we want the mom to breathe. NO HOLDING THE BREATH. Change in position: Change position of mom every 1-2 hours. Birthing beds allow mom to deliver right there. You will see crowning; moms may receive a tear, and this is normal. Some may require an episiotomy. Natural laceration is considered better than an episiotomy. 1st degree tear: Skin and structure of superficial muscle. 2nd degree tear: Goes through muscle of the perineal body. 3rd degree tear: Goes through Anal sphincter. 4th degree tear: Goes through anal sphincter and involves rectal wall. When the water is broken, we want to make sure the baby is safe. Assessing by the woman’s report, Nitramine test, Fermin, Amnisure. Sometimes mom only experiences a tickle, we need to make sure mom is seen immediately. We always assess the baby’s: Heart Rate as soon as their water is broken. Fluid: T: Time A: Amount C: Color O: order Vaginal Exams: We assess: Dilation Effacement Station Position of Cervix Membrane status Position of fetus: We don’t want to do exams too often since we are sticking our fingers that have bacteria into the canal. We run the risk of infection. Comfort: We want to offer comfort and privacy before labor. Fetal Decent: When the baby drops the baby will be on moms’ bladders. WE want to get mom up and help to. Labor Support: Leverage the partner with education to help the mother be calm. We need to show them how to do things. Grandparents can offer emotional support. Pharmacologic: Systemic IV meds: Fentanyl and Nuban Newborns can get morphine and fentanyl Reginal: Epidural Pudendal Non-pharmacologic: General Comfort Cutaneous Massage Hydrotherapy Sensory Music Aromatherapy Complications Bleeding Infection Decrease fetal Perfusion 2 main types of pain management Cutaneous (Physical touch approach) Gate control Acupressure This is used to send competing sensations. Slow or block Massage Cognitive: Help change perception of pain, provide control Prayer Hypnosis We use both non-pharmacological together. WE can give a bolus before epidural to decrease chances of hypertension. Counter pressure is used in the gate-control theory, sending competing sensations to a similar area. Once we break the water, we have to assess the fetal heart rate. We want to assess the fluid for color, texture. In active labor we check fetal heart rate every 30 minutes.