Nursing Care During Labor & Birth - Lecture Slides PDF

Nursing Care During Labor & Birth Chapter 9  Exercise (5 points)  Your best friend/sister/mother/ daughter is pregnant.  What 5 pieces of advice will you give her? (Be brief but specific – in your own words)?  1.  2.  3.  4.  5.  Post to Canvass 02/...

Nursing Care During Labor & Birth Chapter 9  Exercise (5 points)  Your best friend/sister/mother/ daughter is pregnant.  What 5 pieces of advice will you give her? (Be brief but specific – in your own words)?  1.  2.  3.  4.  5.  Post to Canvass 02/21/24 08:00 am Childbirth  Normal physiologic process  Nursing care involves welfare of two  Family affair  Experience will be long remembered  Be sensitive to cultural needs Nursing Care Priorities  Monitoring mother  Progressof labor  Complications  Monitoring fetus  Tolerance of labor  Signs of distress  Pain Management  Safe  Satisfactory experience Labor  Physiologic process during which the fetus, umbilical cord, placenta and amniotic membranes are expelled by  Uterine contractions  Cervical effacement and dilation  Exact trigger not known  Usually occurs when fetus mature enough  38 - 40 weeks after LNMP Let’s see what it looks like:  https://www.youtube.com/watch?v= Xath6kOf0NE  Brief birth animation  Watch as fetus descends into the pelvis, it changes position to adapt to the size and shape of the pelvis  Descent  Engagement (head reaches ischial spines)  Flexion  Internal rotation  Extension  External rotation  Expulsion Signs of Impending Labor  Bloody show – loss of mucus plug, may occur a few days before labor  Burst of energy – 24-48 hours before onset of labor, “nesting”  Spontaneous rupture of membranes (SROM)  Go to hospital, even if there are no other signs of labor  Lightening  Contractions  Braxton-Hicks “false labor”  True labor – regular and progressively more intense Cervical Changes  During pregnancy cervix is thick and closed  During labor:  Effacement  Thinning  Expressed as a % - 100% is fully effaced  Dilation  Opening  Measured in cm – 10 cm is fully dilated True Vs. False/ Prodromal Labor  True labor - produces progressive effacement & dilatation of cervix  False (prodromal) labor - does not produce progressive effacement & dilatation of cervix  Best way to differentiate between true & false labor is to assess dilatation  Reassure woman; she should not be made to feel foolish if labor is false Critical Factors of the Birth Process  “The four + Ps”  Passage  Pelvis  Passenger  Fetus  Powers  Psyche  Position, Pain management, Patience  Preparation, Professional help, Place, Procedures, People Passage  Pelvis  More important to the outcome as it is less flexible  Cartilage soften due to relaxin  Soft tissues  Cervix  Muscles, ligaments, & perineum  Yield to pressure of presenting part of the fetus Passenger: Fetus  Fetal head  Suturesallow molding  Fontanelles - intersections between bones  Lie (fig. 9.2) Pg. 145  Fetalspine lines up to maternal spine  99% longitudinal – parallel Relationship of Presenting Part & Passage  Fetal presentation  Part of fetus that enters pelvis first  Cephalic = head first (96%)  Breech = buttocks first (3%)  Shoulder Fetal Presentation Variations  Cephalic  Breech  *Vertex complete  Full or complete flexion, most hips & knees common & smallest flexed diameter  Frank hips  Face full flexed, knees extension extended  Brow or military  Footling hip(s) & poor flexion, partial knee(s) extended extension Passenger: Fetus  Fetal position (fig. 9.4)  Relationship of landmark on presenting fetal part to front, side, or back of maternal pelvis (3 letters)  LOA most common  Attitude (fig. 9.5)  Degree of flexion  Flexed occupies less space Passenger: Fetus  Fetal station (fig. 9.6)  Relationship of landmark on presenting fetal part ischial spines  Provides information regarding fetal descent  At level of ischial spines = 0  Above is (-) cm  Below is (+) cm Powers: Uterine Contractions  Primary force of labor during 1st stage  Effects of contractions on cervix  Effacement (thin) - %  Dilatation (open) - cm  Involuntary  Can’t consciously start or stop  Influenced by many factors Describing Uterine Contractions  Onset  Beginning of contraction  Duration  Time from beginning of a contraction to end of that contraction  Frequency  Time from beginning of one contraction to beginning of next contraction  Intensity  Strength of contraction at acme/peak Maternal Pushing  Once the cervix is fully dilated  Most women feel urge to push  Voluntary pushing  Added to involuntary uterine contractions  Combined powers propel baby down through the pelvis  Station Maternal Position  Can influence progress of labor  Upright position can reduce length of labor  Standing, sitting, kneeling, walking  Encourage woman to find position of comfort  Not supine  Place wedge under lower back to displace uterus off inferior vena cava Psyche  State of mind can influence course of labor  Influenced by:  Confidence in self & trust in providers  Cultural & individual values  Coping mechanisms, support system  Preparation for childbirth  Decreased pain & increased satisfaction  Nurse provides reassurance, praise, information, and support Labor  https://www.youtube.com/watch?v=s p8V2mZ0C7E (natural home birth)  https://www.youtube.com/watch?v= Bf04LcSBpDw (Khan) Basic Principles for Maternity Care  Whenever possible 1) Labor should begin on its own 2) Freedom of movement 3) Birth support person or doula 4) No “routine” intervention 5) Non-supine position 6) Don’t separate the infant 7) In-person nursing 4 Stages of Labor (Overview)  First stage - beginning of true labor to 10 cm  Latent phase  Active phase  Transition phase  Second stage - 10 cm to birth of infant - pushing  Third stage - birth of infant to delivery of placenta  Fourth stage - 1 to 4 hours after birth - recovery Latent Phase: 1 - 3 cm  Characteristics  Contractions mild & infrequent (q5 by end)  Woman relatively comfortable  Excited although somewhat anxious  Can last 10 – 20 hours  Nursing care  Establish relationship  Orient to unit, review plans & requests  Monitor mother & fetus intermittently  Encourage ambulation  Active Phase: 4 - 6 cm  Characteristics  Contractions more frequent & intense  (q2-3, >60 sec)  Woman more inwardly focused, though still cooperative  May need analgesia or anesthesia (epidural)  Nursing care  Monitor  Comfort measures & hygiene  Keep bladder emptying  Support/assist in breathing/relaxation Transition Phase: 7 - 10 cm  Characteristics  Intense, frequent contractions (q2-3, 60-90 sec)  Woman may become irritable & uncooperative  Nursing care  Continue maternal & fetal assessments  Continue comfort measures  Reassure woman  Don’t leave her alone Birth Settings  Hospital (~99%)  + Ready access to services & personnel  - More expensive, intimidating  Birthing Center  + More homelike, less expensive  - delay if complication occurs  Home  + Control, low-tech, fewer pathogens  - Few attendants willing, delay in emergency Need for Admission  Teach pregnant woman  Regular uterine contractions  Nullipara/primipara; q5 min x1 hr  Multipara w/ hx rapid; q7-10 min x1 hr  Rupture of membranes  Vaginal bleeding  other than “bloody show”  Urge to push during contractions  Any other concerns Admission Data Collection  Maternal VS & condition, cervix  Fetal condition: FHR, Amniotic fluid  Signs of impending birth  Admission procedure – paperwork completed ahead of time  Consents  Labs  IV  Review prenatal record; Blood type & Rh, EDD, birth plan… Observation without Admission  “False” or early labor  Monitor for 20 min to verify fetal well being  Ambulate  If no cervical change (and membranes intact) return home to await true labor  Reassure & reinforce instructions  Frustrating & embarrassing After Admission to Labor Unit  Priority nursing actions Monitor the fetus Monitor the laboring woman Help the woman cope with labor Evaluating Progress of Labor  Contractions  Vaginal exam  Cervix - effacement & dilatation  Fetal station - descent  No set interval  Watch for signs of progress  Minimize exams  Reduce infection  Uncomfortable Maternal Response to Labor  Assess response to labor  Breathing & relaxation techniques  Tension, difficulty coping  Support adaptive responses  Maintain open communication  Hygiene and comfort measures  Teach, keep informed of progress  Encourage  Care for partner(s) Amniotic Fluid  Record color, odor and amount  Color/ odor  Clear,straw colored, with flecks of white vernix - normal  Green – meconium; fetal distress  Cloudy with odor - infection  Nitrazine test to verify alk. pH  Amount is subjective Ongoing Maternal Physical Assessment  Vital signs  1st may be elevated due to excitement; repeat  Temp q4h, q2h after membranes rupture – report Temp ≥100.4  P, R, BP q1hr  I&O  Encourage voiding q 1-2 hrs  Full bladder will interfere with descent Assisting the Laboring Woman  Promote comfort  Environment: light, room temp, covers…  Hygiene: frequently change underpads  Position  Ambulate during early labor  Upright, hands & knees, squatting  Side lying  Avoid supine position Assisting the Laboring Woman  Teaching  Reinforce childbirth preparation class  Teach breathing techniques & positioning  Coach pushing when fully dilated  Provide encouragement  Keep informed of progress  Caring presence  Support the partner Fetal Heart Rate  Monitor 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  Nursing responsibilities  Continuous monitoring of data  Rapid identification of non-reassuring patterns  Prompt intervention  Document interventions & additional information  EFM is part of medical record Fetal Heart Rate  Normal baseline rate 110 - 160  Tachycardia >160  maternal fever  Bradycardia 100.4oF, 38oC  Prevention of Chorioamniotis  Prolonged Pregnancy – Post-term  Pregnancy >42 weeks  Minimal maternal physical risk; stress  Fetal risks:  Placental insufficiency, meconium aspiration,  risk of stillbirth, macrosomia  Medical management  verify true gestation, close monitoring  after 42 weeks; induce labor  Nursing implications  Monitor fetus/neonate Powers: Decreased Uterine Muscle Tone (Hypotonic)  Description  Contractions diminish after 4 cm, too weak for active phase  More likely to occur with overdistension  Medical treatment  Amniotomy/AROM  Augment labor with oxytocin (Pitocin)  Nursing implications  Reassurance  Encourage ambulation, upright position Prolonged Labor (Dystocia)  Long or difficult labor  Risks  Infection  Maternal exhaustion  Postpartum hemorrhage  > anxiety and fear  Nursing implications  Help woman conserve strength  Observe for infection  Support coping  Preterm Labor  Labor before week 37  Leading cause of neonatal mortality in US  Cause unknown  Many risk factors  Medical treatment  Women at risk taught to recognize signs, home monitoring  Attempt to stop preterm labor; tocolysis - drugs; MgSO4, etc.  Speed fetal lung maturity - betamethasone  Activity restriction - partial bedrest  Preterm Labor  Pharmacological treatment  Progesterone  Antibiotics  Hydration  Tocolytics  Drugs that suppress uterine activity  Short term, only weeks 24 - 34  Nursing implications  Manage treatment and monitor  Teaching & support Abnormal Fetal Presentation  Abnormal presentation (face, breech)  Fetus does not pass easily through pelvis  Breech or transverse;  37 weeks - attempt external version; attempt to turn fetus  persistent & labor begins - cesarean  Nursing implications  Assist with version, CS Abnormal Position - OP  Persistent Occiput Posterior  Maternal implications  Prolonged “back” labor  Fetal implications  Excessive molding, caput  Nursing implications  Assistin positioning for best labor progress Macrosomia  Fetus >4,000 gms (8.8 lbs)  Maternal risks:  laceration, postpartum hemorrhage  Fetal risks:  shoulder dystocia, brachial plexus injury or fractured clavicle  Closely monitor labor or cesarean Multifetal Pregnancy  Increased complications  Prematurity, uterine overdistention, GH, abnormal presentation/position, maternal hemorrhage  Nursing care  Monitor each fetus  Anticipate CS  Team prepared for each baby Prolapsed Cord  Emergency!!  Cord slips down between fetus & pelvis - if compressed cuts off circulation  Risk - ROM when fetus not engaged  Treatment  Push up on fetal head to relieve pressure  Deliver immediately - crash cesarean!!  Calm, quick action; debrief afterward Prolapsed Umbilical Cord Precipitous Labor & Birth  Completed in